PhytoScience - Article

Smoking - Nicotine dependence

Nicotine dependence is the physical vulnerability of your body to the chemical nicotine, which is potently addicting when delivered by various tobacco products. Smoke from cigarettes, cigars and pipes contains thousands of chemicals, including nicotine. Nicotine is also found in chewing tobacco.

Nicotine produces physical and mood-altering effects in your brain that are temporarily pleasing; these effects reinforce your continued use of tobacco and nicotine dependence.

Being addicted to tobacco brings you a host of health problems related to the substances in tobacco smoke. These effects include damage to your lungs, heart and blood vessels. Smokers have significantly higher rates of heart disease, stroke and cancer.

Millions of Americans smoke, and smoking is the leading preventable cause of death in the United States. Men who don't quit smoking lose an average of 13.2 years of life, while smoking women lose even more; an average of 14.5 years.

Overcoming nicotine dependence is difficult and takes commitment, support and time. The sooner you quit smoking, the better. But even if you're a longtime smoker, stopping your nicotine dependence plus taking healthy lifestyle steps can reverse much of the damage smoking has done to your body.

Signs and symptoms

Nicotine dependence may mean you have these signs and symptoms:

You can't stop smoking. You've made one or more serious, but unsuccessful, attempts to stop.
You experience strong withdrawal symptoms when you try to stop. Your attempts at stopping have caused physical signs and symptoms of addiction, such as craving for tobacco, anxiety, irritability, restlessness, difficulty concentrating, headache, drowsiness, stomach upset, even constipation or diarrhea.
You keep smoking despite health problems. Even though you've developed problems with your lungs or your heart, you haven't stopped or can't stop.
You give up social or recreational activities in order to smoke. You may stop going to certain restaurants or stop socializing with certain family members or friends because you can't smoke in these situations.

Your degree of addiction depends in part on how much you smoke and how long you've smoked.

Causes

Tobacco smoke delivers at least 60 known cancer-causing chemicals, tiny amounts of poisons including arsenic and cyanide, and more than 4,000 other substances to your body.

Nicotine is the chemical in tobacco that keeps you smoking. It can be as addictive as cocaine. It increases the release of a brain chemical called dopamine, which makes you feel good. Getting that dopamine boost is part of the addiction process.

Tobacco dependence involves psychological as well as physical factors. You may develop strong, repetitive behaviors associated with smoking. You may smoke at certain times of the day or after a meal or in certain locations or under certain levels of stress. These behaviors and routines that you associate with smoking have to be addressed if you are to overcome your addiction to tobacco.

Risk factors

Anyone who smokes is at risk of becoming addicted to nicotine. Tobacco smoking is a behavior that often becomes established during adolescence. About 90 percent of smokers begin smoking before the age of 21, and many start before age 18.

The younger you begin smoking, the greater the chance that you'll become a heavy smoker as an adult. In 2004, 22 percent of American high schoolers said they were current smokers, as did nearly 12 percent of American middle-school-age children. While the rate of teen smoking has been declining since the 1990s, the decrease seems to have stalled in recent years. That's especially bad news because teenagers who smoke are more likely to use alcohol and other drugs.

Youngsters with two smoking parents are twice as likely to pick up the smoking habit themselves. And, children with friends who smoke are also more likely to try cigarettes. Exposure to tobacco in movies or advertisements, particularly for young people, may influence the decision to start smoking or keep smoking.

When to seek medical advice

You may have tried to stop smoking because you've experienced health problems related to smoking or because you're concerned about potential health problems. If you've tried to stop, but have discovered you can't, talk to your doctor about finding a strategy to help you stop successfully.

Complications

When you inhale tobacco smoke, you're ingesting a chemical parade that will march through most of your body's vital organs. The negative health effects throughout your body are numerous, including:

Lungs. Smoking is the cause of most cases of lung cancer. Smoking is also the primary cause of other lung problems, such as emphysema and chronic bronchitis.
Heart and circulatory system. Smoking increases your risk of dying from cardiovascular disease, including heart attack and stroke. If you smoke more than 25 cigarettes daily, your have five times the risk of heart disease compared to someone who doesn't smoke. Smoking 15 cigarettes a day doubles your heart attack risk. Even just one to four cigarettes daily increases your risk of heart disease. Smokers have a higher risk of stroke that nonsmokers do; the more you smoke, the higher your risk.
Cancer. Smoking is a major cause of cancer of the esophagus, larynx, throat (pharynx) and mouth and contributes to cancer of the bladder, pancreas, liver, kidney, cervix, stomach, colon and rectum, and some leukemias.
Appearance. The chemicals in tobacco smoke can dry and irritate your skin, as well as promote wrinkles. Smoking also yellows your teeth, fingers and fingernails.
Fertility. Smoking increases the risk of infertility and miscarriage in women and the risk of impotence and infertility in men.
Pregnancy and newborn complications. Mothers who smoke while pregnant increase the risk of low birth weight, preterm delivery and impaired lung function in their newborns.
Cold, flu and other illnesses. Smokers are more prone to illnesses, such as colds, flu or bronchitis, than nonsmokers are.
Senses. Smoking deadens your senses of taste and smell, so food isn't as appetizing as it once was.

Treatment

Breaking an addiction to nicotine can be very difficult, and many smokers have to make repeated attempts before they're successful. Quitting smoking is possible, even though it may take more than a few tries. Almost 46 million Americans have quit smoking, and so can you.

The benefits of quitting
Although it may be tough to break your nicotine addiction, the benefits are well worth the effort. If you manage to quit smoking before you're 35, you'll miss out on at least 90 percent of the health risks associated with tobacco use. If you quit before you're 50, you can halve your risk of dying in the next 15 years, compared with those who continue smoking.

But, no matter what your age, your health will benefit if you stop using tobacco. Just 20 minutes after your last cigarette, your heart rate goes down. Twelve hours later, the carbon monoxide levels in your blood return to normal. Your lung function improves and your circulation starts to get better between two weeks and three months after your last cigarette. Between one and nine months after quitting, your risk of infections drops and coughing and shortness of breath decrease. After one year, the risk of coronary artery disease drops by half. And, after five to 15 years, your stroke risk will be the same as that of a nonsmoker.

Methods of quitting are numerous
There are many ways to quit smoking, including using medications and getting some sort of counseling or support.

The approved effective medications to help you stop smoking fall into two categories; nicotine replacement therapy and non-nicotine medications. Any of these effective medications combined with behavioral changes can double your chances of quitting.

Combining medications with follow-up visits to your doctor for support and counseling is usually more successful than is trying to stop on your own. If you've tried a medication on your own but haven't been successful in quitting, talk to your doctor about it. He or she can help you move in the right direction by adjusting the dose of your medication, recommending a different medication, or using a combination of medications.

Nicotine replacement therapy
Most nicotine replacement products are available over-the-counter:

Nicotine patch (Nicoderm CQ, Nicotrol, Habitrol, others). The patch delivers nicotine through your skin and into your bloodstream. You wear a new patch each day on your upper body. The treatment period may last for eight weeks or longer. Don't be in a hurry to stop using the patch, especially if you've stopped smoking or dramatically reduced your smoking. If you haven't been able to stop smoking completely after the first week or so of treatment, ask your doctor for help in adjusting the dose of the patch or adding another medication.
Nicotine gum (Nicorette, others). This is a gum-like resin that delivers nicotine to your blood through the lining of your mouth. It's available in a 2-milligram dose for regular smokers and a 4-milligram dose for heavy smokers. The maximum number of pieces a day is 20, though you'll probably chew less. Nicotine gum is recommended for one to three months, with a maximum of six months.
Nicotine lozenge (Commit). This is a tablet that dissolves in your mouth and, like nicotine gum, delivers nicotine through the lining of your mouth. The lozenges are also available in 2- and 4-milligram doses. The recommended dose is one lozenge every couple of hours for six weeks, then gradually increasing the intervals between lozenges over the next six weeks.

These nicotine replacement products are available by prescription:

Nicotine nasal spray (Nicotrol NS). The nicotine in this product, sprayed directly into each nostril, is absorbed through your nasal membranes into veins, transported to your heart and then sent to your brain. It's a quicker delivery system than that of the gum or patch. It's usually prescribed for three-month periods, for a maximum of six months.
Nicotine inhaler (Nicotrol inhaler). This device is shaped something like a cigarette holder. You puff on it, and it gives off nicotine vapors in your mouth. You absorb the nicotine through the lining in your mouth, where it then enters your bloodstream and goes to your brain, relieving withdrawal symptoms.

Non-nicotine medication
Medications that don't contain nicotine include:

Antidepressants. The antidepressant drug bupropion increases the level of dopamine, the chemical that's also boosted by nicotine, in your brain. As with many medications, bupropion (Zyban) has side effects, including sleep disturbance and dry mouth. If you have a history of seizures or serious head trauma, such as a skull fracture, don't use this drug. Another antidepressant that may help is nortriptyline (Aventyl, Pamelor).
Varenicline (Chantix). This medication acts on the brain's nicotine receptors, decreasing withdrawal symptoms and reducing the feelings of pleasure you get from smoking. Potential side effects include headache, nausea, an altered sense of taste and strange dreams.
Nicotine vaccine. The nicotine conjugate vaccine (NicVax) is under investigation in clinical trials. This vaccine causes the immune system to develop antibodies to nicotine. These antibodies then catch nicotine as it enters the bloodstream and prevent the nicotine from reaching the brain, effectively blocking the effects of nicotine.

Counseling, support groups and smoking cessation programs
Many people need help to quit smoking. A number of telephone help lines are available for people giving up nicotine, such as the National Cancer Institute's 800-QUITNOW, or 800-784-8669, and the American Cancer Society's at 800-ACS-2345, or 800-227-2345.

Your doctor may also be able to recommend local support groups or smoking cessation programs. Additionally, some people find that a form of counseling called behavior therapy can help them come up with productive ways to change the behaviors and thoughts associated with smoking.

Prevention

The best way to prevent tobacco dependence is to not smoke in the first place. The best way to prevent your children from smoking is to not smoke yourself. If you're a parent who smokes, the younger your children are when you quit, the less likely they are to become smokers themselves. Even if you don't smoke, here are some strategies you might try as a parent:

Talk with your teenagers. Ask whether their friends smoke. The risk of your child smoking is higher if his or her friends smoke. Most teenagers smoke their first cigarette with a friend who already smokes.
Learn what your children think about smoking. Ask them to read this information so that you can discuss it together. Emphasize that research has found teens can show signs of tobacco dependence after smoking intermittently for only a few weeks.
Help your children explore personal feelings. Use nonjudgmental questions and rehearse with them how they could handle tough situations regarding peer pressure and smoking.
Encourage your teenager to enjoy maximal energy and health. Explain to your teenager that the active, vivacious lifestyles portrayed in many cigarette advertisements are actually more representative of nonsmokers. People who smoke have colds and other respiratory infections more frequently.
Note the social repercussions. Remind your teenager that smoking gives you bad breath and makes your hair and clothes smell.
Work with your schools. Become active in community stop-smoking programs.
Promote smoke-free environments. Encourage public areas and restaurants, including places where your teen may work, to offer smoke-free environments. This helps to denormalize smoking, reducing the chances your teen will start and helping smokers to stop.

Self-care

When you stop smoking, you'll likely experience signs and symptoms of nicotine withdrawal. Your body is accustomed to regular, high doses of nicotine. It sends out distress signals when those levels of nicotine aren't present. Use of medications will markedly reduce withdrawal. Even so, it's important to know how to manage withdrawal symptoms.

Withdrawal symptoms are usually the most intense during the first three days after you stop smoking. But they may continue for several weeks, although at a declining level of intensity. Although most nicotine withdrawal symptoms pass within four weeks, you may experience periodic cravings, or strong urges to smoke, even months after stopping. Triggers or cues that were associated with smoking can provoke the cravings.

Most people who try to stop smoking experience a range of withdrawal signs and symptoms. Here are some of the more common ones and things you can do to deal with them:

Physical discomfort or depression

Exercise. Even taking a brisk, 30-minute walk can help.
Talk to a support person.

Insomnia

Reduce or avoid caffeine or other stimulants.
Relax before going to bed.
Don't eat, watch television or discuss problems in bed.
Make your bedroom quiet and comfortable.
Keep a regular bedtime routine.
Write down your worries on a piece of paper and leave them in another room.

Irritability, frustration, anger

Use relaxation techniques.
Exercise regularly.
Try deep breathing.
Reduce caffeine or other stimulants.
Avoid stressful situations.

Anxiety, nervousness

Use relaxation techniques.
Exercise regularly.
Try deep breathing.
Reduce caffeine or other stimulants.
Talk to a support person.
Use distractions.

Difficulty concentrating

Adjust your schedule to a lighter workload.
Lower expectations on the amount of work you can do.
Understand the amount of energy and time it takes to stop smoking.

Restlessness, impatience

Take short exercise breaks. This not only takes you away from the situation, but helps you relieve withdrawal symptoms.
Try deep breathing.
Avoid caffeine or other stimulants.
Change focus of attention frequently.

Increased appetite

Eat healthy snacks.
Don't delay regular meals.
Drink more water.
Exercise regularly.

Cravings for tobacco, desire to smoke

Wait out the craving, which is usually less than five minutes.
Try deep breathing.
Use distractions.

Change in bowel habits, such as constipation

Maintain a diet of regular meals and drink plenty of fluids.
Use bulk-producing foods.
Limit gas-producing foods.
Limit gum chewing.

Fatigue

Exercise regularly.
Eat regular meals.
Plan more rest and take short naps.

Cough, dry throat, nasal drip, clearing throat

Drink water.
Use cough drops to relieve throat irritation.

Coping skills

Many smokers yearn to stop but find it hard because of nicotine's powerful addictive hold. You may need more than one attempt before you successfully stop.

Maybe you want to stop smoking but don't feel ready to stop right now. Many smokers experience similar feelings. Although they want to stop, most also have reasons to put off taking action. The good news is, most smokers eventually do stop. But how can you build the motivation to make the change now?

Start by addressing the mixed feelings you may have about smoking. Identify the reasons why you'd like to continue and the reasons why you'd like to stop. Make a list of your barriers and benefits to making a change. Continue to update the list as you think of more reasons.

Identify barriers
These barriers are real for you and may make you hesitant to change your smoking behavior. But by identifying barriers before you try to stop smoking, you can:

Start thinking of ways to overcome these barriers. You may even decide that some barriers aren't as big as you had originally thought. You may be able to control weight gain with just a little extra exercise.
Already start working on overcoming certain barriers. For example, if you're concerned about a lack of social support, talk to a friend who used to smoke or to a health care professional. If you're worried about the discomfort of withdrawal symptoms, consider the use of nicotine replacement or bupropion to help.
Develop strategies to build confidence to overcome barriers. For example, in situations that trigger your urge to smoke, think of alternatives.
Set smoke-free boundaries. If there's another smoker in your household, set boundaries by making your home and car smoke-free.

Identify benefits
Stopping smoking is a good change for many reasons. Identify the reasons that are important to you.

First, make a list. Think of short-term benefits (such as breathing easier, saving money, no more smoky-smelling clothes) and long-term benefits (lower risk of disease, increased chances for a longer life, no secondhand smoke affecting the health of your loved ones).
This list gives you strong reasons. Whether your list is long or short, the better you're able to identify the benefits of stopping, the stronger your reasons are to stop.
These reasons build your motivation. Remind yourself of these reasons regularly, especially when you feel your motivation to make a change is lagging.

Build self-confidence
You may have little confidence in your ability to stop smoking. You may have tried to stop many times. If so, try to change your perspective. Instead of thinking of stopping as a huge, impassable obstacle, focus on the smaller details. Identify specific situations in your day that could help or harm your attempt to stop. For example, you may feel confident that you can stay smoke-free in certain situations, such as at your work desk, but less confident about other situations, such as at a party. Take these actions to build self-confidence:

Identify your major areas of concern. This will help you problem solve and develop strategies to stop smoking.
Identify situations in which you have some confidence. You'll find that you have many situations in which you're already able to stay smoke-free.
Seek support. As you work on stopping, seek the social support you need and practice your new coping strategies. In this way, you'll increase your confidence in being able to make a move toward being smoke-free.

Are you giving yourself enough support and encouragement? Make sure to send yourself positive messages about stopping.

Develop a positive attitude by practicing positive self-talk. Start by looking in the mirror and saying, "I can stop smoking" or "I can be smoke-free."
Think of one or two phrases to use repeatedly for encouragement. Examples are: "I can make it" and "Keep it up."

Complementary and alternative medicine

While there's no solid evidence that any complementary or alternative medicine therapy is effective for smoking cessation, some people have found methods such as acupuncture or hypnosis to be helpful. Ask your doctor for a referral to a reputable practitioner, and be wary of any treatment method that promises to make quitting smoking easy.

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