Nicotine: Treatment and rehabilitation
Last modified: Saturday, 20. June 2009 - 1:17 pm
Nicotine and tobacco dependence is best treated as a chronic condition with remission and relapse. Up to 80% of tobacco users say they would like to quit. About one third of smokers try to quit each year, 90% of these without treatment, but only 2.5-5% are successful. Of those who try to quit without treatment, more than 90% fail, with most relapsing within a week. Most people experience relapses and require repeated attempts before achieving long-term abstinence. However, effective treatments do exist, and eventually 50% of smokers succeed in permanently quitting.
Attempts to quit tobacco use should focus on small steps toward future abstinence. Cigarette smokers who try to change to other forms of tobacco, such as pipes or cigars, are still at significant risk of disease. All forms of tobacco use entail serious adverse health effects and continued nicotine dependence. Turning to low-yield or smaller cigarettes, or smoking only part of a cigarette rarely works due to compensatory smoking.
A comprehensive treatment approach ideally has two parts: handling symptoms of withdrawal, and changing habits and social settings associated with tobacco use. The various forms of treatment include drug therapy, behavioral therapies, and general support. Drug treatment of nicotine addiction, combined with behavioral support, will enable 20-25% of users to remain abstinent one year following treatment. Several effective over-the-counter (OTC) and prescription drugs are available. Some medications involve significant cost, especially if a prescription is required, but are less expensive than the cost of continuing tobacco use.
Nicotine replacement therapy
The greatest danger of nicotine dependency is related mostly to the tobacco rather than nicotine itself. Nicotine replacement therapy (NRT) is far safer than tobacco use. Although the ultimate goal is to stop ingestion of nicotine, temporary nicotine replacement therapy is useful in dealing with withdrawal symptoms. Each type of NRT helps to approximately double the achievement of abstinence when used properly but should be combined with behavioral therapy and support. These forms of nicotine have little abuse potential since they do not produce the pleasurable effects of tobacco products. Seriously ill people, pregnant women, and breastfeeding women should consult a physician when considering NRT. All tobacco use should be avoided during NRT to prevent nicotine toxicity.
Nicotine gum (Nicorette) was introduced in 1984 and is currently sold without prescription in two and four mg doses. The user chews the gum briefly and then “parks” it between the cheek and gum so that nicotine can be absorbed through the lining of the mouth. Normally nicotine gum is used two to three months. Optimal usage may involve 10-20 pieces per day. Heavier smokers should use the four mg dose.
Nicotine skin patches (NicoDerm CQ, Nicotrol, Habitrol, ProStep) were introduced in 1991 and 1992, and are sold OTC or by prescription. Nicotine in the patch is absorbed through the skin (transdermally) in different strengths, for 16 or 24 hours a day. The release of nicotine through the skin is continuous and thus provides steady concentrations of nicotine in the blood. The 16-hour patch is removed at night for those experiencing sleeping difficulty. Patches are easy to use and only applied once per day; but dosing is not flexible, onset of symptom relief is slow, and mild irritation can occur at the patch site. Recommended use is six weeks with either constant or decreasing strengths.
Nicotine nasal spray (Nicotrol NS) requires a prescription. Introduced in 1996, the nasal spray delivers nicotine through the lining of the nose when it is squirted into each nostril once or twice an hour. This method provides the fastest delivery of nicotine of the currently available products and reduces cravings within minutes. However, this form has a greater potential for inappropriate use. Nose and eye irritation is common, but usually stops within one week.
Nicotine inhaler (Nicotrol Inhaler) requires a prescription. Introduced in 1998 and designed to look like a cigarette, the inhaler is a plastic cylinder holding a cartridge containing nicotine. Nicotine is absorbed through the lining of the mouth when the user puffs on the inhaler. Each cartridge lasts for 80 long puffs and is designed for 20 minutes of use. A minimum of six cartridges per day is needed for three to six weeks, when usage begins to taper off. This product mimics the hand to mouth ritual of smoking and delivers nicotine faster than the patch, but frequent use during the day is required, and mouth or throat irritation may occur.
In 1996 the FDA approved the antidepressant buproprion (Zyban) for the treatment of nicotine dependence. This sustained-release pill blocks nicotine’s pleasurable effects and helps to maintain abstinence whether the user has depression or not. The length of suggested use is for seven to 12 weeks, including one to two weeks before quitting tobacco. Buproprion doubles the quit rate and has been demonstrated to be safe when used jointly with NRT.
Clonidine (Catapres), a high blood pressure medication, can be prescribed orally or as a patch for nicotine addiction and doubles the quit rate. It appears to reduce craving for tobacco but does not consistently reduce other withdrawal symptoms. The antidepressant nor-triptylene (Pamelor) triples the quit rate. However, both have greater side effects than those previously listed, and are considered second-line therapies.
Other medications that have been studied for nicotine addiction but were found to yield poor or variable results include naltrexone, naloxone, lobeline, mecamylamine, and buspirone. Hypnosis and herbal remedies have been reported to be of potential use but are not scientifically proven. A review of nine studies of acupuncture therapy for smoking cessation shows it to increase the quit rate a modest 1.5 times.
Education, counseling, and behavioral strategies
Knowledge of the seriousness of adverse health effects due to tobacco use is helpful in motivating a user to quit, as well as maintaining abstinence. Physicians who advise their patients to quit smoking can produce cessation rates of 5-10%. Thus, education plays a critical role in tobacco cessation for all ages. A variety of self-help materials (books, tapes, pamphlets, newsletters, software, and Internet sites) are available to inform and aid in quitting tobacco use.
Having a strong motivation to quit tobacco use is usually not sufficient motivation to quit. Other key factors to successful cessation include avoiding smokers and smoking environments and receiving support from family and friends. Even then, most users will require some further assistance beyond self-help materials to successfully quit.
Individual and group counseling by trained therapists is beneficial to those trying to quit tobacco. Over the past decade, this approach has spread from primarily clinic-based, formal smoking-cessation programs to numerous community and public health settings. Two of the most widely available offerings are the American Cancer Society Fresh Start program and the American Lung Association Freedom From Smoking program. These group programs consist of multiple sessions using behavior modification techniques. The goals of behavioral methods are to reduce the reinforcing value of smoking, discover high-risk relapse situations, create an aversion to smoking, develop self-monitoring of smoking behavior, learn coping strategies, and establish alternative rewards. Coping skills are essential for both short-and long-term prevention of relapse. A form of aversive conditioning, called rapid smoking, leads to good quit rates but dangerously high blood nicotine levels.
Groups with problems quitting
Women and African Americans have greater difficulty quitting tobacco use. NRT does not seem to reduce craving as effectively for women as it does for men. Women seem to be less sensitive to nicotine than men, but more sensitive to external stimuli — the sight, smell, and touch involved in smoking. Women have greater concerns about weight gain, restrictions on medication during pregnancy, and influences of the menstrual cycle on mood. Cessation programs should be tailored for women to rely less on NRT and more on behavioral support.
African Americans are more likely than whites to try to quit smoking, but less likely to succeed. This group apparently metabolizes nicotine differently from other racial and ethnic groups. Nicotine uptake is almost 30% higher in African American smokers than white smokers, and elimination from the body is slower than with other groups. Higher nicotine blood levels over a longer period result in stronger nicotine dependence and more difficulty quitting.
Health benefits of smoking cessation
Immediate benefits of smoking cessation include a return to normal blood pressure and pulse rate. Levels of CO and oxygen in the blood return to normal within eight hours. Within 24 hours the chance of heart attack decreases, and within 48 hours nerve endings start to re-grow and the ability to taste and smell increases. In two to three weeks lung capacity has increased, and there is improved breathing and fewer respiratory ailments. In the next one to nine months, there is a decreased incidence of coughing, sinus infection, shortness of breath, and an increase in overall energy. Cilia re-grow in the airways, which increases the body’s ability to handle mucus, clean the lungs, and reduce the chance of infection. There is reduced constriction of blood vessels in already diseased heart patients.
Heavy smokers and long-time smokers are at the greatest risk of disease, so they also have the most to gain from quitting. The decreased risk of disease varies with each disease state depending on how long the smoker has abstained. The risk of death from cardiovascular disease among former smokers approximates that of nonsmokers once the smoker has been tobacco-free for 15 years. The risk of death from lung cancer or COPD is essentially unchanged for the first five years following cessation but then declines steadily from five to 20 years. However, even beyond 20 years cessation, the risk of death due to lung cancer or COPD remains elevated above that of non-smokers. Quitting smoking substantially decreases the risk of esophageal, mouth, voice box, pancreatic, bladder, and cervical cancers. Smokers who quit before age 50 cut their risk of dying in the next 15 years in half.
Cost effectiveness of treatment
Treating nicotine and tobacco dependence can prevent a variety of costly chronic diseases, including heart disease, cancer, and chronic lung disease. It is estimated that smoking cessation efforts are more cost effective than other commonly provided preventive services such as screening for breast, colon, and cervical cancer, treatment of mildly elevated blood pressure, and treatment of high cholesterol.