Nicotine Addiction – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Nicotine use characterized by signs of dependence (compulsive use of a substance despite knowledge of its adverse effects)

Epidemiology

Incidence

20–25% of US population smokes.

Prevalence

70.9 million Americans ≥12 years of age reported current use of tobacco (60.1 million were cigarette smokers, 13.3 million smoked cigars, 8.1 million used smokeless tobacco, 2 million smoked pipes) (1)[B].

Pediatric Considerations

7% of 8th graders, 12% of 10th graders, and 20% of 12th graders have used cigarettes in the past 30 days (1).

Risk Factors

  • Mental illness (including depression, posttraumatic stress disorder, bipolar disorder, and schizophrenia)
  • Low socioeconomic status
  • Low educational status
  • Early firsthand nicotine experience increases risk from chronic abuse
  • Environmental factors are critical for smoking initiation; genetic factors contribute to smoking persistence and difficulty quitting.

Genetics

  • Mutation in the α4 subunit of nicotinic acetylcholine receptors (nAChRs) expressed by neurons was found to lower the threshold for the induction of nicotine dependence.
  • Specific genes have been isolated that are associated with nicotine dependence, including CHRNB3, the β3 nicotine receptor subunit gene.
  • T-variant gene associated with decreased activity of CYP2B6 (enzyme that breaks down nicotine in the brain); may lead to increased craving during smoking cessation. These patients are also 1.5 times more likely to resume smoking during treatment.

General Prevention

  • Physician advice
    • The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among children or adolescents.
  • School-based smoking-prevention education
  • Nonsmoking adolescents who were more aware of or receptive to tobacco advertising were more likely to become smokers later.

Pathophysiology

  • Mechanism by which nicotine binds to nAChR and how this leads to dependence are still poorly understood, though likely involve activation of the mesocorticolimbic system with resulting dopamine release.
  • Nicotine has both stimulating and depressing effects within the CNS; relaxing and euphoric effects may contribute to psychological dependence.

Pregnancy Considerations

  • Carbon monoxide and nicotine may interfere with oxygen supply to the fetus, resulting in fetal growth restriction and decreased birth weight.
  • Smoking may increase the incidence of spontaneous abortion, SIDS, as well as learning or behavioral problems and an increased risk of obesity in children (1).

Etiology

Polymorphisms in neuronal nAChR genes could be associated with increased susceptibility to tobacco dependence.

Commonly Associated Conditions

  • COPD (emphysema and chronic bronchitis)
  • Cancers (lung, oral/pharyngeal, kidney, bladder, cervical, anal)
  • Coronary artery disease
  • Periodontal disease

Diagnosis

Diagnostic Tests & Interpretation

Spirometry: Decreased FEV1 (may be present in COPD)

Differential Diagnosis

  • Depression
  • COPD
  • α1-Antitrypsin deficiency
  • Asthma
  • CHF
  • Respiratory infections
  • Lung cancer
  • Cystic fibrosis

Treatment

Counseling:

  • Advice from doctors helps people who smoke to quit.
  • Providing brief, simple advice about quitting smoking increases likelihood that someone who smokes will successfully quit and remain a nonsmoker 12 months later. More intensive advice (i.e., Motivational Interviewing, etc.) may result in higher rates of quitting. Providing follow-up support after offering the advice may increase the quit rates slightly (2)[A].
  • The USPSTF strongly recommends to screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. Grade: A recommendation.

Medication

First Line

  • Varenicline (Chantix) is a nicotinic acetylcholine partial agonist for the treatment of nicotine addiction. Trials have suggested this agent may be more efficacious than Bupropion (3)[A]. Longer-term therapy (up to 24 weeks) may delay or prevent relapse:
    • Starter package includes 0.5 mg/d for 3 days, then 0.5 mg b.i.d. for 4 days, then 1.0 mg/d starting on day 7.
    • Maintenance package includes 1.0 mg b.i.d. (continue for 12 weeks total).
  • Nicotine replacement therapy (NRT). All forms of NRT increase the chance of stopping smoking by 50–70%. There is no overall difference in effectiveness of different forms of NRT nor a benefit for using patches beyond 8 weeks. Heavier smokers may need higher doses. Starting NRT before planned quit date may increase the chance of success (4)[A].
    • Nicotine gum (Nicorette): For >25 cigarettes/d habit, 4 mg gum q1–2h for 6 weeks; for <25 cigarettes/d habit, 2 mg gum q1–2h for 6 weeks; decrease dosing by q1–2h for 3 weeks; chew, then tuck between cheek and gingiva
    • Nicotine transdermal (NicoDerm CQ): For >10 cigarettes/d habit, 21-mg patch/d for 6 weeks, then 14 mg patch/d for 2 weeks, then 7 mg patch/d for 2 weeks; for <10 cigarettes/d habit, 14-mg patch/d for 6 weeks, then 7 mg patch/d for 2 weeks
    • Nicotine lozenge (Commit): For patients who have 1st cigarette within 30 min of waking, 4-mg lozenge PO q1–2h for 6 weeks; 1st cigarette >30 min after waking, 2-mg lozenge PO q1–2h for 6 weeks; decrease dosing by q1–2h for 3 weeks.
    • Nicotine nasal (Nicotrol NS): 1–2 sprays (0.5 mg/spray) each nostril q1h for 8 weeks, then taper; maximum 10 sprays/h and 80 sprays/d
    • Nicotine inhaled (Nicotrol inhaler): 6–16 cartridges inhaled (4 mg/cartridge) per day for 6–12 weeks, then taper
  • Medications:
    • Bupropion (Zyban): An antidepressant; start 150 mg/d PO for 3 days, then 150 mg PO b.i.d.; stop smoking 5–7 days after starting treatment; continue 7–12 weeks.

Alert

Varenicline (Chantix) has not been studied when used in patients with serious psychiatric illness. It should be used with extreme caution in patients with serious psychiatric disorders (bipolar disorder, depression, or schizophrenia) as use may exacerbate these conditions.

Second Line

  • Nortriptyline: Tricyclic antidepressant; start 25 mg/d, gradually increase to target dose of 75–100 mg/d; stop smoking 2–4 weeks after starting treatment; continue for 12 weeks:
    • Contraindications: Narrow-angle glaucoma or heart disease (AMI, AV, or bundle-branch block, QT prolongation)
    • Caution: Pregnancy category D
  • Clonidine: 0.1-mg patch per week, increase dose as needed; continue for 3–10 weeks:
    • Caution: Must monitor BP closely and taper when discontinuing.
  • Benzodiazepines: Although this class of drug has not improved rates of abstinence from smoking, patients with a high level of anxiety possibly could benefit from anxiolytics as a smoking-cessation intervention.

Additional Treatment

Pregnancy Considerations

  • The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke. Grade: A recommendation.
  • Other interventions:
    • Smokers who get support from partners and other people are more likely to quit.
    • Group programs are double cessation rates than being given self-help materials without face-to-face instruction and group support. The chances of quitting are approximately doubled. It is unclear whether groups are better than individual counselling or other advice, but they are more effective than no treatment. Not all smokers making a quit attempt want to attend group meetings, but for those who do they are likely to be helpful.
  • Smokers should be given a choice of quitting methods, either reducing smoking before quitting or abrupt quitting, as neither has demonstrated superior quit rates.

Pregnancy Considerations

Interventions were effective in helping women to stop smoking during pregnancy (overall by approximately 6%). The most effective intervention appeared to be providing incentives, which helped around 24% of women to quit smoking during pregnancy. The smoking cessation interventions reduced the number of babies with low birthweight and preterm births, confirming that smoking cessation can reduce the adverse effects of smoking on newborn infants.

General Measures

  • Brief strategies to help the patient willing to quit tobacco use—the “5 As”:
    • Ask the patient if he or she uses tobacco.
    • Advise him or her to quit.
    • Assess willingness to make a quit attempt.
    • Assist those who are willing to make a quit attempt.
    • Arrange for follow-up contact to prevent relapse.
  • Enhancing motivation to quit tobacco—the “5 Rs”:
    • Relevance—Encourage the patient to indicate why quitting is personally relevant.
    • Risks—Ask the patient to identify potential negative consequences of tobacco use.
    • Rewards—Ask the patient to identify potential benefits of stopping tobacco use.
    • Roadblocks—Ask the patient to identify barriers or impediments to quitting and provide treatment (e.g., problem-solving counseling or medication) that could address barriers.
    • Repetition—The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting (5)[A].

Complementary and Alternative Medicine

  • Acupuncture: No consistent evidence acupuncture is effective for smoking cessation
  • Hypnotherapy: No good evidence to show whether or not hypnotherapy can help people trying to quit smoking.

In-Patient Considerations

  • Programs to stop smoking that begin during a hospital stay and include follow-up support for at least 1 month after discharge are effective. Programmes are effective when administered to all hospitalized smokers, regardless of admitting diagnosis.
  • Consider NRT to all inpatients who smoke to decrease withdrawal symptoms.

Ongoing Care

Follow-Up Recommendations

  • Patients motivated to quit smoking and who have initiated therapy should follow up routinely with the physician to monitor response and observe for any medication side effects.
  • Encourage routine exercise as a component of smoking-cessation treatment.

Diet

Weight gain (4–5 kg over 10 years) possible after smoking cessation.

Patient Education

  • http://www.smokefree.gov/
  • http://www.nicotine-anonymous.org/
  • http://quitnet.com/

Prognosis

More than 85% of those who try to quit on their own relapse, most within a week (1).

References

1. National Institute on Drug Abuse. Tobacco Addiction. National Institute of Health; 2009 June. NIH Publication Number 09-4342.

2. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews. 2008;2:CD000165. DOI:10.1002/14651858.CD000165.pub3.

3. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews. 2008;3:CD006103. DOI:10.1002/14651858.CD006103.pub3.

4. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews. 2008;1:CD000146. DOI:10.1002/14651858.CD000146.pub3.

5. The Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update A U.S. Public Health Service Report. Am J Prev Med. 2008;35:158–76.

Additional Reading

The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA. 1996;275:1270–80.

Codes

ICD9

  • V15.82 Personal history of tobacco use
  • 305.1 Tobacco use disorder
  • 649.00 Tobacco use disorder complicating pregnancy

Snomed

  • 56294008 nicotine dependence (disorder)
  • 89765005 tobacco dependence syndrome (disorder)

Clinical Pearls

  • Smoking cessation should be encouraged with all patients who smoke.
  • There is no one type of nicotine-replacement therapy that is best; they are equally effective. Choice therefore should be based on patient preference.
  • Consider NRT to all inpatients who smoke to decrease withdrawal symptoms.

Jean-Paul Marat

Many tips are based on recent research, while others were known in ancient times. But they have all been proven to be effective. So keep this website close at hand and make the advice it offers a part of your daily life.

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