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Cigarette Smoking, Nicotine Dependence, and Treatment

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Cigarette Smoking, Nicotine Dependence, and Treatment 578 I || Addiction Medicinel and the Primary Care Phlysician Cigarette Smoking, Nicotine Dependence, and Treatment KAREN LEA SEES, DO, San Francisco Since the 1988 Surgeon General's report on nicotine addiction, more attention is being given to nicotine dependence as a substantial contributing factorin cigarette smokers' inability to quit. Manynew medica- tions are being investigated for treating nicotine withdrawal and for assisting in long-term smoking abstinence. Medications alone probably will not be helpful; they should be used as adjuncts in compre- hensive smoking abstinence programs that address not only the physical dependence on nicotine but also the psychological dependence on cigarette smoking. (Sees KL: Cigarette smoking, nicotine dependence, and treatment, In Addiction Medicine [Special Issue]. West J Med 1990 May; 152:578-584) Physicians have long been frustrated in attempts to DSM-III-R Diagnostic Criteria for Psychoactive Substance help patients stop smoking, and, until recently, they Dependence have had few tools other than advice. Cigarette smoking and now ac- * Substance often taken in larger amounts or over a other forms of tobacco consumption, however, are the person intended. knowledged as causing nicotine dependence, and with that longer period than recognition comes the acceptance oftreating tobacco use not * Persistent desire or one or more unsuccessful efforts to merely as a bad habit, or nasty vice, but as the disease of cut down or control substance use. Most cigarette smokers nicotine addiction. The recognition that using tobacco prod- have tried unsuccessfully to quit in the past, and it is esti- ucts causes nicotine addiction helps remove the long- mated that more than 90% of current smokers would like to accepted idea that it takes only will power to stop smoking quit smoking.5 and thereby brings all treatment modalities normally used in * A great deal oftime spent in activities necessary to get treating other chemical dependencies into the treatment the substance, taking the substance, or recovering from its arena for nicotine addiction. In 1990 physicians have many effects. Smokers spend considerable amounts of time and more treatment options to offer patients who continue to effort each day involved with cigarettes: making sure ciga- smoke. rettes are available, making sure they never run out, going out ofthe way to buy them, cleaning up after smoking, and actual Nicotine Addiction time spent smoking, especially with chain smoking. In addi- The diagnosis of tobacco dependence was first added to tion, each year cigarette smokers spend a substantial amount the Diagnostic and Statistical Manual of Mental Disorders oftime recovering from smoking-related or smoking-exacer- by the American Psychiatric Association in the 1980 third bated illnesses. edition (DSM-III)1; the diagnosis was changed to nicotine * Frequent intoxication or withdrawal symptoms when dependence in the revised third edition (DSM-III-R) pub- expected tofulfill major role obligations at work, school, or lished in 1987.2 In the years since this diagnosis was first home or when substance use is physically hazardous. Smok- introduced as a chemical dependence, not much had hap- ing is the leading cause of fire deaths in the United States,6 pened until recently to emphasize the need for treatment. and smoking in bed is one of the leading causes of domestic This is finally starting to change.3 fires. Certainly this constitutes "when substance use is phys- Since former Surgeon General C. Everett Koop's 1988 ically hazardous." report, "The Health Consequences of Smoking-Nicotine * Important social, occupational, or recreational activi- Addiction,"'4 more attention is being focused on the addictive ties given up or reducedbecause ofsubstance use. Fewer and aspects of cigarette smoking and the use of other tobacco fewer persons, social gathering places, workplaces, and products. medical care facilities tolerate smoking. Smokers, therefore, If the DSM-III-R criteria for psychoactive substance use frequently limit their social activities because of where they disorders are considered, it is difficult to argue that cigarette can and cannot smoke and may choose to not work in smoke- smoking does not cause addiction. All nine of these diagnos- free workplaces. tic criteria apply almost universally to cigarette smokers. In * Continued substance use despite knowledge ofhaving addition, according to the DSM-III-R, only three of the nine a persistent or recurrent social, psychological, or physical criteria need be met to make the diagnosis of psychoactive problem that is caused or exacerbated by the use ofthe sub- substance dependence. stance. All of the US Surgeon General's reports since 1964 From the Department of Psychiatry, University of Califomia, San Francisco, School of Medicine, and the Substance Abuse Inpatient Unit, Veterans Administration Medical Center, San Francisco. Reprint requests to Karen Lea Sees, DO, Assistant Chief, Substance Abuse Inpatient Unit, 116-M, VA Medical Center, 4150 Clement St, San Francisco, CA 94121. THE WESTERN JOURNAL OF MEDICINE - MAY 1990 - 152 o 5 579 have adjudged cigarette smoking the most important cause of preventable death in the United States,9 the death rate in preventable morbidity and premature mortality. Most ciga- smokers being 30% to 80% higher than that in nonsmokers. 0 rette smokers have experienced some smoking-related health More than 350,000 deaths occurring annually in the United problem, be it as simple as a prolongation ofa viral syndrome States can be directly attributed to cigarette smoking4; in or as critical as a life-threatening illness. contrast, the annual deaths from other drugs of abuse are as * Marked tolerance: need for markedly increased follows: alcohol, 125,000; alcohol plus another drug, 4,000; amounts ofthe substance in order to achieve intoxication or heroin, 4,000; cocaine, 2,000; and marijuana, 75. Another desired effect, or markedly diminished effect with continued way of looking at these statistics is on a relative mortality use of the same amount. Many smokers, when they first base to user base. With illicit drug use, approximately 7,000 smoked, became sick and intoxicated after the first few puffs die from a user base of 5 million; with alcohol there are from the cigarette-with exposure to small amounts of nico- approximately 150,000 deaths from a user base of 100 mil- tine. After only a few weeks of smoking, smokers can toler- lion; cigarette smoking accounts for approximately 350,000 ate large doses of nicotine that would have been profoundly to 390,000 deaths from a user base of 50 million.'1 Cigarette toxic on first exposure.7 Changes in behavior, heart rate, smoking kills more than 1,000 people in the United States electroencephalograms, and psychoactive tolerance develop each day. quickly.4 In the United States, estimates are that 25% of deaths * Characteristic withdrawal symptoms. Some or all of from fire, 30% to 40% of deaths from coronary heart dis- the following symptoms are frequently encountered during ease, 80% to 85% of deaths from lung cancer, and 80% to nicotine withdrawal: difficulty concentrating, increased ap- 90% of deaths from chronic obstructive lung disease are petite or hunger, tobacco craving, gastrointestinal distur- directly related to cigarette smoking.6 In addition to lung bances, sleep disturbances, stress intolerance, restlessness, cancer, the relationship between cigarette smoking and other nervousness, drowsiness, fatigue, depression, irritability, forms ofcancer is clearly established, including cancer ofthe impatience, anxiety, headache, and tension.4 Many of the mouth, larynx, pharynx, esophagus, urinary bladder, pan- symptoms of cognitive impairment during nicotine with- creas, kidney, and possibly stomach and cervix. Cigarette drawal peak at 24 to 48 hours of abstinence. Some aspects of smoking also increases the risk of peripheral vascular dis- cognitive functioning remain substantially altered even after ease, spontaneous pneumothorax, peptic ulcers, periodontal ten days, however, and it is unclear how long it takes for these disease, chronic stomatitis, and chronic laryngitis. An in- to return to normal readings.8 The time course for many creased incidence of respiratory tract and ear infections, es- nicotine withdrawal symptoms has not been studied. pecially in children of parents who smoke, and an exacerba- * Substance often taken to relieve or avoid withdrawal tion of symptoms of asthma and hypertension are also well symptoms. Many smokers who return to smoking after a documented.6"l0'12 Studies linking medical-complications to cessation attempt attribute their relapse to some or several cigarette smoke are impressive not only for the active smoker withdrawal symptoms. but also for the passive smoker.'3 Several additional alarming consequences exist for Former Surgeon General Koop's 1988 report summarized women smokers. Women who smoke and use oral contracep- criteria for drug addiction.4 Addiction involves drug-rein- tives are at dramatically increased risk for heart attacks, forced behavior with patterns ofdrug use that are stereotypic, strokes, and thromboembolic events. This is particularly im- highly controlled, or compulsive, and that continue despite portant because oral contraception continues to be supported harmful effects from the drug. Drugs that produce addiction as a rational means of birth control. Women who smoke frequently have psychoactive effects that are pleasant or eu- during pregnancy not only
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