[Next] [Previous] [Up] [Top] [Contents] [Index]

Chapter three

The multiple faces of dependency

: Dr Heikki J. Korhonen

Especially friends influence strongly when starting to smoke.

moking leads to a multiple dependency. It consists of nicotine dependency, a substance strongly affecting the brains and in addition, a psychological and social dependency developing with the smoking habit. Recent studies have brought new knowledge about the mechanisms that keep up the physiological dependency caused by nicotine. Although in smoking cessation psychological and social factors have an important role, the basic element in the dependency problem seems to be the consequences of nicotine effects in the central nervous system.

Smoking is a habit of whose models are adopted in the environment. Especially friends influence strongly when starting to smoke (in the initiation of smoking). Group pressures and identification problems do not comply only to young people. For instance in work society, when others are smoking, this also influences ones own smoking.

When smoking, a person starts to develop various small doings and meeting a smoking friend easily leads to lighting up a cigarette. This social dependency becomes noticeable only in efforts to quit smoking.

Calm down and pause a while

A smoker has accustomed to attaching cigarettes in situations, in which he is tense and one should calm down ahead of a difficult job and get concentrated. Tobacco gets often many positive elements in imagination. Many smokers tend to use smoking in controlling their moods. When taking a pause to have a cigarette one has learned to stop for a thoughtful moment. Tobacco is something that gives a right to have a pause.

For some tobacco is a means to cheer up. Psychological dependency gets explicit, when a person can be without cigarettes for months but in a distressing situation there is an unsurpassable need to light up a cigarette.

Dopamine for pleasure

Nicotine activates the corresponding receptors in the brain and increases the level of dopamine secretion.

Nicotine causes strong physical dependency. Smokers' organism becomes used to the substance. Nicotine activates the corresponding receptors in the brain and increases the level of dopamine secretion. As a result, a smoker experiences pleasure. When the organism gets its regular share of nicotine, it starts to wait for it in order to function "normally". When it does not get nicotine any longer, withdrawal symptoms will appear, usually such as anxiety, sleeplessness, headache and a strong urge to smoke. These physical symptoms are individual. Like in other dependencies, strong physical withdrawal symptoms are not an obligation.

These withdrawal symptoms go normally away in a couple of weeks. The strength of nicotine dependency is demonstrated in the fact that the long term effects of smoking cessation are alike with the heroine.

After cessation it takes for several months before the activity of receptors return to the normal level.

Dr Godfrey Fowler and Dr Karl-Olof Fagerström discussed in the Smokefree Europe conference factors contributing to nicotine dependency. Smoking increases the sensitivity on nicotine receptors in the brain. This sensitivity develops normally very fast.

After cessation it takes for several months before the activity of receptors return to the normal level. The tendency to pick up smoking habit is thus big even years after cessation.

The majority of smokers start again within three months from cessation. During this period the sensitivity of receptors is still very high and psychological and social mechanisms related to nonsmoking are not yet learned.

Doctors advice--a supporting act

Dr Thomas Kottke from Mayo Clinic reviewed the effectiveness of different cessation methods based on the newest research. He said that health care personnel, especially doctors, can have an important supporting role in smoking cessation. Usually an advice from a doctor increases the probability in succeeding the smoking cessation.

Replacement therapy

Nicotine replacement therapy makes the smoking cessation more effective. According to research, nicotine replacement therapy increases the possibility to succeed in cessation by 50-100 per cent. Replacement therapy continues the dosage of nicotine in the beginning of the cessation, so that there is time to overcome the psychological and social dependency.

The replacement therapy must be long enough; treatment lasting only for few days or weeks tends to have bad results. How useful is nicotine replacement? This depends on the smoker's motivation, the level of nicotine dependency and the additional support the smoker is receiving during cessation.

The most useful means nicotine replacement therapy is for those who are the most heavy dependant on nicotine. The level of dependency can be evaluated for instance by using the Fageström questionnaire.n

GPs can help their patients
stop smoking

There is good evidence from many rigorous scientific studies that health professionals, especially general practitioners, can help their patients stop smoking.

Motivation to stop smoking and confidence in the ability to do so are important predictors of success. Overviews of randomised controlled trials of the effect of brief smoking cessation advice, given by doctors in consultations about other matters, indicate achievement of about 5% long-term (ie at least one year) cessation, compared with less than 1% in non-intervention control groups. Following such advice, about 1 in 20 can therefore be expected to stop, compared with about 1 in 100 otherwise. Higher success rates can be achieved when advice is combined in other interventions, especially nicotine replacement therapy--nicotine gum, skin patches, or nasal spray.

Many randonmised controlled trials have now shown that, in ordinary clinical settings, nicotine replacement therapy can double sustained smoking cessation rates, compared with placebo, and about 1 in 10 can be expected to stop. In a large general practice-based placebo-controlled trial we demonstrated that, using nicotine skin patches, about 1 in 4 of those who achieved cessation for one week using such patches could expect (with continued use of patches for up to three months) to achieve sustained smoking cessation for at least a year.

Essential steps in smoking cessation advice:

Seek opportunity to raise the issue of smoking in any consultation, especially in the context of smoking-related illness, pregnancy or forthcoming operation and also discuss parental smoking in the context of respiratory illness in infants and children.
Ensure medical notes include information about whether the patient is a smoker or not.
Enquire about interest in stopping smoking and giving information, and where relevant, advice about stopping, reinforcing patients own motivation where possible and emphasizing the benefits.
Help to plan a strategy for stopping, offering self-help leaflets, and offer support and follow-up.
Encourage use of nicotine replacement therapy, where appropriate, and give explanation of its use and follow-up opportunities.

Dr Geoffrey Fowler, University of Oxford, UK

Cessation guidelines

The following text is the abstract from the United States Agency for Health Care Policy and Research Smoking Cessation Guideline:

This guideline contains strategies and recommendations designed to assist clinicians, smoking cessation specialists, and health care administrators/insurers/purchasers in identifying tobacco users and supporting and delivering effective smoking cessation interventions. These recommendations were made as a result of an exhaustive and systematic review and analysis of the scientific literature. The primary analytic technique used was meta-analysis. The strength of evidence that served as the basis for each recommendation is clearly indicated in the guideline. Public testimony an a peer review were also part of the guideline's development process, as well as a notice in the Federal Register inviting review. The guideline's principal findings are:

Every person who smokes should be offered smoking cessation treatment at every office visit.
Clinicians should ask and record the tobacco-use status of every patient.
Cessation treatments event as brief as 3 minutes a visit are effective.
More intense treatment is more effective in producing long-term abstinence from tobacco.
Nicotine replacement therapy (nicotine patches, gum or nasal spray), clinician-delivered social support, and skills training are particularly effective components of smoking cessation treatment.
Health care systems should make institutional changes that result in the systematic identification of, and intervention with, all tobacco users at every visit.

The guideline proposes strategies for carrying out each of its specific recommendations.

For clinicians, these recommendations are

(1) systematically identify tobacco users and document their status;

(2) strongly urge all smokers to quit;

(3) identify smokers willing to make a quit attempt;

(4) aid the patient in quitting by helping with a quit plan, offering nicotine replacement therapy, giving advice, and providing supplementary information; and

(5) schedule follow-up contact.

Recommendations for smoking cessation specialists are

(1) assess the smoker who has entered an intervention programme;

(2) use a variety of clinical specialists;

(3) ensure that the programme is sufficiently intensive;

(4) use a variety of programme formats;

(5) include effective counseuing techniques;

(6) target the smoker's motivation to quit;

(7)provide relapse prevention intervention;

(8) offer nicotine replacement therapy;

(9) arrange follow-up contact.

Recommendations for health insurance purchasers and health care administrators are

(1) consider making tobacco assessment, counselling, and treatment a contractual obligation of the insurers and providers that sell services;

(2) ensure that institutional changes to promote smoking cessation interventions are universally implemented.

Source: Dr Thomas E Kottke, Mayo Clinic and Foundation, Rochester, Minnesota, USA

Smoke Free Europe - A Forum for Networks - 14 AUG 1997