Nicotine Addiction

Nicotine addiction is the second-leading cause of death worldwide. The important causes of smoking-related mortality are atherosclerotic vascular disease, cancer, and chronic obstructive pulmonary disease (COPD). Smoking also can contribute to other diseases, such as histiocytosis X, respiratory bronchiolitis, obstructive sleep apnea, idiopathic pneumothorax, low birth weight, and perinatal mortality.

Currently, there are about 1.3 billion smokers the world, most (84%) of them in developing countries.[1] If current smoking trends continue, tobacco will kill 10 million people each year by 2020. Through direct healthcare costs and loss of productivity from death and illness, tobacco will cost governments an estimated US $200 billion per year. A third of these costs will be borne by the developing countries. Many factors have led to increased global smoking rates, including the following:

    Trade liberalization
    Direct foreign investment
    Global marketing
    Transnational tobacco advertising, promotion, and sponsorship
    International tobacco smuggling

Research investigating why people smoke has shown that smoking behavior is multifaceted. Factors influencing initiation of smoking differ from those influencing maintenance of smoking behavior. Nicotine dependence, genetic factors, and psychosocial factors all influence maintenance of smoking behavior.

Nicotine in cigarette smoke affects mood and performance and is the source of addiction to tobacco. It meets the criteria of a highly addictive drug, in that it is a potent psychoactive substance that induces euphoria, reinforces its own use, and leads to nicotine withdrawal syndrome when it is absent. As an addictive drug, nicotine has 2 very potent effects, being both a stimulant and a depressant. Thus, cigarettes may both get a smoker going in the morning and “chill out” the smoker during the day.

All healthcare professionals should be aware of the risks of tobacco smoking, understand nicotine addiction, and assist patients with smoking cessation.

In their 2010 guidelines, the American Heart Association (AHA) and the American Stroke Association (ASA) strongly recommended that smokers consider smoking cessation because of the direct correlation between smoking and both ischemic stroke and subarachnoid hemorrhage. Clinicians should provide counseling, nicotine replacement, and oral smoking cessation medications as options. Avoiding exposure to environmental tobacco smoke is reasonable.

Illustrative case study

A young adult man met his primary care physician for the first time, during which his prior military history came to light. The young man recalled the anxiety he experienced when he received his military orders for deployment to Iraq. Before being notified of deployment, he smoked cigarettes only occasionally, perhaps 1 or 2 cigarettes a day.

As the time for deployment approached, the young man started smoking more cigarettes, and by the time he arrived in Iraq, he was up to a full pack a day. Throughout the 12-month deployment, the soldier steadily increased his smoking, reaching a peak consumption of nearly 40 cigarettes a day. He sustained several significant combat-related traumas resulting in mild physical injuries.

After returning home, the young man completed his military obligation and left the service. Although experiencing some lingering physical and emotional pain from his tour of duty, he was improving, except in 1 area: He continued to smoke 2 packs a day, despite efforts to quit. The former soldier’s wife complained that the expensive habit was creating an unnecessary financial strain on their meager resources. Furthermore, the young man himself no longer derived much pleasure from smoking, admitting that only the first cigarette of the day was truly enjoyable.

Despite his apparent willingness to consider quitting the use of tobacco, the former soldier also readily admitted that he was frightened by the prospect. He recognized that his unresolved emotional issues from the war, though currently being addressed in treatment, gave him a reason not to tackle another problem at this time. The doctor appreciated the frank disclosure but took issue with the patient’s conclusion. The patient appeared motivated and open to change but needed additional encouragement to consider a smoking cessation program.

At this point, the doctor decided to discuss concomitant disorders by explaining the common association of a mental disorder with substance misuse. The doctor further explained how tobacco use, at least in the beginning, helped the former soldier cope with anxiety. Trauma suffered in the war led to the developed of posttraumatic stress disorder (PTSD). The continued use of tobacco made it difficult to distinguish the symptoms of nicotine dependence from those of PTSD and delayed recovery from the emotional disorder.

The doctor asked the patient to think about this information and consider a smoking cessation program. Various medications were described that could alleviate nicotine withdrawal symptoms or reduce tobacco cravings. Such medications, combined with a behavioral strategy, offered the safest and surest route to a tobacco-free life. Discussions continued over a few more visits (including a meeting with the wife) before the patient decided to give up smoking. With the doctor’s help, he successfully completed a 3-month smoking cessation program.

credit : medscape.com