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Nicotine, in all its forms, is the most widely abused drug in the U.S. It is hard to overstate the addictive power of nicotine. Large, long term studies reveal that 27% of people who had ever tried smoking went on to develop Tobacco Use Disorder. Furthermore, almost 80% of smokers are daily smokers, and these people are most likely to meet criteria for Tobacco Use Disorder.
Because tobacco use is legal and tolerance develops rapidly, overdose or intoxication, as well as legal consequences, are very uncommon. Rather, Tobacco Use Disorder leads people to self-sequester. They avoid the ever-growing number of places where tobacco is prohibited, especially if they are chain smokers. The number of cigarettes or packs smoked daily and lag time from waking up to the day’s first cigarette are the most powerful indicators of severity.
Despite how common tobacco use is, there is no healthy amount. Even light smoking poses measurable health risks. Tobacco use is the number one preventable cause of death in the U.S., and its health consequences take 480,000 lives annually. Tobacco negatively affects almost every system of the body. It increases the risk of several types of cancer – esophagus, throat, mouth, bladder, pancreas, kidney, cervix, and most of all lung, increasing that risk 25 times. Smoking is the source of 1 in 3 cancer deaths.
Smoking raises the risks of heart disease and stroke 2-to-4 times, significantly aggravates asthma, and causes Chronic Obstructive Pulmonary Disease (which encompasses emphysema and chronic bronchitis). It worsens diabetes, damages the eyes, impairs erectile function, increases respiratory infections, causes gum disease, stains teeth, and wrinkles skin. Aside from these direct effects, secondhand smoke contributes to thousands of heart disease and lung cancer deaths every year in non smokers.
Causes and Risk Factors
Over 21% of U.S. adults are current tobacco users. Almost 90% of current smokers begin as adolescents, with 1 million people under 18 starting smoking every year. Starting earlier is associated with increased severity of tobacco use. In the past month, 25.3% of high schoolers and 7.4% of middle schoolers reporting using tobacco products (with e-cigarettes being the most popular in both groups).
Friends who smoke and drink
Adolescents with a peer group of at least half smokers are twice as likely to take up smoking. Smoking in adolescents also frequently co-occurs with drinking problems, with 75% of adolescents treated for Alcohol Use Disorder being daily smokers.
Like with other substance use disorders, genetics account for roughly 50% of the variation in developing Tobacco Use Disorder. The genes related to dopamine and disordered reward pathways in the brain are common across different substances, including tobacco. Genetic variants for nicotine metabolism and nicotine receptors increase the risk for Tobacco Use Disorder by 27% in people who have tried smoking at least once. They also cause faster evolution from occasional to daily use, and people with these genes are 43% more likely to ultimately smoke over 20 cigarettes per day. These same genes make people more likely to use smoking as a crutch in stressful situations and make them more likely to relapse after trying to quit.
Smoking and mental illness
People with psychiatric disorders smoke over 44% of all cigarettes sold a year in the U.S. Having any psychiatric disorder roughly doubles the probability of smoking and significantly reduces the probability of quitting. The rates of daily smoking is 31% to 55% in anxiety disorders, 30% in depressive disorders, and 70-85% in Schizophrenia. Schizophrenia patients are especially heavy smokers. Half of people with schizophrenia smoke more than 25 cigarettes daily and take more puffs per cigarette than the average smoker.
Diagnosing Tobacco Disorder
How much do you smoke?
No doctor’s visit is complete without a tobacco smoking assessment. Light smokers use fewer than 10 cigarettes daily, heavy smokers consume more than a pack a day, and average users are in between.
Types of nicotine
By far the most common form of nicotine is cigarettes. However, it also comes in the form of chewable tobacco, cigars, kreteks (clove-flavored cigarettes), and loose tobacco (smoked in pipes, hand-rolled cigarettes, or water pipes). E-cigarettes, also known as vaporizers, use heat to aerosolize nicotine-containing liquid, which is then inhaled. E-cigarettes have only recently come under FDA control, and, though the vapor does not have the same toxic chemicals as smoke does (such as tar), its health effects are as yet unknown.
Diagnosis requires that patients experience at least two of the following symptoms over the course of one year.
- Smoke increasing amounts or smoke for longer than originally intended
- Want or try to cut down but can’t
- Spend inordinate amounts of time finding, using, and recovering from using tobacco
- Have a strong drive to continue smoking
- Have problems in major life domains, such as education, work, and home life because of smoking
- Continue to smoke even in the face of social and relationship problems
- Sacrifice hobbies, jobs, and relationships to smoke
- Risk their physical well-being to continue to smoke
- Continue to use tobacco in the face of direct physical and mental health consequences
- Develop tolerance to tobacco, needing increased amounts to achieve the same ‘high’
- Experience a characteristic withdrawal (irritability, anxiety, increased appetite, restlessness, low mood, difficulty sleeping, distractibility), often smoking more to dull the symptoms.
Increasing numbers of symptoms determines the severity of the disorder. Four or five symptoms qualify as a moderate case; it’s a severe case if there’s six symptoms or more. Patients are in early remission if they have had none of those criteria for at least three months and not more than one year. Late remission extends beyond one year.
Treating Tobacco Use Disorder
Therapy and support programs
Most smokers receive a few minutes of brief counseling (most likely Motivational Interviewing) every time they meet with a doctor who inquires about their smoking. These are designed to evaluate patients’ motivation to quit and gently move them toward that goal. Hospitals and other healthcare workplaces often offer group support programs to their employees or to the public. Nicotine Anonymous is an adaptation of the 12-step formula that has been used for decades in Alcoholics Anonymous. It offers free access to in-person meetings as well as online and phone meetings.
Nicotine replacement therapy
Though not a stand-alone treatment, nicotine replacement therapy (NRT) increases chances of abstinence by 60% (compared to placebo) by quelling unpleasant withdrawal symptoms. Nicotine replacement is available as a patch, a nasal spray, gum, lozenges, orally dissolving tablets, and inhalers. The patch is much more long acting (up to 24 hours) than the other forms, whose short onset times make them useful tools in treating sudden cravings. The patch is best used to mitigate withdrawal and doses are tapered over several weeks. Long and short acting types can be combined to form a baseline and cover cravings.
Zyban (bupropion) is an antidepressant that acts similarly to nicotine by raising levels of the brain neurotransmitters norepinephrine and dopamine. Patients start taking it a week before stopping smoking, and it helps mitigate withdrawal. Chantix (varenicline) blocks the effects of nicotine on the brain and reduces withdrawal. Compared to placebo, at 6 months, Zyban alone increases the chance of abstinence by 62%. Chantix alone boosts that to 124%. Nortriptyline, an antidepressant, and clonidine, an antihypertensive, are second-line therapies that offer hope to people who have not improved with other treatments. These medications can be combined as needed with NRT.
Managing Tobacco Use Disorder
The hotlines are open
The national quit line, 1-800-QUIT-NOW, and the National Cancer Institute (NCI) quit line, 1-877-44U-QUIT (available in English and Spanish) offer free access to counselors. They can help you make a quitting strategy and provide information about available resources. The national quit line redirects to each state’s quit line, and several states offer limited supplies of free nicotine replacement therapy.
Make a quitting plan
The National Cancer Institute strongly recommends making a quit-day plan. Identify benefits to quitting (saving money, better health), know your usual smoking triggers (like drinking, driving, or socializing) and plan to avoid or change them. Let your friends and family know you are quitting and enlist their help. Have strategies ready to deal with urges, such as exercising or low calorie snacks. If you want to use medications or NRT, see your doctor ahead of your quit date so that you have all your resources ready when the day comes. NRT is most effective when started on the quit date.
For the tech savvy smoker, Smokefree, a creation of the NCI, offers two smart phone apps. QuitGuide and quitSTART help you track cravings, triggers, and slips and chronicle your progress as a newly minted ex-smoker. Smokefree also has SmokefreeTXT, a text messaging service that will send you periodic supportive messages and suggestions leading up to and following your quit date.
Not too late
It is never too late to quit smoking. Your body, especially your heart, blood vessels, and lungs, immediately begins to recover from smoking’s ill effects after you quit. Even if you already have cancer related to smoking, there is still reason to quit because nicotine promotes tumor growth. Remember that you have plenty of allies in the battle against cigarettes. Almost 69% of all current smokers want to quit, and 43% try to quit in a given year.