Nicotine and related disorders Health Article

Diagnosis

Smokers usually self-diagnose their nicotine dependence and nicotine withdrawal. Such questionnaires as the Fagerstrom Test for Nicotine Dependence (FTND), a short six-item assessment of cigarette use, help to determine the level of tobacco dependence. Physicians and mental health professionals are less concerned with diagnosis, which is usually straightforward, than with determining the physical and psychological factors in each patient that must be addressed for successful smoking cessation.

Treatments

Most smokers want to quit; over 75% have tried to stop at least once. Each year, over 40% of smokers make at least one attempt to quit. Many people try a dozen times before they are successful in finding the right combination of medications, therapies, and support to achieve success. Even with repeated attempts, however, only half of all smokers are able to stop smoking completely and eliminate their dependence on nicotine.

Most people do not suddenly wake up one morning and decide to stop smoking. Instead, they go through several preparatory stages before taking action. First is the precontemplation stage, in which the smoker doesnçt even think about quitting. Precontemplation is followed by the contemplation stage, in which the smoker thinks about quitting, but takes no action. Contemplation eventually turns to preparation, often when counselors or family members encourage or urge the smoker to quit. Now the smoker starts making plans to quit in the near future. Finally the smoker arrives at the point of taking action.

Having decided to stop smoking, a person has many choices of programs and approaches. When mental health professionals are involved in smoking cessation efforts, one of their first jobs is to identify the physical and psychological factors that keep the person smoking. This identification helps to direct the smoker to the most appropriate type of program. Assessment examines the frequency of the person's smoking, his or her social and emotional attachment to cigarettes, commitment to change, available support system, and barriers to change. These conditions vary from person to person, which is why some smoking cessation programs work for one person and not another.

Medications

Before 1984, there were no medications to help smokers quit. In that year, a nicotine chewing gum (Nicorette) was approved by the United States Food and Drug Administration (FDA) as a prescription drug for smoking cessation. In 1996 it became available without prescription. Nicorette was the first of several medications that are used for nicotine replacement therapy, intended to gradually reduce nicotine dependence in order to prevent or reduce withdrawal symptoms. This approach, called tapering, is used in withdrawal of other addictive drugs.

About 15% of people using nicotine gum are able to stop smoking permanently. This rate is about three times higher than for people who simply go "cold turkey" and stop smoking without any assistance. Nicotine gum comes in two strengths. As it is chewed, nicotine is released and absorbed through the lining of the mouth. Over a six- to 12-week period, the amount and strength of gum chewed is decreased, until the smoker is weaned away from his or her dependence on nicotine. Chewing gum may not be pleasant or socially acceptable to some people, and cannot be used by people who have diseases of the jaw. In addition, some people report that the gum makes them feel queasy.

The nicotine transdermal patches have been available without prescription since 1996. They are marketed under several brand names, including Habitrol, Nicoderm, NicoDerm CQ, Prostep and Nicotrol. All but Nicotrol are 24-hour patches. Nicotrol is a 16-hour patch designed to be removed at night. The patches are worn on the skin between the neck and the waist, and provide a steady delivery of nicotine through the skin. Patches come in varying strengths. After several weeks, users can move down to a patch that delivers a lower dose. Some people using the 24-hour patches experience sleep disturbances, and a few develop mild skin irritations, but generally side effects are few.

Two other nicotine delivery devices are available by prescription only. One is a nicotine nasal spray. It has the advantage of delivering nicotine rapidly, just as a cigarette does. Treatment with nasal spray usually lasts four to six weeks. Side effects include cold-like symptoms (runny nose, sneezing, etc.). A nicotine inhaler is also available that delivers nicotine through the tissues of the throat. A major advantage of the inhaler is that it provides an alternative to having a cigarette in one's hands while it delivers nicotine.

One prescription drug that is not nicotine replacement therapy has also been approved for treatment of nicotine dependence. Bupropion(Zyban) was originally developed as antidepressant medication that appears to increase dopamine levels in the brain. Bupropion has been shown to be effective in smoking cessation. It has the advantage of being a pill taken twice a day. Its side effects include dry mouth and insomnia; in addition, it may not be suitable for people with certain medical conditions.