Nicotine Dependence (305.1)

DSM-IV-TR criteria

Specifiers:

• With Physiological Dependence
• Without Physiological Dependence
• Early Full Remission
• Early Partial Remission
• Sustained Full Remission
• Sustained Partial Remission

• Nicotine dependence is both a psychological and physical reliance on the drug nicotine that can be found in a variety of tobacco products. Throughout the world, tobacco is one of the most widely used legal substances. Nicotine research indicates that the use of even a small amount can lead to dependency. Even though nicotine has been linked to cancer-related deaths and a myriad of health related issues, an individual who is dependent upon nicotine has difficulty in cessation due to continued compulsions to use the substance. Nicotine, like many of the other substances that are grouped into substance use disorders, can produce a euphoric feeling that alters the mood of the user. These effects can be seen in the individual brain patterns of the user. Regular and normal functioning of a person with nicotine dependency often relies on this substance to complete everyday activities. At the same time, quitting tobacco use causes withdrawal symptoms, including but not limited to irritability and anxiety.

Associated features

Nicotine comes from the tobacco plant which is dried and used in cigarettes, chewing tobacco, cigars, and pipes. The use of nicotine can generate a feeling of increased alertness or relaxation in the individual. This may also depend on how much a person smokes, the strength of inhalation, and how often the person uses nicotine. The psychological aspects connected with nicotine can be triggered by normal everyday events such as waking up, getting into a car, or finishing a meal. Psychological triggers can occur when an individual is faced with particular situations or issues that make them angry, stressed, anxious, or bored. The physical reliance is related to the functioning of the brain and how nicotine affects it. Certain receptors in the brain cells come to rely on nicotine molecules to enable the normal functioning of an individual on a daily basis.

Child vs. adult presentation

• Children and adolescents often exhibit nicotine dependence symptoms even if they have never smoked. These symptoms are often a result of living with parents or guardians that smoke in the home or in the car or if they smoked while in the room. There is also an increased risk in children for developing asthma, ear infections, and colds. Infants of smokers are often more prone to sudden infant death syndrome ([[www.sids.org/|SIDS]]). Adolescents are often affected by peers that smoke in their presence; it happens all the time because not all people smoke and it is a social gathering activity to talk and smoke. Second-hand smoke can cause withdrawal symptoms in children that can be expressed as depression, irritability, problems sleeping, increased appetite, and anxiety. Nicotine dependence in children can often be seen to impair concentration and results in poor school performance. They may also experience cravings for nicotine and increased temptation to smoke when they are around others that smoke.Children that have parents that smoke are more likely to engage in the act than those who have parents that are non-smokers. It has been estimated that around 20% of teen smokers exhibit substantial nicotine dependence. Recent research suggests that some adolescents may begin to experience a loss of control over their smoking within weeks of smoking the first cigarette. In both adults and children, using any amount of tobacco can quickly lead to nicotene dependence.
• Adults, as well as children, that are exposed to nicotine may experience both short-term and long-term effects. Short-term effects include an increase in heart rate, blood pressure, and metabolism. The “fight-or-flight” response may also be experienced as a result of increased adrenaline production that causes rapid heartbeat, increased blood pressure, and rapid, shallow breathing. It takes an average of seven seconds for the effects of nicotine to reach the brain. Research indicates that there may be a drop in skin temperature, decreased appetite, diarrhea, and saliva excretion. The physical appearance of a smoker may also be altered. Smoking can change the structure of the skin, causing premature aging and wrinkles, as well as causing yellowing of teeth, fingers, and fingernails. Long-term effects include re-occurring problems with blood pressure, coronary heart disease, emphysema, shortness of breath, reduced fertility, and abnormal sperm forms. Individuals with HIV or other immuno-deficiency diseases are more apt to contract life-threatening illnesses due to the effects of a weakened immune system that are caused by nicotine. In addition, the nicotine in tobacco can damage cell structure, causing increased cell proliferation, which may cause several types of carcinomas. Nicotine has also been known to block the release of insulin into the blood stream, leading to hyperglycemia.The blockage of insulin also increases the smoker’s risk of developing type 2 diabetes and, those who already have diabetes, are at an increased risk for complications including kidney disease. Nicotine can also cause complications in pregnancy such as miscarriage, preterm delivery, and SIDS as well as low birth-weight in newborns. Newborns with low birth-weight are more likely to die or have learning or physical problems.

Gender and cultural differences in presentation

• Many of the cultural and gender differences can be seen in the history of nicotine itself. Mayan cultures indicated use of tobacco in their stone carvings as far back as 900 A.D. The Native American cultures used tobacco ceremonially and the men of the tribe would often use it as a sign of wealth and friendship. Tobacco was brought to Europe in the 1500’s where it became popular via pipes, cigars, and snuff. Tobacco, however, was often punishable in some European and Asian cultures by mutilation and/or death. In the United States, tobacco still maintains its popularity and its respectability as a valuable cash crop.
• Historically, more men than women use nicotine, especially in the form of chewing tobacco. It is often used to fit in socially and to project a certain image while at the same time give sensory rewards and emotional relief to the individual using it. Smoking, at one time, projected the appearance of wealth and prestige in Rome and France where it was socially acceptable for women to smoke as well. In the United States, smoking has begun to take on a negative connotation. New laws forbidding the act of smoking in public places and in vehicles around children have emerged. In addition, pregnant women who smoke are looked down upon as it goes against the new social norms. In one city in Arizona, it is not only illegal to smoke in public places or in the presence of children, but it is also illegal to smoke in vehicles with the windows rolled down.
• Besides the traditional cigarettes and smokeless tobacco, there are several other types cigarettes that must be considered. Bidis are handmade cigarettes composed of tobacco hand-wrapped in a dried tendu or temburni leaf and tied with a string. Bidis comes in many flavors, including chocolate, wild cherry, and cinnamon. These types of cigarettes are relatively cheap and have a harmless appearance; however, because the the wrappers have a low combustibility the user has to smoke more. This is a problem because bidis produces more carbon monoxide and tar than conventional cigarettes. Bidis are popular in South Asian countries such as India, Sri Lanka, Bangladesh, Pakistan, Afghanistan, Cambodia, and Nepal. In these countries, poverty, low education, scheduled castes, and scheduled tribes are found to be associated with higher prevalence of tobacco use. Clove cigarettes called Kreteks contain a mixture of Indonesian tobacco and shredded clove spice wrapped in either an ironed corn husk or a slip of paper. Many smokers who use Kreteks inhale the chemicals much deeper because of their anesthetizing effects.
• Although 60-70% similar to conventional cigarettes, they produce twice as much tar, nicotine, and carbon monoxide. The active ingredient in cloves known as Eugenol is the anesthetic and it is known to contribute to the development of respiratory tract infections. These infections are due to the numbing effect the ingredient has on the back of the throat and trachea which hides the harshness of the cigarette. This numbing effect contributes greatly to an increase in nicotine dependence. This type of tobacco product is mainly used in Indonesia; however, internet sales have increased its popularity to all other parts of the world. Another type of tobacco product is known as a hookah, or its alternate name “hubble bubble”. A hookah is a long-necked water pipe in which the smoke passes through a long tube and through an urn of water that makes a bubbling noise. In India and Persia, the bulb used to hold the water is made of coconut shells although in many cases they are made of glass, porcelain, silver, or crystal embedded with gold and silver. There has been little research done to support the claim that hookah smoking delivers less harmful substances to the smoker than do conventional cigarettes; however, hookah smoke contains significant amounts of carbon monoxide and nicotine. Hookah smoking has gained popularity in not only India and Persi, but also many of the Arab countries, London, England, and Paris, France have caused a regained interest due to the proliferation of Hookah cafes.

• Smokeless tobacco is used as a broad term that refers to more than thirty types of products. These products are used around the world but are most common in northern Africa, Southeast Asia, and the Mediterranean region. These products are consumed without burning the product and can are used orally or nasally. Most of these products are placed in the mouth, cheek, or lip and are sucked (dipped) or chewed. Fine tobacco powder may be inhaled and absorbed through the nasal passages. Southeast Asia is a major producer and exporter of smokeless tobacco. In countries such as India and Bangladesh, smokeless tobacco is often associated with areas of low education and low income. Despite the harmful effects, smokeless tobacoo may be used to treat toothaches, headaches, and stomachaches. Harmful effects include an increase in the risk of oral cancers, oral submucous fibrosis, hypertension, and reproductive health problems.

• In some cultures, such as First Nations People, tobacco is used as a medicine in ceremonial practices. For the purposes of honoring and including cultural traditions and healing practices in relation to new laws being written regarding the use of tobacco, the difference between tobacco use and dependence, ceremonial tobacco, and recreational use must be clearly defined.
• The 1998 Surgeon General’s report, Tobacco Use Among U.S. Racial/Ethnic Minority Groups, addressed diverse tobacco-control needs of the four primary U.S. racial/ethnic minority populations: non-Hispanic blacks, American Indians/Alaska Natives (AI/ANs), Asians/Pacific Islanders, and Hispanics. The report results indicated that the prevalence of cigarette smoking among adults age 18 and older ranged from 40.4% for AI/ANs to 12.3% for the Chinese population. The prevalence amoung youths aged 12-17 years ranged from 27.9% for AI/ANs to 5.2% for the Japanese population.

Epidemiology

It has been found that 55%-90% of those that are diagnosed with mental disorders also use nicotine on a regular basis. In the general population, 30% of individuals were found to be users of tobacco that were absent mental illness. It has also been indicated that 25% of the population of the United States has been diagnosed with nicotine dependence. Of those that use tobacco on a regular basis, 45% can stop using nicotine eventually; however, it has been estimated that only 5% will be successful without help. People who have depression, schizophrenia, and other forms of mental illness are more likely to be smokers simply because it may be a form of self-medication for these disorders. People who abuse alcohol and illicit drugs are also more likely to be smokers. Diagnosis of substance dependence, including nicotine dependence as well as others, is based upon the ‘Four Cs’ Test. This test is conducted by psychiatrists, psychotherapists, social workers, and addiction counselors. This test focuses on four areas: compulsion, control, cutting down, and consequences. Compulsion is the intensity with which the desire to use a chemical, such as tobacco, overwhelms the patient’s thoughts, feelings, and judgements. Control focuses on the degree to which patients can (or cannot) control their chemical use once they have started using. Cutting down refers to the analysis of the withdrawal symptoms experienced by an individual. This aspect focuses on the effects of reducing chemical intake. The final factor deals with the consequences associated with the chemical dependence. This area deals with the denial or acceptance of the damage caused by the chemical. The ‘Four Cs’ Test is the DSM-IV based diagnosis of nicotine dependence.

Etiology

Nicotine dependence is caused by the reliance of receptors in the brain that deal with mood-altering and physical effects on the body. The nicotine binds to nicotine receptors that then stimulate such neurotransmitters including dopamine. These neurotransmitters become dependent on the chemical in order to regulate normal body functioning. Nicotene is responsible for a host of health problems; however, the physical and mood-altering effects in the brain are temporarily pleasing. It is these effects that spur continued use of tobacco products and this is ultimately what leads to dependence. Adolescents that smoke may be more prone to being diagnosed with nicotine dependency because their brains are not fully developed. The genes that are inherited play a role in some aspects of nicotine dependence. This is based on more than just the immediate environment (i.e. having parents that smoke). For example, the likelihood that an individual will start smoking and keep smoking may be partly inherited. Some people experiment with smoking and don’t experience the pleasure, so they never become smokers. Other people develop dependence very quickly such as the dependence seen in adolescents. Some “social smokers” can smoke just once in a while, and yet another group of smokers can stop smoking with no withdrawal symptoms. These differences can be explained by genetic factors that influence how receptors on the surface of the brain’s nerve cells respond to nicotine.

Empirically supported treatments

• Medications, which include nicotine replacement therapy, can be effective treatments for nicotine dependency. Nicotine replacement therapy includes products that include nicotine at lower doses, without the appearance of the over 3,000 chemicals that are in tobacco products. These products include nicotine patches, gums, and lozenges. Prescription products, such as nicotine nasal spray (Nicotrol NS) and nicotine inhalers are also available on the market to help combat nicotine dependence. Many medications used to help curb the cravings of nicotine dependency do not include nicotine. Certain antidepressants, such as Zyban or Wellbutrin, can help increase the levels of norepinephrine and dopamine in the brain to reduce the need for nicotine. Varenicline, which targets nicotine receptors in the brain, and high blood pressure medication such as Clonidine are examples of other non-nicotine medications that are in use to help individuals reduce and/or stop the use of nicotine. Research shows that amalgamating medications and behavioral counseling is an effective way for long-term success in being sober from tobacco. The counseling helps develop the skills needed to stay away from the substance. In addition, the development of vaccines are being investigated which will prevent nicotine users from relapse. There are no physical tests top determine the exact degree to which an individual is dependent upon nicotine. A physician may assess the degree of an individual’s dependence by asking questions or having a questionnaire completed. The more cigarettes a person smokes each day and the earlier in the day a person smokes after awakening, the more dependent the individual is.

• Most of the nicotine replacement products are available over-the-counter. The nicotine patch, which includes NicoDerm CQand Habitrol, delivers nicotine through the skin and directly into the bloodstream. A new patch is placed on the skin each day and the treatment period usually lasts for eight weeks or longer. The patch dosage may be adjusted or an additional medication may be needed in order to stop smoking if this has not occurred after two weeks. Nicotrol inhaler is a nicotine inhaler that is shaped like a cigarette. This allows the smoker to satisfy the urge as well as the physical act of smoking. This inhaler delivers nicotine vapors into the mouth where it is absorbed in the lining of the mouth directly into the bloodstream. However, the inhaler may cause side effects such as mouth and/or throat irritation and occasional coughing.
• Current funding is being used to create opportunities for development and implementation of youth tobacco-control programs. Research shows that combining medicine with behavioral counseling provides the best chance for long-term success in abstaining from alcohol. Medication is used to lessen the withdrawal symptoms in an individual that has nicotine dependence while the behavioral treatments focus on helping the individual develop the skills needed to stay away from tobacco over the long run.

Links:

• Nicotine in the brain Nicotine in the Brain
• What’s Inside a US Blended Cigarette? Inside a Cigarette
• Effects of Nicotine on the Brain. Effects of Nicotine on the Brain
• What happens when you quit smoking: Smoking Withdrawals
• Dr. Richard Hurt from the Mayo Clinic discusses possible ways to quit smoking (uploaded by CBSNewsOnline, direct link https://youtu.be/_9DurNWR-hQ)

• An individual’s personal story on quitting smoking (uploaded by livestrong)
• Methods to help smokers quit (uploaded by TheIowaClinic)