Nicotine Dependence

Signs & symptoms

Nicotine is as addictive as heroin and causes release of the pleasure chemical dopamine and other neurotransmitters in the brain within minutes of the first puff, which reinforces continued tobacco use.

Tobacco users get hooked because of that pleasant feeling or "rush" and often continue to use nicotine to prevent withdrawal symptoms.

Some of the complex factors involved in tobacco and nicotine dependence are:

• How the body handles nicotine, how it is absorbed and removed and how the body responds to it
• Environmental factors, such as smoking while drinking coffee or after meals
• Physiologic factors, such as a person’s genetic predisposition to addiction

When you stop smoking, the withdrawal side effects will appear in one to two days, peak during the first week, and then subside within two to four weeks.

Symptoms of nicotine withdrawal include:

• Anxiety
• Cravings
• Depression
• Difficulty concentrating
• Impaired performance
• Increased appetite and weight gain
• Irritability, frustration and anger
• Restlessness and impatience
• Sleep disturbances, such as insomnia or sleeping too much

Health Risks

Tobacco use is responsible for about one in five deaths annually in the United States.

Smoking can damage virtually all systems of your body and can cause:

Cardiovascular disease

• Abdominal aortic aneurysm
• Coronary artery disease (angina pectoris, ischemic heart disease, myocardial infarction)
• Cerebrovascular disease (transient ischemic attacks, stroke)
• Peripheral arterial disease

Lung disease

• Acute lung disease, such as pneumonia
• Chronic lung disease, such as emphysema and chronic obstructive pulmonary disease (COPD)

Cancer

• Acute myeloid leukemia
• Bladder and kidney
• Cervical
• Gastrointestinal
• Laryngeal, pharyngeal, oral cavity and esophageal
• Lung
• Pancreatic
• Increased risk of breast cancer
• Increased risk of cancer recurrences in general

Reproductive conditions

• Increased rate of impotence and sperm abnormalities in men
• Infant mortality
• Poor pregnancy outcomes such as low birth weight and preterm delivery
• Reduced fertility in women

Other conditions

Other conditions related to smoking include:

• Cataracts
• Osteoporosis
• Periodontitis or gum disease
• Peptic ulcer disease

Second-hand smoke

Second-hand smoke can cause premature death and disease in both children and adult non-smokers.

Children exposed to second-hand smoke are at an increased risk for sudden infant death syndrome (SIDS) and may also develop:

• Acute respiratory infections
• Ear problems
• More severe asthma
• Respiratory symptoms and slowed lung growth if parents smoke

Adults exposed to second-hand smoke are at increased risk for coronary heart disease and lung cancer. Second-hand smoke may also have an immediate negative effect on your cardiovascular system.

Treatments

Quitting smoking for good and overcoming nicotine dependence requires a multi-faceted approach that may include counseling, support groups, behavioral therapy and medication.

The UCSF Fontana Tobacco Treatment Center offers classes with nurses and pharmacists trained in treating tobacco dependence. The center helps smokers maximize the likelihood of success in efforts to quit. Services include Smoking Cessation classes and a Relapse Prevention Program.

Quitting "cold turkey" is likely to be only 5 percent successful after a year. In general, using medications will double or triple a person's success at stopping. Counseling also doubles the success rate. Behavioral therapy to identify triggers and modify routines is an important part of the process.

Most smokers require multiple attempts to stop smoking completely, learning from each attempt. The key step is to make an attempt to stop smoking.

People who have underlying anxiety, depression or other disorders may need more intense intervention. Alcohol use or exposure to other smokers are also risk factors for relapse.

Counseling

Individual counseling with a health care provider, counseling in a structured stop smoking group, or counseling on a telephone quit line is an important part of quitting smoking. Support from other people who are trying to quit is invaluable. For many of the participants in our stop smoking program, regular attendance to our weekly Relapse Prevention Support Group has been critical to ongoing success.

Medications

Using one or a variety of stop smoking medications has also been shown to increase quitting success rates. Medications ease nicotine withdrawal symptoms, providing enough relief to allow the smoker to focus on learning new ways of thinking and behaving without cigarettes.

The majority of smokers who are unsuccessful at stopping will relapse within the first two weeks, usually due to intense cravings. However, it's important to know that there are many medication options that can be tried, so if one doesn't work, another can be tried. It's never too late to quit.

The medications listed below are aids to cessation – they ease the quitting process and help it change from seemingly impossible to difficult, but attainable. In many cases, smokers who use medications to help them quit report that it was even easier than they had thought! If a patient relapses or slips (and smokes) within the first two weeks due to craving, our strategy is to evaluate what triggered a person to smoke, and to adjust their smoking cessation medications if needed; often we find people are not using enough nicotine replacement therapy.

Nicotine replacement therapies (NRT)

• Nicotine patch. This medication slowly releases nicotine and provides a consistent low level of nicotine throughout the day. It is available over-the-counter in strengths of 7, 14 and 21 mg. Patients typically start at the highest strength of 21 mg and taper the dose over 8 to 12 weeks. The main side effects from the patch are local skin irritation and vivid dreams that require removing the patch before bedtime. The patch location should be rotated every day. Never cut the patch because this causes nicotine to evaporate. Nicotine levels are elevated in one to two hours after application, an important fact for highly dependent smokers who have intense morning cravings. For intense cravings, short acting NRT gum, nasal spray, lozenge or inhaler can be added, as needed, with supervision.
• Nicotine gum. Nicotine gum comes in 2 and 4 mg strengths and is available without a prescription. It can be combined with the patch for patients experiencing intense cravings. The gum should be chewed slowly and then packed between the gum and check, where the nicotine is absorbed across the lining of the mouth. When the tingling sensation goes away, the gum should be chewed again and then packed. The instructions should be carefully reviewed with a pharmacist or other health care professional to maximize its effectiveness. Nicotine gum is often chewed incorrectly. Patients with jaw disorders or significant dental work should not use nicotine gum. Reported side effects include nausea or hiccups.
• Nicotine oral inhaler. An inhaler can satisfy hand-to-mouth and oral activity that many smokers feel is important. Cartridges containing nicotine and menthol are placed inside a plastic holder that resembles a cigarette and puffed into the mouth and throat where nicotine is absorbed. Patients can use between six and 16 cartridges per day, which can be combined with a nicotine patch. Cough and throat soreness are reported side effects. Nicotine inhalers are available by prescription only.
• Nicotine lozenges. Nicotine lozenges come in 2 and 4 mg strengths and is available without a prescription. A lozenge is placed in the mouth and slowly dissolves so nicotine is absorbed over 20 to 30 minutes across the lining of the mouth (10 minutes for the mini-lozenge). Potential side effects include nausea, headaches and hiccups.
• Nicotine nasal spray. This form of nicotine reaches the brain faster than the gum, lozenge and inhaler. Potential side effects include nasal and sinus irritation and watery eyes, but this usually improves with regular use. When used with the nicotine patch, the nasal spray can be used on an hourly basis and as needed with intense cravings. It is available by prescription only.

Drug therapy

• Chantix (varenicline). Varenicline, also known by the brand name Chantix, is a pill that binds to nicotine receptors in the brain. It doesn't cause the same level of activation as nicotine, but it relieves withdrawal symptoms. It also blocks the pleasant effects of nicotine if a person slips and smokes. Side effects include nausea, vomiting and insomnia. Smokers should be advised about possible neuropsychiatric effects and should be monitored during treatment. It is available by prescription only.
• Zyban (bupropion, Wellbutrin). Buproprion, also known by the brand name Zyban, is a sustained release (SR) medication that's also used as an anti-depressant. It alters dopamine levels in the brain, which helps to relieve nicotine withdrawal symptoms. It is associated with a very rare risk of seizure, and cannot be used by those with seizure disorders. It is available by prescription only. The most common side effects include headache, insomnia and dry mouth. It can be used with NRTs.

Other therapies

There are many other treatments available to stop smoking, such as hypnotherapy, acupuncture, aversion therapy and yoga, but there is little data to suggest that these approaches are any better than medications alone.

Our general approach is to suggest proven medications in addition to other therapies that patients might be interested in pursuing.

Exercise is an important part of the program for stress reduction and to promote good health. It can be as little as walking 10 blocks three times per week.

Stress management workshops are available for those who identify stress as a factor in smoking. Relapse prevention programs can help patients stay on track.

Ultimately, successful quitters seem to replace smoking with something else they enjoy, ranging from exercise to volunteer work to a multitude of other creative options. The public library is a great smoke-free place to investigate new hobbies or activities to keep ex-smokers on track.