eMedicine Specialties > Psychiatry > Addiction

Nicotine Addiction: Follow-up

Author: R Gregory Lande, DO, FACN, Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Oct 14, 2009

Follow-up

Further Outpatient Care

Long-term follow-up is recommended because individuals who successfully quit smoking are at high risk for relapse. The health care deliverer should make provisions for support, measurement of progress, and a mechanism to deal with relapse. For motivated patients who have failed smoking cessation, consider referral to an expert for the treatment of a relapse.

Deterrence/Prevention

  • More than 90% of first-time use of tobacco occurs before high school graduation. Because the average age at first use is 14.5 years, smoking prevention must start early.
  • Approximately 40% of teenagers who smoke eventually become addicted to nicotine.
  • Social attitudes and policies toward smoking can have a major impact on smoking behavior. Healthcare associations, public health organizations, and consumer groups should lobby for the following:
    • Restriction of access to tobacco products for minors
    • Restriction of smoking in public places
    • Restriction of advertisements
    • Increased prices through taxation
    • Increased awareness about the harmful health effects of smoking
  • Tobacco industry marketing and public health tobacco-control activities are 2 of the major determinants of cigarette smoking behavior. These vie with each other to influence the proportion of each generation who initiate smoking, the intensity level reached by smokers, and the time before smokers are able to quit successfully. The evidence for causality in this association is considered convincing. Strong evidence supports the notion that tobacco-control programs reduce smoking behavior.

Patient Education

  • Patient education with regard to the health effects of smoking should occur with all patients who smoke. Patients should be provided with a variety of options and advice that will allow them to escape the harmful effects of tobacco use and the highly addictive drug, nicotine.
  • Family education should be a primary recommendation every clinician undertakes in an effort to reduce teen smoking. Preliminary results from well-designed randomized controlled studies suggest that family interventions can reduce teen smoking.24
  • School-based smoking prevention programs educate students about tobacco use. Although widely seen in school curricula, the scientific evidence supporting this approach is limited.25
  • Both print and visual media are saturated with antismoking messages. A systematic review of the scientific literature shows a weak impact in preventing smoking.26
  • Work-based smoking cessation programs that provide both behavioral treatment and medication support can be effective interventions with good quit rates.27
  • Naturally, many patients quit smoking on their own by going cold turkey. This would probably not be the typical patient seen in a clinician's office in the precontemplative or contemplative stage of change. For these patients, many clinicians may refer them to a variety of self-help materials such as books or pamphlets. As a sole treatment strategy, the evidence that self-help materials lead to smoking cessation is weak.28 A better approach would use self-help materials as a tool to encourage personal education and to facilitate later dialogue between the clinician and the patient.
  • Patients interested in Web-based smoking cessation programs may find the following links helpful:
    • The American Lung Association offers " Freedom from Smoking."
    • Another helpful Web site is the Tobacco Control Research Branch of the National Cancer Institute.
    • Smoking cessation counselors are available to answer smoking-related questions in English or Spanish by telephone or confidential online chat at the National Cancer Institute’s (NCI) Smoking Quitline.
    • The American Cancer Society's website provides educational materials and can direct interested individuals to a community based smoking cessation program called FreshStart.
    • Nicotine Anonymous is a fellowship-based program modeled along the same lines as Alcoholics Anonymous.

Miscellaneous

Medicolegal Pitfalls

  • Relapse during the first year after achieving smoking cessation occurs in approximately 50% of patients, irrespective of therapeutic regimen.
  • The changes in the central nervous system, eg, neurone genetics, cell structure, and cell function, induced by smoking do not reverse with pharmacological therapy.
  • Highly nicotine-dependent smokers may require an initial therapy for 6 months or longer. Some individuals may require low-dose maintenance therapy for years.
  • Controlled studies are required to help guide management of relapses and prolonged tapering periods. Immediately restarting nicotine medication might be helpful if a relapse occurs.
  • According to Gro Harlem Brundtland, the director of the World Health Organization, "A tax increase is the single most important intervention by governments to curb tobacco consumption." A 10% tax increase worldwide could inspire 42 million people to stop smoking and would prevent approximately 10 million premature deaths.

Special Concerns

  • Tobacco use is the greatest potentially remedial problem throughout the world, and it is the number-one preventable cause of death in the developed world. Clinicians have a particularly important role as patient advocates in health promotion, discouraging smoking initiation, encouraging and assisting smoking patients to quit, and participating in social efforts designed to curb smoking at various levels.
  • The gains in understanding the neuropathology of nicotine addiction have already opened new frontiers, including effective nicotine replacement and oral therapy. Greater therapeutic advances are anticipated in the next few years.
  • Smoking and weight gain
    • Concerns about weight gain following smoking cessation are a well-known barrier. Smokers with weight concerns are more likely to relapse. Smoking for weight control reasons has been associated with being female, smoking more cigarettes per day, lower motivation to quit smoking, body image dissatisfaction, and higher Fagerström.29
    • Interventions designed specifically for weight-concerned smokers such as on-site exercise program improved smoking abstinence rates and delayed weight gain. Cognitive-behavioral therapy to reduce weight concerns improved smoking cessation success and reduced weight gain.
    • NRT can have an additional, positive effect on weight gain as another significant barrier to smoking cessation. NRTs can attenuate postcessation weight gain, although upon termination of nicotine replacement use, weight continues to increase to the level of exsmokers who used placebo.30
  • Smoking and depression
    • An association between nicotine addiction and depression is well established.
    • Previous studies also have demonstrated that dependent smokers have lower monoamine oxidase A and B activity than nonsmokers. Smokers with a past history of major depression also were found to have significantly lower resting plasma norepinephrine levels. Past history of depression also was found to be more frequent in female smokers.
    • Reports of severe major depressive episodes after smoking cessation indicate that the onset of severe depressive symptoms ranges from 2 days to 6 weeks after abstinence from smoking.
    • In some cases, depression after smoking cessation was resolved with the use of nicotine replacement therapy or the use of antidepressants; in others, depressive symptoms dissipated after a relapse to smoking. The significant predictors of major depressive episodes were having a history of major depression and experiencing elevated withdrawal symptoms at the end of treatment.
    • Obtaining information about any history of depressive symptoms is important, and when such a history is present, remaining alert to the possible onset of depression even weeks after smoking cessation treatment has ended also is important.
    • Antidepressants such as fluoxetine and sertraline may be a useful cessation aid for smokers with prior major depression, and other authors have suggested that smokers with prior major depression benefit from mood management counseling and nortriptyline as cessation aids. Whether these treatments also prevent the onset of postcessation depression remains to be examined. It also remains to be known whether effective management of withdrawal symptoms prevents postcessation depression.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Sat Sharma, MD, FRCPC and Morley Lertzman, MD, FRCP(C) to the development and writing of this article.



More on Nicotine Addiction

Overview: Nicotine Addiction
Differential Diagnoses & Workup: Nicotine Addiction
Treatment & Medication: Nicotine Addiction
Follow-up: Nicotine Addiction
Multimedia: Nicotine Addiction
References
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Further Reading

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Keywords

smoking cessation, lung cancer, cigarettes, cigarette smoking, chronic obstructive pulmonary disease, COPD, emphysema, atherosclerotic vascular disease, atherosclerosis, nicotine addition, quitting smoking, tobacco addiction, lung disease

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Contributor Information and Disclosures

Author

R Gregory Lande, DO, FACN, Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center
R Gregory Lande, DO, FACN is a member of the following medical societies: American Osteopathic Academy of Addiction Medicine and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Sarah C Aronson, MD, Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland
Sarah C Aronson, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories
Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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