NICOTINE

DEPENDENCE
SYNDROME
Understanding And Addressing Nicotine Addiction
Overview
 Introduction

 Indian smoking products

 How do people become addicted to nicotine?

 Symptoms and withdrawal symptoms of

nicotine addiction.

 Treatment of nicotine dependence.

Introduction
 Tobacco use is the world's leading cause of
death, accounting for 4 million deaths per
year.

 On the basis of current use patterns by the

year 2030, it may kill more than 10 million
people annually.

 Tobacco was introduced in India by the

Portuguese 400 years ago. Since then
tobacco consumption continued to rise in
India.
Nicotine is Not Harmless
 Increase in blood pressure, respiration, and
heart rate

 Adversely affects nervous, cardiovascular,

respiratory, and reproductive systems

 May contribute to cancerous tumor

development

 Can be lethal if orally ingested

 Associated with poor reproductive health

outcomes
Nicotine is Not Harmless
 Early exposure can produce lasting effects on
brain and lung development

 Early exposure is associated with cognitive,

emotional, and behavioral deficits

 Increases the risk of nicotine addiction and

alcohol and other drug use and addiction
INDIAN SMOKING
PRODUCTS
 Tobacco is used for smoking as well as in smokeless forms in
India.

 Bidi and cigarette smoking: Bidi smoking stick is specific

to India although it is being exported and raising alarm bells
in other countries as well. It is about 6 times more common
than cigarette smoking . Although bidi contains about 1/4th
the amount of tobacco compared to a cigarette. It delivers a
comparable amount of tar and nicotine.

 Smokeless Tobacco: In India, tobacco is used in smokeless

manners in a wide variety of ways with multitude products
such as betel quid, mixture of tobacco, lime areca nut,
tobacco with lime, mishri, gutkha and many others.

 Cigars: Cigars smoking is limited to certain social groups.

Nicotine Addiction Linked to Other
Substance Use Disorders
How Do People Become Addicted
to Nicotine?
 Brain cells (neurons) stimulated by nicotine release
chemicals, such as dopamine, that produce feelings of
pleasure and that maintain or perpetuate those feelings

 After continued use, the body adjusts to the presence of

nicotine and increasing amounts are needed to produce
the same rewarding effects (i.e., tolerance) and to stave off
the negative effects of its absence (i.e., withdrawal)

 Withdrawal symptoms--such as anxiety, depression, and

cognitive deficits--can occur within minutes of the last dose
of nicotine, increasing the risk of repeated use to avoid
discomfort

 As tolerance develops, nicotine ingestion must occur more

frequently and at shorter intervals to alleviate withdrawal
symptoms
 High nicotine levels
achieved in 11 seconds
from inhalation.

 The half life of nicotine

is only 2hrs. This along
with its rapid clearance
from the CNS results
in withdrawal
symptoms occurring
quickly.
Factors that Increase risk of
nicotine use and addiction
 Genetics
 Physiological
 Environment :
1) Prenatal exposure to nicotine,
2) Parents or peer use of nicotine products,
3) Childhood trauma,
4) Use of products containing menthol
(menthol is associated with increased risk of
smoking initiation, greater smoking frequency,
nicotine addiction. Menthol reduced the rate of
nicotine metabolism)
Symptoms of Nicotine Addiction
Fagerstrom test for Nicotine
Dependence
Pharmacological nicotine
dependence
 Craving (nicotine hunger)
 Habit (behavior)
 Nicotine withdrawal symptoms
Tobacco dependence has Two Parts
Tobacco dependence is a 2-part problem

Physical Behavior
The habit of using
The addiction to nicotine
tobacco
Treatment
Treatment

Medications for cessation

Behavior change program

Treatment should address both the addiction

and the habit
Treatment of nicotine dependence
A. Identification and assessment of
tobacco use.

B. Interventions

C. Monitoring the progress

Identification and assessment
of tobacco use.
5A’s for brief smoking cessation counseling

 Ask about tobacco use

 Advise to stop smoking
 Assess willingness to quit
 Assist with quit plan
 Arrange follow up
Interventions
 Pharmacotherapy

 Psychosocial therapy
Interventions: Pharmacotherapy
First line therapies:
Three general classes of FDA-approved
drugs for smoking cessation:
 Nicotine replacement therapy(NRT):
-Nicotine gum, patch, lozenge, nasal spray, inhaler
 Psychotropics
-Sustained release bupropion
 Partial nicotine receptor agonist
-Varenicline
 Second line therapies:
- Clonidine
- Nortriptyline
Nicotine replacement
therapy(NRT):
 NRT relives craving and withdrawal
symptoms.
 Many studies have
shown using NRT
can nearly double
the chances of
quitting with
success.
Nicotine in NRT vs Smoking
 Absorbed more slowly (less acute effect).

 No carbon monoxide; No oxidants

 Nicotine is not a significant risk factor for

cardiovascular events, even in people with
cardiovascular disease.

 NRT and bupropion taken over long periods

are safer than cigarette smoking.
Nicotine gum
 Sugar free chewing gum base.

 Contains buffering agents to enhance buccal

absorption of nicotine.

 Available: 2mg, 4mg; Mint, Cinnamon, Paan

etc
Chewing technique:
Dosing

OR
Side effects:
Nicotine patch (Transdermal)
 Nicotine is well absorbed across the skin.

 Delivery to systemic circulation avoids

hepatic first pass metabolism.

 Plasma nicotine levels are lower and

fluctuate less than with smoking
Direction for use:
Dosing:

Heavy Smoker Light Smoker

> 10 cigarettes/day < 10 cigarettes/day

Step 1 (21mg x 6 weeks) Step 2 (14mg x 2 weeks)

Step 2 (14mg x 2 weeks) Step 3 (7mg x 2 weeks)
Step 3 (7mg x 2 weeks)
Side effects
Nicotine lozenge
 Use: allow to dissolve (Don’t chew but suck
like a hard candy)

 Pros: Flexible dosing, Keeps the mouth bust,

OTC

 Cons: Need to use it

correctly. May cause
insomnia, nausea, hiccups,
heartburn, coughing.
Dosing
 Based on time to first cigarette (TTFC)
4mg if < 30mins to TTFC
2mg if > 30mins to TTFC

 Length of treatment: 12weeks

 Frequency= 1lozenge every 1-2 hrs for 6

weeks, with gradual reduction in the number
used per day over the second 6 weeks

 Max dose: 5 lozenges every 6hrs or 20/day

Nicotine inhaler
 The nicotine inhaler consists of a
mouthpiece and a plastic nicotine
containing cartridge.

 When the smoker inhales through

the device, nicotine vapor (not
smoke) is released and deposited in
the Oropharynx and absorbed
through the oral mucosa.

 Frequency: 6 to 12 cartridges per

day for the first 6 to 12 weeks,
followed by gradual reduction of
dose over the next 6 to 12 weeks.
Nasal Spray
 Produces a more rapid rise in plasma
nicotine concentration than orally
absorbed products. Peak of nicotine
occurs 10 minutes after use

 Frequency 1 to 2 sprays per hr are

recommended for about 3 months.

 The max dose is 10 sprays/ hr or 80 total

sprays/day
Changes to NRT indications
 More than one form of NRT can be used
concurrently.

 NRT can be used by pregnant and lactating

smokers.

 All forms of NRT can be used by patients

with cardiovascular disease.

 All forms of NRT can be used by smokers

aged 12 to 17 years.
Non- Nicotine Pharmacotherapy
 First line non nicotine medications
-bupropion
-Varenicline

 Others (nortriptyline, clonidine)

Bupropion

craving
symptoms of withdrawal
Dosing
 Patients should begin therapy 1 to 2 weeks
prior to their quit date to ensure that
therapeutic plasma levels of drug are
achieved.

 Initial treatment:
150md po OD x 3 day

 Then
150mg po BD
Duration 7 to 12 weeks
Contraindications
 Seizures, heavy alcohol use, serious head
injury, bipolar, anorexia or bulimia (eating
disorders).

 Neuropsychiatric effect - Suicidal/self-

injurious behavior and/or depression.
Varenicline
Side effect
 The most frequently reported adverse events with
varenicline were nausea, headache, insomnia and
abnormal dreams.

 Serious neuropsychiatric symptoms have occurred in

patients being treated with varenicline.

 All patients being treated with varenicline should be

observed for neuropsychiatric symptoms.

 Recommended that it should be avoided in smokers

with current unstable psychiatric status or a history
of recent suicidal ideation.
Second line treatment
 Nortryptylline:

 Clonidine:
-Antihypertensive agent, centrally acting alpha-
agonist.
 E-cigarette
 The e-cigarette delivers
vaporized nicotine through the
heating of a nicotine-containing
solution, producing a visible
‘vapor’ that can be inhaled and
exhaled.

 However, FDA has not finalized

its regulatory process.

 Difference between nicotine

inhaler and e-cigarette is that in
nicotine inhaler you don’t inhale
nicotine into your lungs. It stays
mostly in your throat and mouth.
There's’ no heating element or
liquid nicotine.
Herbal drug for smoking cessation
Lobeline:
-Derived from the leaves of Indian
tobacco plant.
-Partial nicotine agonist.
-No scientifically rigorous trials
with long-term follow up.
-No evidence to support
use for smoking cessation.
PSYCHOSOCIAL TREATMENTS
 Behavior therapy
-Skill training and relapse prevention
-Stimulus control
-Aversive therapy
-Social support:
-Contingency management
-Cue exposure
-Relaxation

 Self help material

 Educational, supportive groups, religious and spiritual

influences.

 Hypnosis :The usual goal of hypnotherapy for smoking cessation is

to implant non-conscious suggestion that will deter smoking.
Thank you