Nicotine | Nicotine Addiction | Nicotine Withdrawal



Quit Smoking With Acupuncture

Nicotine | Nicotine Addiction | Nicotine Withdrawal

Although many people smoke because they believe cigarettes calm their nerves, smoking releases epinephrine, a hormone which creates physiological stress in the smoker, rather than relaxation.

Once inhaled, the nicotine produces a warm feeling of well being: the nicotine "rush". This is almost immediate, but is very short lived. Most users develop tolerance for nicotine and need greater amounts to produce the desired effect. Smokers become physically and psychologically dependent.

Risks associated with smoking cigarettes include diminished or extinguished sense of smell and taste, frequent colds, smoker's cough, gastric ulcers, chronic bronchitis, increase in heart rate and blood pressure, premature and more abundant face wrinkles, emphysema, heart disease, stroke, cancer of the mouth, larynx, pharynx, oesophagus, lungs, pancreas, cervix, uterus, and bladder.

Smoking is particularly dangerous for teens because their bodies are still developing and changing and the 4,000 chemicals including 200 known poisons (source, The U.S.A. Dept of Health Detox and Withdrawal Protocol Manual) in cigarette smoke can adversely affect this process.

Cigarettes are highly addictive As most smokers will testify, the habit of smoking creeps up on you without you realizing it and giving up smoking takes considerable will power. Withdrawal symptom include: changes in body temperature, heart rate, digestion, muscle tone, and appetite. Psychological symptoms include: irritability, anxiety, sleep disturbances, nervousness, headaches, fatigue, nausea, and cravings for tobacco that can last days, weeks, months, years, or an entire lifetime.

Nicotine addiction in the form of cigarette smoking accounts for more deaths each year than AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires combined. Between 1995 and 1999 in the U.S.A, there were 490,000 smoking-related premature deaths annually, and smoking cost the country at least $157 billion yearly in health-related economic losses. This amounts to approximately $7.18 per pack of cigarettes (Fellows et al. 2002), a truly staggering figure. Smokers are at increased risk for several medical problems, including myocardial infarction, coronary artery disease, hypertension, stroke, peripheral vascular disease, chronic obstructive lung disease, chronic bronchitis, and several types of cancer (lung, stomach, head and neck, and bladder). Other problems associated with nicotine addiction include gastro-oesophageal reflux disease and gastric ulcerations, cataracts, and premature wrinkling of the skin.

There also appears to be an anti-oestrogen effect (suppression of an important hormone) that may lead to early development of osteoporosis in women (Okuyemi et al. 2000). In 1988, the U.S. Surgeon General’s Report concluded that nicotine is the principal addictive agent in tobacco. Nicotine binds to nicotinic acetylcholine receptors in the brain and has the direct ability to stimulate the release of dopamine in the nucleus accumbens area. This increase in dopamine is similar to what occurs when patients use stimulants and is felt to be an essential element in the reward process of addiction (Glover and Glover 2001). As many as 90 percent of patients entering treatment for substance abuse are current nicotine users (Perine and Schare 1999).

There has long been controversy in the field of addiction medicine as to how best to handle the problem of nicotine dependence in patients seeking treatment for other types of substance abuse. Traditionally, it has been argued that patients would find that trying to stop smoking while also contending with other (more pressing) addiction problems would be too difficult and distracting in early abstinence. However, others argue that nicotine dependence is a lethal disease and that physicians have the responsibility to intervene in this addiction with the same aggressiveness they show toward other addictive substances. This pro-intervention position has received increasing attention from clinicians, inasmuch as it is now understood that alcohol consumption is associated with increased nicotine usage (Henningfield et al. 1984).

Gulliver and colleagues (1995) have demonstrated that the urge to smoke is correlated with the urge to drink, and others have shown that continued nicotine dependence may be a relapse trigger for resumption of drinking (Stuyt 1997). The concern that smoking cessation may precipitate relapse to other substances of abuse has not been supported in the literature (Hughes 1995). Treatment programs that have attempted to treat nicotine dependence in conjunction with other drugs of addiction have met with limited success (Bobo and Davis 1993; Burling et al. 1991; Hurt et al. 1994) and have generated increased interest in smoking cessation as a part of a patient’s overall substance abuse treatment (Sees and Clark 1993).

One study reported that forcing unmotivated patients (or patients who did not consider smoking a problem) to quit was counter therapeutic (Trudeau et al. 1995). Moreover, it has traditionally been accepted that nicotine detoxification concurrent with detoxification from other substances makes the undertaking more difficult. Several factors are involved including the following:

  • Patient ambivalence and/or lack of interest in smoking cessation.
  • Physician ambivalence about the importance of smoking cessation early in treatment.
  • Treatment staff’s use of nicotine.
  • Treatment staff’s ambivalence about the importance of nicotine cessation early in treatment.
  • Easy availability of cigarettes from peers, family, visitors, staff, and at 12-Step meetings.
  • Lack of sufficient training and expertise on the part of physicians and staff in managing nicotine withdrawal.
  • Treatment staff’s resistance to patient smoking cessation because withdrawal symptoms include irritability, anxiety, and depression, all of which can make patients more difficult to manage.

Withdrawal Symptoms Associated With Nicotine The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) (APA 2000) notes that typically, a person in nicotine withdrawal will have four or more of the signs presented in Figure 4-9, though some clinicians believe that three or more is sufficient to make the diagnosis of nicotine withdrawal. Furthermore, it should be noted that symptoms vary in duration and intensity, with decreased heart rate and light headedness resolving in 48 hours, while increased appetite may remain present for weeks to months (Glover and Glover 2001).

Smokers who have severe craving during withdrawal are less likely to be successful in their attempt at quitting (Hughes and Hatsukami 1992). Depression during withdrawal also has been linked to relapse to smoking (Covey et al. 1993). Assessing Severity Since 1978, the standard instrument used to measure physical dependence on nicotine has been the eight-item Fagerstrom Tolerance Questionnaire (FTQ) (Fagerstrom 1978). A later revision known as the Fagerstrom Test for Nicotine Dependence (FTND) (see Figure 4-10) has been reduced to six questions (Giovino et al. 1995; Heatherton et al. 1991). Scores greater than seven are consistent with nicotine dependence. While both the FTQ and FTND are very useful for estimating a patient’s physical dependence on nicotine, there is still a need to assess more accurately the degree to which smoking behaviour plays a role in maintaining addiction.

Nicotine Withdrawal

A. Daily use of nicotine for at least several weeks.

B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by 4 or more of the following signs:

  • Dysphoric or depressed mood
  • Insomnia
  • Irritability, frustration, or anger
  • Anxiety
  • Difficulty concentrating
  • Restlessness
  • Decreased heart rate
  • Increased appetite or weight gain

To better understand a patient’s level of nicotine dependence, providers can assess biochemical markers including nicotine, cotinine, and carbon monoxide. Nicotine and its metabolite cotinine can be measured in urine, blood, or saliva. Cotinine continues to be present in bodily fluids for up to 7 days after cessation. Clinicians should use caution when interpreting the meaning of nicotine and cotinine assays, as they are not specific to tobacco-derived nicotine and may indicate the patient’s compliance with nicotine replacement therapy rather than smoking. Carbon monoxide is easily measured in expired breath and can show whether the patient has been smoking within a few hours prior to the test. It can be used to monitor smoking cessation for patients receiving nicotine replacement therapy and patients often find it a helpful motivator in their attempt to maintain abstinence (Benowitz 1983).

Medical Complications of Withdrawal From Nicotine

There are no major medical complications precipitated by nicotine withdrawal itself. However, patients frequently experience uncomfortable withdrawal symptoms starting within a few hours of cessation. In addition to the symptoms previously noted, patients may complain of increased coughing, a desire for sweets, and difficulty concentrating (Hughes and Hatsukami 1992). Clinicians should be aware that withdrawal symptoms can masquerade as other psychiatric conditions, especially anxiety and depression

Smoking cessation also may affect the metabolism of other drugs primarily through the Cytochrome P 450 (CYP450) system. This system is one of many hepatic liver enzyme systems that is responsible for the metabolic breakdown of various drugs into inactive compound products. Different drugs and compounds have varying affinities for the CYP450 system. The higher the affinity, the faster the breakdown of the drug or compound in the body. Some compounds can slow the metabolism or breakdown of other drugs with a lower affinity, leading to a buildup of that drug or compound in the body. During detoxification from nicotine, some medications will have their metabolism altered, including theophylline, caffeine, tacrine, imipramine, haloperidol, pentazocine, propranolol, flecainide, and estradiol; in general, these effects are short-lived and seldom drastic.

Nicotine also reduces beta blockers’ ability to lower blood pressure and heart rate and decreases the amount of sedation from benzodiazepines as well as decreases the amount of pain relief provided by some opioids, most likely because of its stimulant effects (Zevin and Benowitz 1999).

Management of Withdrawal Without Medications

About one third of current smokers attempt to quit smoking each year and more than 90 percent of these try to do so without any formal nicotine cessation treatment. Most smokers will make several attempts on their own to quit and ultimately, only about 50 percent are successful over a lifetime (U.S. DHHS 2000b). While some smokers are able to quit on their own, others may require intervention in the form of behavioural treatment and/or pharmacotherapy. There are insufficient data available to determine who will benefit most from a particular type of treatment. Some patients may prefer to stop smoking without the use of medication.

Acupuncture has been known to have excellent results in helping smokers quit. The effect of acupuncture on the body includes: balanced emotions, lowered stress, suppression of cravings, improved sleep and improved liver, kidney and lung function. Although acupuncture my be extremely beneficial in helping smokers withdraw and detoxify from nicotine, is cannot replace sheer will power in stopping anyone from starting again.

Non pharmacological interventions for the management of withdrawal from nicotine can be separated into two basic categories: self-help interventions and behavioural interventions.

Self-help interventions

Many tobacco users prefer to attempt to quit without any assistance from professionals. A number of self-help products are available that can assist them in their cessation attempts. These include a wide array of pamphlets, manuals, video and audiotapes (e.g., from the American Lung Association and the National Cancer Institute), 12-Step self-help support groups, and telephone help lines. The U.S. Public Health Service’s Guideline, which analyzed all types of self-help interventions together, found that the self-help approach to cessation yielded results only slightly better than no intervention at all. To date, self-help interventions alone have not been very successful at helping people achieve abstinence from tobacco. The Guideline suggests, however, that self-help can be a useful adjunct to other forms of treatment (Fiore et al. 2000a).

Behavioural interventions

The U.S. Public Health Service study noted that when physicians took as little as 3 minutes to advise their patients to stop smoking, long-term quit rates were modestly improved from 7.9 percent to 10.2 percent (Fiore et al.2000a). Westmaas and colleagues note that “simple, clear advice from a physician can be considered an easy, cost-effective intervention that not only moves smokers closer to the decision to quit, but also may motivate some smokers to make an actual attempt”

(Westmaas et al. 2000, p. 58). The greater the amount of time in face-to-face interventions, the higher the success rate for patients, but interventions as short as 3 minutes have been found to be effective (Fiore et al. 2000a). A counselling session of longer than 10 minutes produced a cessation rate of 20.1 percent compared to a rate of 10.9 percent for no treatment. The guideline also indicated that if cessation information is given by multiple types of providers (e.g., physician, psychologist, dentist, nurse, and pharmacist) it can have a dramatic effect on cessation rates, increasing the rate to 23 percent compared to 10.8 percent for patients who had no provider contact. A review of behavioural intervention studies concluded that both supportive care by a clinician and the ability of patients to develop problem solving and coping skills improved success rates for smoking cessation (Anderson and Wetter 1997). Other components such as cigarette fading (gradually decreasing the number of cigarettes smoked over a period of time), establishing a quit date, enhanced environmental support, improved diet and increased exercise, relaxation training, and contingency contracting were not associated with improved outcome. Aversive conditioning, such as rapid smoking techniques, is effective but not routinely recommended (Fiore et al. 2000a).

Nicotine Replacement Therapy (NRT)

Nicotine polacrilex gum was approved by the FDA in 1984. In the 1990s other NRTs received FDA approval, including the nicotine transdermal patch, the nicotine nasal spray, and the nicotine inhaler. Nicotine gum and nicotine transdermal patch are now available over the counter. After the acute withdrawal period, patients are then weaned off the medication until they become nicotine free. All NRTs are effective, with 1-year quit rates between 11 and 34 percent (Okuyemi et al. 2000). There has been some concern about the addictive potential of NRTs, and it has been reported that 5 to 20 percent of patients using nicotine polacrilex gum continue to use it for more than 1 year (Hughes 1989). There was also initial concern that the nicotine nasal spray, with its rapid onset of action and high plasma concentrations, might become a drug of abuse.

This has not been reported in the literature, and it could be speculated that this is because of the nasal spray’s relatively uncomfortable side effects that cause many patients to dislike the product (Schuh et al. 1997). In general, withdrawal symptoms from NRTs are mild compared to those that occur in smoking cessation, and continued use of these products may be the result of patients’ fear of returning to active smoking (APA 1996). For those patients who continue to use NRTs, providers should balance the patient’s continued dependence on nicotine with the considerable health benefit of decreasing active tobacco usage. It is clear that constituents of tobacco other than nicotine are responsible for causing cancer. No ill effects have been attributed to long-term use of nicotine replacement therapy (Benowitz and Gourlay 1997).

Bupropion SR

Bupropion SR (Sustained Release) was initially manufactured under the name Wellbutrin as a treatment for major depressive disorder. In 1997, the FDA approved bupropion SR for smoking cessation, and it has been marketed under the name Zyban. Bupropion is a novel antidepressant that is involved primarily with dopamine but also affects adrenergic mechanisms in the central nervous system. Its exact mechanism of action is unknown, but it is not a nicotine substitute or replacement like the NRTs. The recommended dose is 150mg daily for 3 days and then 150mg twice daily for 7 to 12 weeks. Typically patients set their quit date 1 to 2 weeks from the time they start the medication in order to get the drug to therapeutic levels. This is an ideal time for the patient to focus on making behavioural changes and enlisting social support to augment his quit attempt. Bupropion SR has proven useful in smoking cessation with a 12-month abstinence rate of 35.5 percent compared to a placebo at 15.6 percent and the nicotine patch at 16.4 percent (Westmaas et al. 2000). The most commonly reported side effects include dry mouth and insomnia. Bupropion SR should not be used in patients with a history of seizures, heavy alcohol use, head trauma, or with anorexia or bulimia. Other nonnicotine pharmacotherapy Covey and colleagues examined nonnicotine pharmaceutical products that have been evaluated in controlled trials of smoking cessation (Covey et al. 2000). These drugs include the following:

  • The alpha-2 agonist antihypertensive, clonidine
  • The tricyclic antidepressant, nortriptyline
  • The monoamine oxidase inhibitor (MAOI) antidepressant, moclobemide
  • The serotonin 5-HT1A agonist anxiolytic, buspirone
  • The antihypertensive CNS nicotinic receptor blocker, mecamylamine
  • Oral dextrose tablets

Although none of these agents has been approved by the FDA for smoking cessation, clonidine, nortriptyline, and moclobemide have all been found to be effective treatments (Covey et al. 2000). Clonidine may be a helpful adjunct to nicotine replacement during acute nicotine withdrawal. Doses of 0.05mg to 0.1mg three times a day can be tried as tolerated (sedation and low blood pressure are concerns), and the medication needs to be tapered when discontinued to avoid rebound hypertension. The Public Health Service’s Treating Tobacco Use and Dependence: Clinical Practice Guideline (Fiore et al. 2000a) has classified nortriptyline and clonidine as second-line treatments. Clonidine is an antihypertensive and may be appropriate for patients addicted to certain types of drugs but not appropriate for others. The antidepressant selective serotonin reuptake inhibitor (SSRI) fluoxetine has been tested in a number of multisite trials (Cook et al. 2004; Hitsman et al. 1999; Niaura et al. 2002) and found to have a small benefit at best, although for patients who experience mild depressive states it may be a worthwhile adjunctive treatment. The usefulness of other SSRIs for smoking cessation is unknown, but studies have generally been unfavorable.

Combination drug therapy - Combining NRT products

NRT products typically provide less than half the nicotine plasma levels that cigarette users achieve through smoking (Benowitz et al. 1997; Dale et al. 1995; Gupta et al. 1995; Lawson et al. 1998). To attempt to increase nicotine levels, several clinical trials have evaluated the effectiveness of combining available products. The simultaneous use of nicotine gum and the nicotine patch has been evaluated in several studies. Short-term gains in cessation were seen with the combination compared to either medication alone, but no long-term benefits in abstinence were demonstrated (Anderson and Wetter 1997). Blondal and colleagues (1999) compared the combination of nicotine nasal spray and the nicotine patch to the patch alone and found that at 3 months 37 percent of the patients were smoke free (compared to 25 percent for the patch alone). An open-label study of the combined use of nicotine inhaler and the nicotine patch found a 12-week cessation rate of 30 percent and good tolerability for the combination (Westman et al. 2000). So-called “combination NRT” involves combining different types of nicotine replacement products, such as the patch and gum, on the premise that doing so will boost nicotine blood levels.

Further rationale for this practice is that a “passive” nicotine delivery system (i.e., patch) produces relatively steady levels of nicotine in the body that prevent the user from going below a threshold minimum while “active” NRTs (i.e., gum, inhaler, spray, sublingual tablet, etc.) permit the user to respond to situational cravings with ad libitum dosing on an acute basis. Several clinical trials have evaluated the effectiveness of combining available NRT products (for a review see Silagy et al. 2000). After reviewing available data, the Guideline panel (Fiore et al.2000a) felt that there was moderately strong evidence to conclude that “Combining the nicotine patch with a self-administered form of nicotine replacement therapy (either the nicotine gum or nicotine nasal spray) is more efficacious than a single form of nicotine replacement, and patients should be encouraged to use such combined treatments if they are unable to quit using a single type of firstline pharmacotherapy” (Fiore et al. 2000a, p.77).

NRT using high-dose nicotine patch therapy

The highest dose of nicotine available by patch is 22mg. Several studies have evaluated whether higher doses of nicotine (up to 44mg) improve abstinence rates. The effect of this strategy has been small and the routine use of higher dose patches is not recommended (Hughes et al. 1999; Killen et al. 1999).

Combining nicotine patch and bupropion SR

In a double-blind, placebo-controlled study, the combination of bupropion SR and the nicotine transdermal patch showed higher abstinence rates at 12 months (35.5 percent) compared to bupropion SR alone (30.3 percent), nicotine patch alone (16.4 percent), or placebo patch and pill group (15.6 percent) (Jorenby et al. 1999). This combination was well tolerated. Clinicians who use this combination should first start the patient on bupropion SR 150mg for 3 days and then increase the dosage to 150mg twice daily for 1 to 2 weeks prior to the day of smoking cessation. On the “quit day,” nicotine patch therapy should be initiated and the combination treatment continued for 3 to 6 months (Okuyemi et al. 2000).

Patient care and comfort

Most smokers attempt cessation on an outpatient basis and without any assistance from professionals. However, if a patient decides that she or he wants help with smoking cessation, it is important for the clinician to present a supportive and non-judgmental attitude and develop a therapeutic alliance with the patient. It must be emphasized that nicotine dependence is a chronic relapsing disorder and that patients often make several attempts at quitting before succeeding. Most smokers who want treatment will seek help from their primary care physician. The physician has the responsibility of providing pharmaceutical treatment, education about common problems associated with cessation, and emotional support to patients attempting to quit. Discussing nicotine withdrawal symptoms can often help allay patient concerns. Fear of weight gain is a barrier for many who want to quit smoking (French et al. 1995).

This is an especially important issue for women and may deter their attempts to stop smoking (Gritz et al. 1989). Though the health gains of stopping smoking clearly outweigh the health risks of weight gain, this argument does little to assuage patients’ fears. Dieting during smoking cessation is not recommended in general and has been shown to increase the likelihood of smoking relapse (Hall et al. 1992). Physicians should, however, recommend both exercise and proper nutrition for patients attempting to stop smoking.

Patients should be informed that alcohol use also is considered a risk factor for relapse to smoking by most clinicians (Shiffman 1982), and patients who can abstain from drinking during the withdrawal period should do so. Patients generally will find a smoke-free environment helpful during quit attempts. If the patient lives in a household where others smoke, household members and friends can help by not smoking in front of the patient and limiting the number of smoking cues in their residence.

Patients with more severe nicotine dependence may benefit from enrollment in a specialized smoking cessation program. They might also benefit from more intensive medical management using several drugs (NRT + anticraving), medication for longer periods of time, closer follow-up, and longer enrolment in treatment. For the most severely dependent smokers, there are a limited number of residential facilities that treat nicotine dependence on an inpatient basis. Providers of detoxification services should be familiar with the programs available in their communities in order to make referrals.

Acupuncture for quitting

The are a large amount of people in South Africa and world-wide who have used acupuncture to assist them in quitting. The are various types of protocols used to do this by practitioners. In many cases, from practitioner to practitioner, different protocols are used to treat the same problem. This is mainly because patients display different “patterns“ or symptoms and so treatments may vary between patients with the same disorder. Different protocols are also used by acupuncturists purely because the practitioner may prefer a certain protocol or because he or she has experienced better results with one particular way.

More and more people are confessing incredible results but as with any other method of quitting, it does have its failures. Any method employed in quitting smoking must be seen as assistance in accomplishing sobriety from smoking. As with all the other methods, acupuncture will help you quit, but only you can stop yourself from starting again. It is not a “cure” for smokers, but it does work and its costly.

Clinics, Drug Rehabs etc.

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