Learn About Tobacco Dependence
What is Tobacco Dependence?
Key Symptoms
What Causes Tobacco Dependence?
Conventional Treatments
Medications
Tests and Procedures
Treatment and Prevention
How Supplements Can Help
Self-Care Remedies
Alternative Therapies
When to Call a Doctor
References
Evidence Based Rating Scale
What is Tobacco Dependence?
Tobacco dependence is a chronic medical condition involving any habitual use of the tobacco plant and its products. The predominant means of using tobacco is through smoke inhalation of cigars, cigarettes, and pipes; however, there are a variety of products known as smokeless tobacco that are chewed, sniffed, or sucked. (1) Smoking any form of tobacco long-term is almost always an addiction--and one of the toughest of all habits to kick. Smoking, even an occasional cigarette or cigar, increases shortness of breath and cough and results in higher cardiovascular mortality risks. Light smoking increases the risk of coronary heart disease, lung cancer and stroke. Additionally, light daily smoking is associated with a higher rate of death from heart disease in men and women. (2) Even chewing smokeless tobacco has been associated with oral cancer, with coronary vasoconstriction and may affect vascular disease. (3) It is safe to say that any level of tobacco use is dangerous.
Smoking is a dangerous behavior that can lead to a variety of health problems. One condition known as Chronic Obstructive Pulmonary Disease (COPD) is mainly due to inhaled tobacco exposure that causes chronic inflammation resulting in poor reverse airflow (flow of air out) in the lungs, which eventually expand causing the classic “barrel chestâ€. (4) Only minutes after lighting up a cigarette or cigar, there is an increase in blood pressure, pulse rate and the ability to concentrate. However, the nicotine in tobacco enters and leaves the system very quickly, leaving people with unpleasant withdrawal symptoms after only a few hours without tobacco. (5)
Smoking poses many lesser known dangers as well. It can weaken the bones (osteoporosis) and contribute to the development of gum disease, hearing loss, and vision loss. (6-10) It can impair fertility and sexual potency and cause premature wrinkling of the skin and graying of the hair. (11-14) Smoking seems to benefit postoperative nausea and vomiting, but it slows recovery and wound healing, and increases complications after surgery. (15-16) People do not even have to smoke to be harmed. According to the American Lung Association, second-hand smoke kills more than 50,000 Americans a year. (17)
The use of smokeless tobacco products such as chewing tobacco has increased over the last two decades. About 5 million people use these products, including about 750,000 teenagers. Smokeless tobacco products can cause oral cancers, gum disease, and cardiovascular disease. (5)
The good news is that it is never too late to reap the benefits of quitting. The positive reactions become apparent almost immediately. Within 20 minutes of your last cigarette, blood pressure drops. After a day or two, the chances of having a heart attack start to go down, and food begins to taste and smell better. And within 72 hours, circulation improves and the lungs start to heal.
However, sticking with a smoking cessation program early on is critical. Almost everyone who "cheats" in the first few days resumes smoking. But keep off cigarettes, and after two weeks breathing will become noticeably easier. After a few months, coughing stops, sinuses clear, and overall energy levels increase. A year down the road, the risk of a heart attack is half what it was after the last cigarette was stamped out. Keep at it, and countless health risks from this deadly addiction will become a thing of the past. (18)
Key Symptoms
Smoking and Using Smokeless Tobacco
-
Bad Breath
-
Hoarseness
-
Impotence
-
Premature graying, balding, or wrinkling of skin
-
Persistent cough
-
Recurring bouts of bronchitis or pneumonia
-
Sore throat
-
Yellowed teeth
Withdrawal Symptoms
What Causes Tobacco Dependence?
An addiction to tobacco is really an addiction to one of its chief components, nicotine. This powerful drug races straight to the brain when inhaled, boosting levels of a brain chemical called dopamine. The increase in dopamine produces a soothing high, an instant "reward" that relieves anxiety, helps in focusing, and contributes to the cycle of addiction. Indeed, some experts feel that nicotine is as addictive as opiates such as heroin. (19)
Nicotine is one of the most potent stimulants of dopamine: it regulates arousal, concentration, stress reactions, and vigilance, making tobacco users more alert. It also inhibits monoamine oxidase, an enzyme that breaks down dopamine. Additionally, nicotine affects learning and memory, and alters the function of other neurotransmitters associated with psychiatric disorders including dopamine, norepinephrine, and serotonin.
Nicotine also combines with acetylcholine receptors that are widespread throughout the body and affect everything from cardiovascular to psychological processes. Nicotine binds to receptors in the brain and stimulates them to increase cerebral metabolism. Chronic nicotine use results in desensitization and inactivation of the acetylcholine receptors and subsequently causes upregulation, or an increase in the number of receptors, which also plays a role in tolerance and dependence. When the unoccupied receptor sites recover after nicotine abstinence, such as after a night of sleep, cravings and withdrawal symptoms set in. This is why the first ingestion of nicotine in the morning is often the most satisfying.
When someone tries to stop smoking, nicotine levels drop, causing nervousness and unease as levels of dopamine and other brain chemicals also fall. Smokers may actually feel like they are going through a period of grieving and become depressed. Irritability may strain relationships with friends and family during the withdrawal period, further undermining the drive to quit. Physical symptoms of withdrawal, including headaches, sweating, and digestive upset, further attest to the addictive power of nicotine.
There are other forces at work as well. Smoking is a shared social ritual that, in itself, has a calming effect on many people. It also serves as a gratifying oral substitute, and ad campaigns and movies give it a veneer of glamour and sophistication that draw in countless teenagers. Additionally, it is very common for ex-smokers to put on a few extra pounds in the months after quitting. Sadly, fear of gaining weight keeps many a smoker from trying to quit.
Research indicates there may be a genetic reason for tobacco dependence. In humans, the CYP2A6 enzyme is responsible for inactivating nicotine and activating tobacco-related pre-carcinogens. Variations in this enzyme may protect individuals from becoming nicotine-dependent smokers. Advances in molecular biology and completion of the draft of the human genome may provide more insight into nicotine dependence. (19)
Certain groups are more vulnerable to tobacco dependence. Tobacco use typically begins in childhood or adolescence with 80% of smokers beginning by age 18. Risk factors for this group include peer pressure, parental influence, behavioral problems in school, rebelliousness, and genetics. Studies in the developing brains of animals indicate nicotine can cause permanent changes that increase the risk of addiction in this young age group. Tobacco use is also high in persons with mental illness or other substance abuse problems. Risk factors may include a genetic predisposition and the capacity of nicotine to alleviate some psychiatric symptoms.
The smoking behavior of women is more strongly influenced by conditioning cues and negative withdrawal effects while the behavior of men is more likely influenced by pharmacologic cues such as enhancement of mood and mental function. Women also metabolize nicotine faster than men, which may contribute to their higher risk for dependence and difficulty in quitting. In fact, anyone who metabolizes nicotine quickly will smoke more cigarettes daily than someone who metabolizes nicotine slowly. (20)
Conventional Treatments
Quitting smoking "cold turkey," without any outside help, seldom works. Fortunately, effective medications and other treatments are readily available. It's never easy, but it's well worth the effort. The key is to find an approach that works for the individual. The first and most important aspects of quitting are the desire and decision to quit.
The cornerstone of medical treatment consists of nicotine replacements--such as nicotine chewing gums and skin patches--and the antidepressant drug Zyban (which goes by the technical name bupropion). The nicotine products provide a small dose of the nicotine that smokers crave, without the harmful tar and other cancer-causing toxins found in cigarette smoke. Nicotine itself appears to be safe, at least in the short term, and using it in a gum or patch is far preferable to continuing to smoke. Like nicotine, the drug Zyban also reduces the urge to smoke. Combining a nicotine product with Zyban boosts the chance of success even further.
In addition to medications, getting outside support is often key. The importance of having a doctor or behavioral expert to assist in kicking the habit cannot be underestimated. (5)
Medications
Two types of medications have become widely available in recent years to aid smoking cessation: nicotine replacements, and the antidepressant drug Zyban (bupropion). Nicotine patches and gums, once available only by prescription, are now sold over-the-counter in pharmacies, although it's a good idea to check with a doctor first before using them.
Using one of these treatment approaches more than doubles the chances of successfully quitting. Doing both simultaneously may be even more effective. They have the added benefit of helping to keep weight off, at least while they're being taken. Side effects are generally mild and may include digestive upset, headaches, dry mouth, or trouble sleeping. (People who are prone to seizures, however, may have to stay away from Zyban.)
Nicotine Replacements: Using skin patches, chewing gums, lozenges, nasal sprays, or inhalers containing small doses of nicotine are safe and effective ways to ease the symptoms of tobacco withdrawal. Familiar brands include Nicotrol and Nicoderm CQ patches, Nicorette gum, and the Commit nicotine lozenge. Which type to try is a matter of personal preference, although they certainly can be combined to boost the chances for success even further. Chewing the peppery-tasting gum, for example, helps satisfy oral urges, while wearing the patch is a convenient all-day preventive. These products fight cravings right away. As the urge to smoke fades over the course of several weeks, the dose is gradually tapered. Most people stop using them altogether after several months. It is essential not to cheat when using nicotine products. Not only is cheating likely to profoundly undermine future attempts at quitting, it can also lead to the toxic buildup of nicotine in the body. (19)
Zyban: The mood-elevating drug Zyban (buproprion) was discovered to be an effective smoking-cessation aid almost by accident, when doctors began noticing that many of their patients who were taking the drug to fight depression (called Wellbutrin when used as an antidepressant) happened to quit smoking. Studies confirmed its anti-smoking benefits. Zyban seems to balance levels of various brain chemicals, including dopamine--the very substance that gives rise to nicotine addiction. It also affects norepinephrine and other compounds in the brain. Tablets are typically taken twice a day. (19)
Other Medications: Doctors enlist other medications in the battle to quit smoking as well. Nortriptyline (Pamelor, Aventyl), an older type of antidepressant known as a tricyclic, is beneficial for some, although not approved by the FDA for this use. The high blood pressure drug clonidine (Catapres) also seems to sometimes help calm individuals and reduce anxiety. Varenicline (Chantix) may have some benefit because it blocks the pleasant effects of nicotine and helps reduce withdrawal symptoms. NicVAX is a vaccine being studied for its benefit. It works by stimulating the immune system to make antibodies for nicotine. (19) Researchers are also finding success with naltrexone (ReVia), a potent drug used to wean addicts off of heroin and alcohol. In one small study, naltrexone combined with buproprion was given to overweight or obese patients for smoking cessation. At the end of the study, the drug combination along with behavioral counseling decreased nicotine use, reduced withdrawal symptoms, and did not cause weight gain. (21) Further study of this drug for smoking cessation is needed, however.
Tests and Procedures
Doctors can diagnose, evaluate, and treat tobacco dependence during the time it takes for a routine office visit. They may ask carefully chosen questions about the individual's smoking behavior or use a standard guideline such as the CAGE questionnaire, the four C's test, or the Fagerstrom Test for Nicotine Dependence. CAGE was originally used to determine alcohol dependency and has been modified for use in determining smoking dependency. The acronym comes from the four questions it asks, which are:
1. Have you ever felt a need to Cut down or control your smoking, but had difficulty doing so?
2. Do you ever get Annoyed or angry with people who criticize your smoking or tell you that you ought to quit smoking?
3. Have you ever felt Guilty about your smoking or about something you did while smoking?
4. Do you ever smoke within half an hour of waking up (Eye-opener)?
Two "yes" responses constitute a positive screening test.
The Four C's test is taken from the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV). The four categories beginning with the letter “C†are:
1. Compulsion
-
Do you ever smoke more than you intend?
-
Have you ever neglected a responsibility because you were smoking, or so you could smoke?
2. Control
3. Cutting down (and withdrawal symptoms)
-
Have you ever tried to stop smoking? How many times? For how long?
-
Have you ever had any of the following symptoms when you went for awhile without a cigarette: agitation, difficulty concentrating, irritability, mood swings? If so, did the symptom go away after you smoked a cigarette?
4. Consequences
-
How long have you known that smoking was hurting your body?
-
If you continue to smoke, how long do you expect to live?
-
If you were able to quit smoking today and never start again, how long do you think you might live?
The Fagerstrom test assesses the intensity of the individual's tobacco dependence to help doctors determine the appropriate medication for nicotine withdrawal. Nicotine dependence increases as the score on the test increases as follows:
1. How soon after you wake up do you smoke your first cigarette?
-
Within 5 minutes (3 points)
-
5 to 30 minutes (2 points)
-
31 to 60 minutes (1 point)
-
After 60 minutes (0 points)
2. Do you find it difficult not to smoke in places where you shouldn't, such as in church or school, in a movie, at the library, on a bus, in court, or in a hospital?
-
Yes (1 point)
-
No (0 points)
3. Which cigarette would you most hate to give up; which cigarette do you treasure the most?
4. How many cigarettes do you smoke each day?
-
10 or fewer (0 points)
-
11 to 20 (1 point)
-
21 to 30 (2 points)
-
31 or more (3 points)
5. Do you smoke more during the first few hours after waking up than during the rest of the day?
-
Yes (1 point)
-
No (0 points)
6. Do you still smoke if you are so sick that you are in bed most of the day, or if you have a cold or the flu and have trouble breathing?
-
Yes (1 point)
-
No (0 points)
Scoring: 7 to 10 points = highly dependent; 4 to 6 points = moderately dependent; less than 4 points = minimally dependent. (22)
Treatment and Prevention
The best prevention strategy is to resist the temptation to start smoking in the first place. But since this is not an option for the millions of smokers who are already hooked, the best step to take is to face the problem, become educated, and enlist the help of healing therapies and caring professionals. Non-smokers should avoid exposure to second-hand smoke as much as possible.
Alternative practitioners have helped many to stop smoking with a combination of nutritional supplements and complementary therapies. A caring attitude also goes a long way in helping the long-term smoker let this potentially deadly habit go.
Ultimately, though, it is up to the smoker. Individuals should choose an option that's right for them. Alternative therapies are often effective when used as a complement to conventional treatments, and the two can often be safely combined. Alternative therapies may even help those who become "hooked" on nicotine gums and patches.
How Supplements Can Help
Kicking the habit is never easy, but there are several dietary supplements that may help calm the nerves and curb the cravings during this trying period. All may be used in conjunction with other aids, such as nicotine gums and patches. Anyone who is taking antidepressant medication, however, should use these supplements only under a doctor's supervision.