Tobacco Addiction

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Dr. Annette Shonder
Psychologist, Sociologist,
American Board
Certified Clinical Counselor
Certified Clinical Hypnotherapist
Phone: 00971-4-4574240

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Dr Gregor Kowal
Senior Consultant
in Psychiatry and Psychotherapy,
German Board Certified,
Medical Director,
Clinic for Health and Medical Care
Phone: 00971-4-4574240

Most smokers use tobacco products regularly because they are addicted to nicotine, crave it, and need ongoing consumption to avoid withdrawal symptoms. Even only a few hours of smoking will trigger neurological adaptations and most smokers soon find a level of smoking that they maintain over time. Unlike other drugs, such as amphetamines or benzodiazepines, tolerance of nicotine does not continue to build.  This means that most smokers habitually come to smoke a certain number of cigarettes a day without escalating consumption to ever increasing amounts.   A smoker will come to depend on smoking to feel psychologically normal and physically well and relaxed.  If nicotine consumption is suddenly ceased withdrawal symptoms that include negative physiological and psychological effects will occur.  A study indicated that 80% of the smokers who were questioned reported that they want to quit, and another 10% said they would like to cut down (Inaba & Cohen, 2007).  Yet, the addiction to smoking makes quitting difficult.

Neurophysiological approach:

One of the most obvious characteristics of addiction is that a substance is compulsively used and abused despite negative health consequences. Research has shown that the addictive nature of nicotine is in part attributable to activation of the reward pathway.  This pathway, also called the mesolimbic pathway, regulates feelings of pleasure.  Nicotine increases levels of the neurotransmitter in the reward circuit.  This is thought to underlie the pleasurable sensations that many smokers experience (Is Nicotine, n.d.).
Additionally, nicotine stimulates the central nervous system.  The neurotransmitters play a role in this process.  They affect heart rate, blood pressure, memory, learning, reflexes, aggression, sleep, sexual activity, and mental acuity. This stimulating effect can contribute to a smoker feeling more alert and mentally sharp. There are other chemicals implicated in the addiction to smoking.  It is believed that some ingredient in tobacco causes a marked decrease in the levels of a particular enzymes (MAO). This enzyme is responsible for the breakdown of some neurotransmitters.    Hence, when there is less MAO there will be higher output of the neurotransmitters which increases pleasurable feelings and the desire of repeated use (Is Nicotine, n.d.).

Acetaldehyde is another chemical found in tobacco.  In animal studies it was found that that this chemical reinforces the properties of nicotine and might contribute to tobacco addiction.  This area of research also found that younger animals were more sensitive to the enhancing effects of acetaldehyde leading them to conclude that the brains of adolescents may be more susceptible to tobacco addiction (Is Nicotine, n.d.).

Psychological approach:

Behavioral, psychodynamic and environmental factors associated with smoking must also be addressed as relevant aspects of nicotine addiction. A substance can become addictive if it is rewarding causing a pleasure or enjoyment. In this context addiction is a learned behavior. According to the principles of operant conditioning, rewarded behaviors will increase. The danger of drugs (among them tobacco) relies on their ability to initiate an immediate reward. This also explains why the addictive substance tends to replace other, more healthy sources of rewards. These other types of rewards are frequently delayed (such as the return of good health) whilst the drugs create a short cut to the reward system. As addiction progresses, the availability of natural, healthy pleasures, which require more effort, decline. This creates a powerful addictive vicious cycle.For the smokers, the feel, smell, and sight and the ritual of obtaining, handling, lighting the cigarette – usually during a break or in a relaxed atmosphere – are all associated with the pleasurable effects contributing to the above mentioned operant conditioning. There is strong evidence that those non-pharmacological factors (opening the box, lighting the cigarette, inhaling and tasting the smoke in the throat) play an equally important role in creating the habit as nicotine. Nicotine substitution by patch, tablets or chewing gum (even the intravenous application of nicotine) has only little impact on cravings. Different studies have shown that the most satisfaction and reinforcement of the smoking habit occur when the peripheral, non-pharmacological factors are combined with the nicotine’s central effect. From the psychodynamic point of view smoking is a regressive behavior related to the earliest phase of human development which Freud called the “oral phase”. The satisfaction and relaxing effect of putting a cigarette in the mouth corresponds to the pleasure of a child suckling the mother’s breast.

Genetics: 

Genetics also play a role in addiction to nicotine.  Inheriting different forms of 6 genes will dictate the feature of the brain receptor to which nicotine binds.  This genetic variably offers an explanation for why some people develop a pack a day habit that they cannot seem to break, and others smoke a few cigarettes on occasion but do not have a compulsion to smoke.  For quite a while researchers have been studying nicotinic acetylcholine (nACH) receptors.  Meanwhile genes have been identified that serve as a blueprint of proteins that serve as subunits in nACH receptors.  “Variations in the DNA that encodes these genes may alter the structure or amount of the proteins produced, which in turn can modify what happens when nicotine molecules attach to the receptor (Whitten, 2009). Inaba and Cohen (2007) reported about genetically altered mice that had no interest in self-administering nicotine which was attributable to the removal of the protein that is held responsible for positive-reinforcement properties of nicotine.  Undoubtedly, the role of genetics in nicotine addiction plays a significant role.

Treatments for Tobacco Addiction: 
The majority of smokers who want to quit smoking attempt it on their own.  However, rates of success for self-quitters are very low.  Studies show that most self-quitters relapse within the first week of their quitting attempt.  Only about 3-5 % of individuals who quit on their own reach prolonged abstinence at 6-12 months post-quit.  Research clearly indicates that professional treatment and prolonged support for smoking cessation yields the highest success rates (Tobacco Addiction, n.d.).  These treatment professionals include counselors, psychotherapists, addictions specialists and psychiatrists.  The following are treatment methods that can be used in combination to increase success rates:

CBT:  Cognitive Behavioral Therapy 
This evidence based treatment method trains individuals to understand their trigger situations, regulate their feelings, and identify adaptive coping mechanisms.  It helps lay the foundation for a sustainable, healthy lifestyle.  Therapists with addiction training will also provide general psycho-education on addiction including relapse prevention.

NRT:  Nicotine Replacement Therapy
Nicotine replacement therapy is a good option in addition to behavioral treatments to address withdrawal symptoms and cravings.  When nicotine consumption is abruptly stopped people can experience withdrawal symptoms within 2 – 3 hours of their last tobacco use.  At the 2 – 3 day mark, these symptoms will peak.  The severity of nicotine withdrawal symptoms hinges upon how long and how much a person smoked.   The following is a list of possible symptoms:

An intense craving for nicotine
Anxiety, tension, restlessness, frustration, or impatience
Difficulty concentrating
Drowsiness or trouble sleeping, as well as bad dreams and nightmares
Headaches
Increased appetite and weight gain
Irritability or depression  (Nicotine, n.d., para. 3)

The Food and Drug Administration (FDA) has approved a number of NRTs:
Gum
Inhalers
Nasal spray
Skin patch

Hypnosis:
Clinical hypnotherapists with 3-5 sessions can set the stage on a subconscious level to remain smoke free.  Everyone has their unique reasons for why they began smoking, and why they want to quit smoking.  A clinical hypnotherapist can uncover and address subconscious causes for smoking, increase motivation to remain smoke free, and build ego strength to cope with daily life.

Pharmacotherapy:

The idea behind pharmacotherapy is that medication is used in conjunction with therapy, such as CBT.  Medications serve the purpose of reducing cravings and preventing the desired effects of smoking.

The two medications approved by the FDA (Food and Drug Administration)
https://en.wikipedia.org/wiki/Food_and_Drug_Administration are:
1.  Bupropion which is marketed under the name of Zyban/Wellbutrin
2.  Varenicline which is marketed under the name of Chantrix

As is the case with all medications, a careful assessment by an experienced physician is necessary.

Smoking prevention:

The first line of defense is the prevention of nicotine addiction. The simplest way to avoid development of any kind of addiction (among them smoking) is not to use the addictive substances. Most smokers begin to smoke as teenagers. Research shows that young people are particularly susceptible to tobacco marketing campaigns creating the image of being mature, sophisticated and glamorous. The Tobacco industry is one of the most lucrative branches of economy creating good financial rewards not only for the shareholders, but also for the governments due to  tobacco taxes. Schools generally provide education on the use of tobacco and other addictive substances, but their impact is unclear. Parents still have the biggest impact on their children`s decision whether to smoke. The best way to prevent a youngster from taking up smoking is to have parents who don`t smoke. Children from smoking households are more likely to begin smoking than children from nonsmoking households. Although cigarette commercials have been banned in the US from television for over 30 years, tobacco products remain among the most heavily marketed. According to the American Lung Association, the tobacco industry spent an estimated $12.49 billion on advertising in 2006. Some states place restrictions on the type and locations of tobacco advertising, and legislation enacted in 2009 gave the U.S. FDA strong authority to regulate tobacco products. The FDA requires prominent health warnings on all cigarette packaging and advertisements in the United States. A similar development can be observed in Europe and the Middle East.

Summary:

Tobacco smoking is one of the most addictive habits. The addiction can be established even after few days of smoking. The smokers are inhaling thousands of carcinogenic substances responsible for much higher cancer rate and other diseases such as chronic bronchitis. Moreover smoking significantly increases the risk for atherosclerosis which is the main cause of the heart attacks and strokes. The physical condition of smokers is lower compared to their peer group of non-smokers. The life expectancy of long term smokers is significantly reduced.

The best way to avoid the addiction is not to start.  Smoking cessation is possible at every stage and can be successful for all smokers under all circumstances.

……..

Rate of nicotine metabolism may predict best way to quit smoking

(Source: American Psychiatric Association, Psychiatric News 12.01.2015)

A smoker that can quickly metabolize nicotine could determine which type of cessation strategy has the best chance of success. The smokers with normal metabolism levels had better quit rates with varenicline therapy, which does not involve nicotine replacement, compared to a nicotine patch. For people with slow nicotine metabolism, the patch may be the better option.

It has been known for a while that smokers clear nicotine from their bodies at different rates, but until now it wasn’t known if this measurable trait – the nicotine metabolite ratio (NMR) – could be used to optimize treatment and improve outcomes. The study researchers randomly assigned 1,246 smokers (662 slow metabolizers and 584 normal metabolizers) to 11 weeks of the nicotine patch and placebo pill, varenicline and placebo patch, or double placebo; all participants also received behavioral counselling. After 11 weeks of treatment, normal metabolizers taking varenicline were about twice as likely not to smoke as those using the nicotine patch. And while slow metabolizers displayed similar effectiveness rates on the patch, they reported far fewer side effects for patch therapy.