Addiction Treatment Blog

A custom loathsome to the Eye, hateful to the Nose,
harmful to the Braine, dangerous to the Lungs, and in
the black, stinking fume thereof, nearest resembling the
horrible Stygian smoke of the pit that is bottomless.

King James I, ‘Counterblaste to Tobacco’, 1604.

When asked to ban smoking in France, Napoleon was candid: 'This vice brings in one hundred million francs in taxes every year. I will certainly forbid it at once - as soon as you can name a virtue that brings in as much revenue.'

History

Tobacco is the dried leaf of Nicotiana tabacum, one of a number of Nicotiana species all of which contain similar alkaloids and which can be smoked. These plants are members of the Solanaceae or potato family and are indigenous to Americas. When Colombus landed there in 1492 he observed the natives smoking rolls of dried Nicotiana leaves which were known as ‘tobacos’. The plant and related species were widely known to the North American Indians and the Aztecs. The popularity of tobacco smoking spread rapidly in the Europe of the 16th century. Sir Walter Raleigh was a famous advocate of pipe smoking in Elizabethan England, a practice that found less favour under the Stuart King, James I. Jean Nicot is reputed to have introduced tobacco to France in 1560, his name being commemorated in the genus Nicotiana and the principle alkaloid, nicotine (which was isolated in 1828).

Nicotine is found in small quantities in several other solanaceous plants (e.g. aubergine, tomatoes) but the amounts are generally too small to have pharmacologically significant effects after human ingestion. However, there are a large number of compounds in Nicotiana leaves other than nicotine, and tobacco smoke contains over 3000 chemicals.

Effects Sought

Individuals typically begin smoking tobacco when young, commonly in the early to mid teenage years. As with other abused substances, the reasons for starting are multifactorial: a combination of peer pressure, teenage rebellion, the desire to experiment etc. It is claimed that smoking alleviates anxiety and stress and promotes relaxation. There is probably an element of positive and negative reinforcement involved in this response. The positive effect results from the known general mood-elevating properties of nicotine and perhaps from relief of muscular tension. Nicotine can reach the brain within seven seconds of inhaling cigarette smoke and rapid onset\ short-lasting peaks of mild mood stimulation are believed to be important aspects of positive reinforcement. However, nicotine does not produce the intense euphoria of drugs such as cocaine. The initial effect is a mild ‘buzz’ or headiness to which the chronic smoker soon becomes largely tolerant. Negative reinforcement results from the desire to avoid nicotine withdrawal symptoms (which include anxiety). Anxiety also tends to stimulate habitual behaviour per se (e.g. biting nails, drumming fingers) and smoking is clearly an habitual pursuit.

Subjectively, nicotine has both calming properties (relaxation, decreased anxiety) and stimulant effects (arousal, increased concentration, loss of appetite).

Administration

Tobacco is smoked in cigarettes which may be purchased ready-made or rolled by the smoker using tobacco and cigarette paper. Ready-made cigarette usually have a filter which removes varying proportions of the constituents of the smoke before it enters the smoker’s lungs. Tobacco may also be smoked in pipe or as cigars. Nicotine is a liquid which normally boils at about 250°C. The end of a burning cigarette is at least 800°C and such temperatures are high enough to volatilise nicotine so that it can be inhaled. Occasionally tobacco is chewed; those who use this route tend to keep a ‘quid’ of tobacco in the side of the mouth, thus enabling buccal absorption. This allows a gentle peak plasma level of nicotine to develop. Nicotine is absorbed if swallowed but at least three-quarters of the dose is destroyed by the liver before reaching the systematic circulation. Snuff is a form of tobacco inhaled directly into the nose from the hand. It was much more popular in the 18th and 19th centuries than it is today.

Pharmacokinetics and Pharmacology

Nicotine is metabolised mainly in the liver. Although several metabolic pathways are involved, the most important is the conversion of nicotine to the inactive cotinine by the cytochrome P450. Nicotine has an average half-life around two hours. Cotinine’s longer half-life of 20 hours makes it useful marker for exposure to tobacco/

Nicotine is an agonist at the nicotinic receptors for acetylcholine. Most of its actions are confined to the central nervous system (CNS) at the doses achieved through smoking. Much larger amounts are needed to affect the nicotinic receptors on skeletal muscle. The mechanism of the psychotropic effects of nicotine is not known. The drug binds to nicotinic receptors in central ganglia of the autonomic nervous system where it can be an agonist depending upon the dose. Nicotine also triggers the release of many CBS neurotransmitters.

Adverse Effects

It was not until 350 years after King James’ pronouncement about the evils of tobacco that the true harmful effects of smoking began to be realised. In the UK, over 110,000 people per year die as a result of smoking tobacco. The majority of these deaths are from lung cancer and coronary heart disease. The table below lists some of the other diseases known to be caused by smoking. Statistics on tobacco-related illness are alarming: in 1991, for example, it was estimated that over 283,000 people in the UK were admitted to hospital for the treatment of smoking-related illness. These patients used nearly 9500 beds per day and cost the National Health Service £437 million in inpatient costs alone.

It has been estimated that 3 million deaths per year occur worldwide as a result of tobacco smoking. This is projected to increase to 10 million in 30 to 40 years’ time. In developed countries about 20 per cent of all deaths are caused by smoking. In the light of the statistics such as these, it is remarkable that the smoking of tobacco continues to be socially and politically acceptable. Unlike most other drugs of abuse, tobacco is legal substance in every country in the world.

Intriguingly, epidemiological data suggest that some diseases seem to be less common in smokers. These include cancer of the endometrium, hyperemesis gravidarium, ulcerative colitis, recurrent aphthous ulcers and Parkinson’s disease.

Besides the serious health consequences, the tobacco smoker frequently suffers from a range of other minor ailments, including decreased exercise tolerance, reduced appetite, weight loss, halitosis and an increased susceptibility to coughs and colds.

Non-smokers who are exposed to significant amount of tobacco smoke may cough, become pale and feel nauseous. Other common complaints include dizziness, feeling faint, tremor, headache and palpitations.

Mortality and Morbidity Linked to Tobacco Smoking

Cancers strongly linked to smoking

• Cancer of lung, mouth, pharynx and larynx
• Cancer of oesophagus, bladder, kidney and pancreas

Cancers less strongly linked to smoking

• Cancer of stomach, liver, cervix, nose and lip
• Adult myeloid leukaemia

Other diseases linked to smoking

• Chronic obstructive airways disease, pneumonia
• Myocardial infarction, pulmonary heart disease, aortic aneurysm, ischaemic heart disease, peripheral vascular disease, cerebrovascular accidents
• Peptic ulcer, Crohn’s disease, hernia, periodontal disease
• Osteoporosis, hip fracture
• Catarcts
• Fires are an important cause of accidental death or injury that may result from careless smoking

Treatment of Tobacco Dependence

Most smokers become dependent upon tobacco to some extent; they also exhibit tolerance. It is well-established that nicotine is the substance in tobacco that causes physical dependence. Symptoms of withdrawal begin within 24 hours and can include craving for nicotine, anxiety, irritability, emotional liability, inability to concentrate, insomnia, increased appetite drowsiness and headaches.

Various pharmacological methods have been used to help smokers stop but it is important to realise that non-pharmacological methods will boost the response to drug therapy and are also often effective in their own right. Behavioural therapy, setting a date to stop, self-help groups, health advice and group counselling are all potentially useful and are reviewed elsewhere.

Nicotine replacement

The most popular forms of nicotine replacement therapy (NRT) utilise transdermal nicotine delivery systems (e.g. Nicotinell, Niconil) or nicotine-impregnated chewing gum (Nicorette). Although both treatments can be effective, the rate of success is probably limited for three major reasons. The first is that neither treatment physically resembles a cigarette, and the ritual and social behaviour associated with the act of smoking is important in maintaining the addiction. Secondly, simply replacing ’smoked’ nicotine with ‘therapeutic’ nicotine is not an end in itself – just a different source of the dependence problem. Thirdly, neither treatment provides the almost immediate peak in brain nicotine concentrations which occurs during smoking. Patches provide a constant concentration of nicotine in the blood whereas the gum formulation can provide peaks in nicotine levels but they are slow to develop.

There are no particular reasons to believe that any one of the marketed transdermal products is more effective than another. The four main differences are in the nature/efficiency of the delivery system, the strengths available, the support materials provided by the manufacturer and the duration of nicotine release. On this latter point, one patch (Nicorette) releases nicotine for 16 hours per day allowing a nicotine-free night-time as occurs when cigarettes are smoked. This may allow an easier night’s sleep. The advantage of the 24 hour release patches (Nicotinell, Niconil,) is that they provide an early morning nicotine plasma level which may act as a greater deterrent to smoking upon waking. Despite these differences the 24-hour and 16-hour release patches seem to be equally effective.

Of the NRT products, nicotine gum has been available for the longest time and has been researched the most thoroughly. The 4 mg strength seems to be more effective than the 2 mg, especially in the heavily dependent smoker. Disadvantages of the gum include side effects: it can cause mouth ulcers, increased salivation and sore throat as a consequence of the irritant properties of nicotine. Some users find the taste unpleasant. Furthermore, the gum requires a chewing technique which is probably not easy to master.

A nicotine nasal spray should have a faster onset time and produce higher peak plasma levels of nicotine than other forms of NRT. Trials with a prototype device suggest that it is at least as effective as other forms of nicotine replacement therapy. Nicorette nasal spray is available in the UK and a nasal spray was approved by the Food and Drug Administration in April 1996 for prescription us in the USA. Initially, the spray is used when required, if the subject feels the desire for a cigarette, but the frequency of use is gradually reduced towards the end of the three-month maximum treatment period. The formulation has not been directly compared to nicotine gum or transdermal patches but in one placebo-controlled trial abstinence rates at one year were 26 per cent for nicotine-treated patients and 10 per cent for placebo respectively. This compares well to abstinence rates seen with patches (20.5 per cent) and gum (18.3 per cent) based on a meta-analysis of available trials. However, more trials of the nasal spray are needed to confirm these findings. One disadvantage of the nasal spray is that the irritant nature of nicotine can produce sneezing, runny nose, watery eyes and sore throat. Because the spray provides more immediate psychoactive effects than any other form of nicotine replacement therapy it is theoretically more open to abuse.

Several over-the-counter ‘anti-smoking- products containe nicotine (e.g. Stoppers, Resolution) but these have not been formally assessed in controlled studies.

Nicotine substitutes

Preparations containing the nicotine-related alkoloid lobeline have been used in the past to aid nicotine withdrawal, but they are no longer available in the UK. Nicobrevin contains another alkaloid, quinine, together with a variety of other ingredients. These products have also not been adequately tested in clinical trials. The ineffectiveness of lobeline has led the Food and Drug Administration in the USA to order the withdrawal of such products from the market.

Deterrents

Silver acetate reacts with the constituents of cigarette smoke to produce an unpleasant taste in the mouth. Products utilising this effect include Tabmint chewing gum and Giv-Up mouthwash. Again, these products do not appear to have been subjected to formal clinical assessment. The Food and Drug Administration has also recently removed them from sale in the USA.

Other drugs

Clonidine, buspirone and antidepressants have met with limited success in assisting tobacco abstinence in small-scale trials.

National and international perspectives

At national level, the Government has been loath to be too active in the fight against smoking. There is a significant national and international tobacco lobby, supported of course by millions of dependent individuals. More cynically, tobacco and tobacco-related products generate vast sums for the Treasury each year. When asked to ban smoking in France, Napoleon was candid: ‘This vice brings in one hundred million francs in taxes every year. I will certainly forbid it at once – as soon as you can name a virtue that brings in as much revenue.‘ Despite the attitude of Western governments, the prevalence of smoking in the Western world has been slowly declining. For example in the UK, 93 billion cigarettes were sold in 1992/3 compared to 98 billion in 1985. In contrast, it is unpleasant to learn that the number of tobacco smokers continues to increase rapidly in less developed continents such as Asia, Africa and South America, where in many countries there are insufficient resources to meet even basic healthcare needs, let alone the consequences of widespread population self-poisoning. It has been estimated that if current trends continue, 70 per cent of the projected 10 million worldwide deaths from tobacco in 2025 will occur in developing countries.

Are You Addicted to Smoking or have Nicotine Addiction?

If you are addicted to any of the substances mentioned above, or finding hard to cope with the withdrawal effects, don’t forget that there is help available. The Causeway Retreat is Europe’s finest addiction treatment care centre, offering professionals, individuals and couples the latest treatment methods on addiction related problems. If you would like to learn more about The Causeway Retreat, please give us a call on 0207 100 7260 or simply fill the form below to get in touch with us. Any information you supply to The Causeway Retreat remains 100% confidential and will never be shared with anyone.