APPROACHES TO TOBACCO CESSATION IN ADULTS

Regular tobacco use and nicotine dependence are serious health concerns. It is one of the main causes of chronic diseases such as lung cancer, chronic bronchitis, heart disease, and mouth cancer, and subsequent deaths. According to the Centers for Disease Control and Prevention, approximately 40 million adults in the US smoke cigarettes, and approximately 3 million middle and high school students use at least one tobacco product. Smokers are at a four-fold higher risk of death due to cancer than nonsmokers.

Tobacco abuse can be in the form of smoking, chewing, or sniffing. Globally, cigarette smoking is the most common form of tobacco abuse. Other forms include waterpipe tobacco, cigars, pipe tobacco, snuff, dips, snus, bidis, and kreteks. All forms of tobacco are considered harmful, and there are no safe consumption limits.

Many researchers view tobacco use and dependence as a chronic disease that requires several repeated attempts to quit before one is successful. Several interventions have been introduced to reduce its use among adults and young people.

In this article, we discuss the harmful effects of tobacco and approaches to cease their use among people.

Why are tobacco products addictive and difficult to quit?

Nicotine is a highly addictive chemical that is present in tobacco products. Nicotine addiction makes tobacco products difficult to quit. Addiction is characterized by compulsive drug seeking, even with adverse health effects.

Regular use of tobacco products exposes the brain to nicotine, causing addiction. On average, a smoker intakes 1-2mg of nicotine per cigarette. If a smoker consumes 20 cigarettes per day (1 pack) and takes ten puffs of each cigarette, his or her brain receives 200 hits of nicotine each day.

When a tobacco product is inhaled, chewed, or vaped, the nicotine in tobacco is absorbed into the blood and delivered to the brain. Usually, inhaled or smoked tobacco products are absorbed more rapidly in the blood than chewed or smokeless tobacco.

Immediately after nicotine exposure, the body reacts in two ways. These include:

• Upon exposure to nicotine, the adrenal gland is stimulated and releases adrenaline, which increases heart rate, blood pressure, and respiratory rate.
• Upon exposure to nicotine, the brain releases dopamine (chemicals), which causes a transient state of euphoria and may temporarily boost cognitive skills, such as the ability to hold memory and sustain attention. Individuals who continue to consume tobacco experience pleasurable effects.

Over time, staying without nicotine for too long becomes difficult, as individuals may experience irritability, craving, depression, anxiety, sleep disturbance, and a decline in cognitive functions. These withdrawal symptoms complicate quitting tobacco.

What are the harmful effects of tobacco usage?

Research suggests that more than 7000 chemicals are released from combustible tobacco products. In addition, hundreds of compounds are added to improve the flavor and absorption of tobacco.

The most common form of tobacco abuse is cigarette smoking, one of the leading causes of lung cancer. Approximately 30 percent of cancer-related deaths are due to tobacco smoking. Nicotine does not cause cancer. However, 69 chemicals present in tobacco smoke are considered carcinogenic (cancer-causing). Moreover, it also causes chronic bronchitis and emphysema (a condition that involves damage to the air sacs in the lungs, causing difficulty in breathing) and increases the risk of heart diseases (e.g., stroke, heart attack, and vascular disease), leukemia, type 2 diabetes, cataract, pneumonia, and an impaired immune system.

Chewing tobacco has a similar effect and increases the risk of mouth cancer. It is also linked to cancer of the pharynx (throat area), esophagus (food pipe), stomach, and colorectum (large intestine).

The risk of miscarriage, premature or stillborn babies, and babies with low birth weight increase with smoking in pregnancy. This may also be associated with learning and behavioral issues in children.

Passive smokers or individuals who stand or sit next to people who smoke are also at risk of developing lung cancer and heart disease. Long-term exposure to passive smoking or second-hand smoke can cause chronic bronchitis, reduced lung function, and pneumonia in adults. Children are also at risk of developing asthma, lung infections, ear infections, and death due to SIDS (Sudden Infant Death Syndrome or the unexplained death of a healthy baby).

What are the different approaches to tobacco cessation?

There are several effective treatments for tobacco cessation. These include behavioral therapies and medications. Research suggests that combining behavioral therapy and medications results in higher tobacco cessation rates than with minimal intervention.

The following is a detailed description of these interventions:

a. Behavioral Therapy: Behavioral therapy or behavioral counseling interventions target individuals who are motivated to quit tobacco. These interventions included physician and nurse advice, counseling with a specialist, group behavioral interventions, counseling over the telephone, and mobile phone-based interventions. Counseling can be performed in primary or community-based settings. This counseling includes several sessions that take place within 90-300 minutes.

There are several approaches to tobacco cessation counseling. These include:

• Cognitive behavioral therapy: This therapy helps identify the trigger factors (e.g., people, places, and situations) that aggravate behavior. It also teaches relaxation techniques to prevent relapse and empowers individuals to cope with stressful situations and trigger factors.
• Motivational interviewing: This type of counseling is used to help individuals stop smoking. It helps individuals to explore the reasons that make them feel unsure about quitting smoking. It also helps them find ways to quit smoking and points out discrepancies between their goals and behavior. This approach is more patient-focused and non-confrontational.
• Mindfulness: This technique motivates individuals to learn to increase awareness and detachment from thoughts and desires, which may result in relapse. During these sessions, individuals are taught techniques to cope with negative emotions, such as stress and cravings, without resorting to tobacco use.
• Text messaging and web-based services: The use of technology, including mobile phones, the Internet, and social media platforms, helps deliver interventions for smoking cessation. These technologies increase access to healthcare for all individuals, irrespective of geographical barriers. Technology-based tobacco cessation approaches are more cost-effective than other approaches and more relevant among young adults.

b. Medications: Medications that aid in tobacco cessation include the following:

• Nicotine Replacement Therapy (NRT): NRT helps to quit smoking. In this treatment, individuals are asked to use products that provide small doses of nicotine over time. This helps satisfy patients’ urge to smoke and relieves nicotine withdrawal symptoms without exposing them to toxic chemicals present in cigarette smoke. These products are available in different forms, such as skin patches, chewing gums, lozenges, nasal sprays, and inhalers. These products are available over-the-counter and are prescribed. Over-the-counter NRT products are available only for people older than 18 years. The different over-the-counter NRT products can be classified as below:
  • Skin patches: Skin patches are placed on the skin, similar to adhesive bandages. Research suggests that the use of patches is safe for up to 24 weeks.
  • Chewing gum: Chewing gum or nicotine gum helps control nicotine cravings. It can be used every 2 hours to manage withdrawal symptoms.
  • Lozenges: These are available in different flavors and can be used every 1-2 hours to control nicotine withdrawal symptoms.
• Bupropion: It is an antidepressant medication used for tobacco cessation. This Food and Drug Administration (FDA) approved medication acts by inhibiting the release of chemicals (dopamine and norepinephrine) in the brain, which helps to decrease nicotine withdrawal symptoms and the desire to smoke.
• Varenicline: This FDA-approved medication for tobacco cessation works by inhibiting the pleasing effects of nicotine on the brain.
• Other drugs: In addition to bupropion and varenicline, research suggests that the use of another antidepressant drug, such as nortriptyline, and an antihypertensive drug, such as clonidine, helps in tobacco cessation.

Summary

Tobacco use is a serious public health concern and a major cause of chronic diseases, including heart disease and cancer. Nicotine, a highly addictive chemical, is present in all tobacco products, making them challenging to quit. Smoking, chewing, and sniffing tobacco all have harmful effects, and there is no safe level of tobacco consumption. Quitting tobacco requires repeated attempts, and there are several effective treatments, including behavioral therapy and medication. Tobacco cessation counseling interventions, such as cognitive behavioral therapy, motivational interviewing, and mindfulness, can help identify trigger factors and teach relaxation techniques to prevent relapse.

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References:

• NIDA. What are treatments for tobacco dependence? National Institute on Drug Abuse website. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence. April 12, 2021 Accessed December 25, 2022.
• US Preventive Services Task Force, Krist AH, Davidson KW, et al. Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(3):265-279.
• Aveyard P, Raw M. Improving smoking cessation approaches at the individual level. Tob Control. 2012;21(2):252-257.
• Choi HK, Ataucuri-Vargas J, Lin C, Singrey A. The current state of tobacco cessation treatment. Cleve Clin J Med. 2021;88(7):393-404. Published 2021 Jul 1.
• Giulietti, F., Filipponi, A., Rosettani, G. et al. Pharmacological Approach to Smoking Cessation: An Updated Review for Daily Clinical Practice. High Blood Press Cardiovasc Prev 27, 349–362 (2020). 
• https://www.cdc.gov/tobacco/patient-care/care-settings/clinical/index.html
• https://www.fda.gov/consumers/consumer-updates/want-quit-smoking-fda-approved-and-fda-cleared-cessation-products-can-help
• https://www.ahrq.gov/prevention/guidelines/tobacco/5steps.html

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