With help from rural physicians, cancer center researchers gain insight into tobacco addiction

July 12, 2012

By David Martin

A smoke shop in Hutchinson, Kan., sends the wrong message.

The maxim "If at first you don't succeed, try, try again" first appeared in teaching manuals in the 19th century. The message may be old, but for people who want to quit smoking, it continues to resonate.

Tobacco use is the leading preventable cause of disease and death in the United States. The best health decision a smoker can make is to become an ex-smoker. To better understand the nature of the addiction, researchers at the University of Kansas Medical Center followed a group of smokers for two years.

One of the questions the study attempted to answer is what happens to smokers who try — but do not immediately succeed — in breaking their dependence. The traditional thinking has been that they become more hardened — that some biological, psychological or environmental phenomenon tightens nicotine's grip. But the study, the first of its kind, found that smokers who made multiple quit attempts did not develop a more stubborn habit.

The message of the study, according to its senior author, is that smokers who try and fail to stop should not be considered lost causes. "We basically say, 'Don't give up on them,'" says Edward Ellerbeck, M.D., M.P.H., the Sosland Family Professor of Preventive Medicine and chair of the Department of Preventive Medicine and Public Health. Since 2005, Ellerbeck has served as co-leader of the Cancer Control and Population Health program at The Universityof Kansas Cancer Center.

The research was supported by a grant from the National Cancer Institute (NCI) at the National Institutes of Health. This form of population-based research is one of the elements the NCI considers when it designates institutions as leaders in integrating research and cancer care. On July 12, The University of Kansas Cancer Center announced that it received this important designation.

The study identified 726 smokers from than 50 rural primary care clinics throughout the state of Kansas. At six-month intervals, the smokers were asked if they wanted nicotine patches or medication known to reduce cravings.

Smokers who requested the pharmocotherapy aids were more likely to quit than those who didn't. This result, which had been documented in other studies, came as no surprise. After all, a willingness to try a patch or another form of quit assistance indicates that a smoker is at least open to change.

The most interesting aspect of the study, however, was not the difference in cessation rates between the medicated and the non-medicated. What made the Kansas study unique was its ability to measure how resistance to quitting might or might not build up after repeated attempts.

The study, called KanQuit, showed that 1 in 2 smokers were willing to make a second effort to quit within six months of a failed attempt. Moreover, the smokers who opted for second, third and even fourth courses of pharmocotherapy were more likely to overcome their addictions than the smokers in the study who did not request medication.

Ellerbeck and his co-authors concluded that the results should encourage physicians to keep the conversation running with patients who smoke.

"The more you talk with people about smoking, the more likely they are to actually make a quit attempt," Ellerbeck says. "It doesn't work every time. In fact, it doesn't work most of the time. But it works often enough that it's still one of the most valuable things we can do as physicians working with our patients."

Policymakers can learn from the results, as well, Ellerbeck says. Benefit providers often restrict the number of tobacco dependence treatments they will pay for in a given year. Ellerbeck calls this "penny-wise and pound-foolish," adding, "There's no evidence that people are going to abuse those medications, or if they keep using them they will no longer be effective."

A point of emphasis

Ellerbeck credits the previous chair of the preventive medicine and public health, Jasjit Ahluwalia, M.D., M.P.H., for making tobacco use a point of emphasis. Ahluwalia conducted research that led to acceptance that smoking status should be considered a routine vital sign. Studies have shown that a smoking vital-sign stamp increases the likelihood that doctors will discuss a patient's habit.

A physician who works in rural Kansas says documenting smoking status in medical records is helpful, partly because it's not always obvious that a patient smokes. "Now that we have electronic health records and are tracking smoking status for meaningful use, I know if a patient is a current smoker, former smoker or has never smoked," says Lynn Fisher, M.D., a family physician in Plainville, Kan. "It gives me the opportunity to assess if a smoker is ready to stop, discuss treatment options or maybe just hand out a quit card."

Doctors like Fisher helped Ellerbeck and his colleagues conduct the KanQuit study. A program called Kansas Physicians Engaged in Preventative Research connects faculty and medical students at KU with primary care physicians throughout the state. The program exposes students to rural practice and gives researchers access to real-world information.

Ellerbeck collaborated on the KanQuit study with Paula Cupertino, Ph.D.; Allen Greiner, M.D., M.P.H.; Jonathan Mahnken, Ph.D.; Laura Musselman, M.P.H; Niaman Nazir, M.B.B.S., M.P.H.; Lisa Sanderson Cox, Ph.D.; and Jo Wick, Ph.D. More recently, Ellerbeck was the senior author of a study of smokers who continued to smoke after the completion of the two-year KanQuit program.

The follow-up study found that half of these smokers continued to try to quit, though only 5 percent actually did so within one year of the close of the study. Of course, there's always a next time to try, try again.

Last modified: Aug 09, 2012