Tobacco Dependence

In America today, tobacco stands out as the agent most responsible for avoidable illness and death. Millions of Americans consume this toxin on a daily basis. Its use brings premature death to almost half a million Americans each year, and contributes to profound disability and pain in many ways. Approximately one-third of all tobacco users in this country will die prematurely because of their dependence on tobacco. In fact, tobacco use is the chief avoidable cause of illness and death in our society, causing cancer, heart disease, stroke, complications of pregnancy, and chronic obstructive pulmonary disease. Pharmacokinetics of Cigarette Smoke Within seconds of inhaling cigarette smoke, a bolus of nicotine travels from the carotid arteries to the brain where the molecules bind to nicotine receptors. Nicotine stimulates the norepinephrine and serotonin systems, enhancing concentration and memory and decreasing anxiety. This results in dopamine secretion that causes pleasurable sensations and relief of symptoms of nicotine deprivation. Nicotine also interacts with acetylcholine receptors, creating a variety of physiologic reactions. Some reactions are beneficial, such as suppressing appetite and pain, while others are not, such as elevated BP and nicotine addiction. Nicotine replacement therapy mimics but does not match these intense effects caused by the nicotine in cigarette smoke. (Fiore, M., & Westman, E. Using pharmacotherapy for cessation. Patient Care. 2001; 35(24):18-27.) Tobacco Dependence Shows Many Features of A Chronic Disease Tobacco dependence shows many features of a chronic disease. Although a minority of tobacco users achieves permanent abstinence in an initial quit attempt, the majority persist in tobacco use for many years and typically cycle through multiple periods of relapse and remission. By recognizing that tobacco dependence is a chronic condition, clinicians will better understand the relapsing nature of the ailment and the requirement for ongoing, rather than just acute care. This framework helps clinicians view relapse as a subsequent component of this chronic disease, rather than a lack of motivation or commitment on the patients' part or lack of ability on the clinicians' part. A failure to appreciate the chronic nature of tobacco dependence may undercut clinicians' motivation to treat tobacco use consistently. Helping Your Patient Develop A Quit Plan Set a quit date -- In preparation for quitting the patient should set a quit date, ideally within 2 weeks. The patient should tell their family, friends, and coworkers about the quit attempt and request understanding and support. Review past quit attempt experiences -- Urge the patient to consider reusing strategies that were helpful and to avoid situations that led to relapse. Anticipate challenges -- It is important for the patient to anticipate challenges to the planned quit attempt, particularly during the critical first few weeks (e.g., withdrawal symptoms such as negative mood, urges to smoke, and difficulty concentrating). Remove tobacco products -- Prior to quitting, patients should remove tobacco products from their environment and avoid smoking in places where he or she spends a lot of time (e.g., work, home, car). In addition, if a spouse or significant other is continuing to smoke, specific strategies to limit that risk should be established. Tobacco and alcohol -- About half of smokers who try to quit and relapse have their first drag of smoke with some alcohol in their bloodstream. Avoiding or limiting alcohol in the first few weeks after a quit attempt should be considered. Children and Adolescents The PHS Guideline recommends that clinicians screen pediatric and adolescent patients and their parents for tobacco use and provide a strong message about totally abstaining from tobacco use. A recent study has shown that adolescents' smoking status was identified in 72% of office visits, but smoking cessation counseling was provided at only 17% of clinic visits of adolescent smokers. Therefore, clinicians both need to assess adolescent tobacco use and offer cessation counseling and behavioral interventions shown to be effective with adults. It is also recommended that the content of these interventions be modified to be developmentally appropriate. Children and adolescents may benefit from community- and school-based intervention activities. The messages delivered by these programs should be reinforced by the clinician. The Guideline further recommends that clinicians in a pediatric setting offer stop-smoking advice to parents to limit children's exposure to second-hand smoke. The Youth Tobacco Cessation Collaborative (YTCC) was formed in 1998 to address the question of which strategies and treatments are most effective in assisting youth to quit smoking. The YTCC is composed of ten member organizations in the United States and Canada who are involved in funding research, program, and policy initiatives focused on youth tobacco use. In 2003, the YTCC published its National Youth Tobacco Cessation Blueprint establishing both short- and long-term goals "to insure that every young tobacco user (age 12 - 24) has access to effective cessation interventions by 2010" (Orleans, CT, et al. (2003). Youth Tobacco Cessation Collaborative and National Blueprint for Action. American Journal of Health Behavior, 27 (Suppl 2), S103-S119). On their website, the YTCC makes available current research on youth tobacco cessation. Clinicians working with adolescents who smoke may find this a valuable resource.