Tobacco Use: Treating Nicotine Addiction Like a Disease
There are decades of information that concretely establishes tobacco use as hazardous to your health. With the effects of nicotine on the brain and the symptoms of nicotine withdrawal, the challenge for users of tobacco products to end their dependency on tobacco is evident by the various options of Nicotine Replacement Therapy (NRT) available to consumers. Given the relapsing nature of tobacco dependency and the measurable changes within the brain that are a staple of a chronic medical condition, it makes sense to treat nicotine addiction in ways similar to other chronic diseases like asthma, diabetes and depression.
For smokers, the challenge lies in breaking the dependency cycle of nicotine. Looking deeper into the effects of nicotine on the brain, long–term NRT might be the difference between staying smoke free or being a lifetime smoker. While long–term pharmacological treatment may not be ideal, it is a significant health improvement over continued tobacco use. Because of the obvious health benefits of not smoking, would it not be wiser to treat tobacco use long–term and reduce the impact of tobacco related diseases on an already at–risk population?
Nicotine & Addiction: A Learned Pattern
Research has shown how nicotine acts within the brain to produce a number of effects. Of primary importance to its addictive nature is the fact that nicotine activates reward pathways in the brain (dopamine receptors). This reaction is similar to that seen with cocaine and thought to be the underlying pleasurable sensation experienced by many smokers. Nicotine's pharmacokinetic (process by which a drug is absorbed, distributed, metabolized, and eliminated by the body) properties also enhance its abuse potential. Cigarette smoking produces a rapid distribution of nicotine to the brain, with nicotine levels peaking within 10 seconds of inhalation. However, the acute effects of nicotine dissipate in a few minutes, as do the associated feelings of reward, which causes the individual to continue smoking, maintaining the drug's pleasurable effects and preventing symptoms of withdrawal.
An emerging theoretical explanation of addictive behavior is that addiction is inherently irrational. The addiction behavior pattern uses the same mechanisms as natural rewards, but individuals behave in a non–optimal (addicted) way because of nicotine's neuropharmacological effects on dopamine. Humans consistently discount the long–term rewards of discontinued substance use more than the short–term penalties for continued substance use. This is a classic example of hyperbolic discounting. However, hyperbolic discounting may not be the fundamental reason for individuals getting trapped in the cycle of addictive behavior. Rather, TDRL (temporal–difference reinforcement learning) theory suggests that the neuropharmacological effect drugs like nicotine and cocaine have on dopamine signals drives the individual into the addicted state.
Treating Nicotine Dependence as Chronic Disease
Smoking related diseases are the leading cause of preventable death in the United States. Consistent exposure to nicotine causes measurable changes within the brain, particularly within the mesolimbic "reward" center. These biological changes are indicative of a chronic medical condition. Ending a steady consumption of nicotine results in physiologic changes within the brain and the user experiences "withdrawal syndrome." Unfortunately many insurance carriers either do not cover cessation therapy or limit the duration of covered therapy. For serious addictions like heroin, medications that have been shown to prevent relapse (methadone) are often covered long–term.
Benefits of Long Term Cessation Medication
For some users of tobacco products, quitting smoking is the easy part. Their addiction is not to tobacco itself, but to the nicotine that resides within. Through pharmacological treatments like the nicotine patch, inhalers and gum, smokers can break the physical habits of smoking, but these treatments provide little relief for the chemical dependency on nicotine. Of smokers that successfully quit smoking using NRT and achieve smoking abstinence at 12 months, an estimated 30% relapse and resume smoking.
For some, long–term pharmacotherapy is the difference between staying smoke free or a life long addiction to tobacco. An extension of NRT treatment periods, additional behavioral counseling or other medical treatments are all of greater benefit to the patient in comparison to the alternative—a return to smoking and development of tobacco related diseases. Extended courses of NRT treatment, as required by some patients, is a method currently supported by the U.S. Public Health Service Guidelines. There is a clear overall health benefit for individuals who no longer smoke—quitters using long–term nicotine replacement therapy are exposed to lower levels of nicotine without the 4,000 toxins found in cigarette smoke.
The rates of disease and death associated with tobacco use are greater than any other chronic disease. The health of tobacco users not only improves with cost effective treatment to quit smoking, but helps avoid the costlier treatments of tobacco related diseases in the future. Improving the availability of these treatments will not only improve the success of current smokers attempting to quit, but provide the option to smokers looking for a path to tobacco independence.