A Primer on Tobacco Treatments
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It has been shown that the majority of cigarette users want to stop smoking.  However, by one year over 85% of smokers have returned to smoking unless they have pharmacological help and that the average smoker has made about ten attempts to quit before long term success.  Even with treatment, so many smokers return to using.  Why is it so difficult?
One important thing to remember before a discussion of treatments is that 99% of the harm of cigarettes comes from the burning of tobacco and the inhalation of carbon monoxide, formaldehyde and over 70 other oxidants and cancer causing chemicals.
  The nicotine may be the addictive component but it does not cause cancer, atherosclerosis or lung disease.  This is why it is considered safe to replace nicotine even though it may maintain the addiction.  Interestingly, a recent study of marijuana smokers found relatively low complications from smoke (but not necessarily zero). This suggests that chemical treatment of the tobacco or the tobacco paper is a cause of much of the toxicity from smoking.

Another thing to remember is that the cigarette industry has had centuries and billions of dollars to perfect the attractiveness of their product by increasing the addictive potential.  The industry has added various chemicals to enhance the burning of the leaf.  This creates a smoke with extremly small particles that penetrate deep into the lung.  This allows an extremely rapid and significant uptake which makes the tobacco particularly addictive. Most treatments cannot reproduce either the speed of nicotine uptake or the peak nicotine levels obtained

Patients often like to brag about having reduce the number of cigarettes they smoke.  The problem is that their technique of smoking almost always changes.  They breathe deeper, hold their breath longer and smoke more of the cigarette. Therefore, unless there is more than a 70% reduction in the number of cigarettes, they are usually not seeing less nicotine or toxic chemicals.

Nicotine substitution is often what most patients turn to first.  I feel nicotine patches, such as Nicoderm, are the most ideal nicotine option as they eliminate
nicotine on-demand and has the best chance to eliminate the use of nicotine completely.  Anyone using more than a half pack starts on the highest dose of 21 mg.  Of course the problem is the slow nicotine uptake and relatively low blood levels.  To partially solve this problem, I advise my heavier  tobacco users to use more than one patch.  I routinely go up to two 21 mg patches. Alternatively, nicotine gum or lozenge or e-cigarette on top of the patch may help stop cigarette use.  This helps many, many patients. Of course, many other patients still find this option less than satisfying because they are looking for that on-demand nicotine surge 

Of course, all the agents have issues with low speed of nicotine uptake.  Although the nicotine inhaler as well as the e-cigarette are inhaled, the nicotine particles are relatively large and they do not get as deep into the lung.  Therefore, nicotine uptake is slower and less satisfying.  One agent that comes close to mimicking the rapid uptake is the Nicotrol nasal spray.  Yes- this is snorting nicotine and yes it maintains the addiction but at least we avoid all the harmful effects of smoke.

IMPORTANT: it is okay to use patches or any nicotine product indefinitely.  Although the idea is to stop since no more than 3 months of treatment are recommended by the company, there is no clear cut harm to long term continued use.  It is infinitely better to do nicotine substitution of any type than tobacco.

People want to know how safe the e-cigarettes are.  These devices work by misting nicotine in warm water.  The devices contain propylene glycol, which is used to keep the nicotine in solution. It is not known to be harmful.  However, since the e-cigarettes are not a prescription medicine, they have not been studied long term with the rigor that the medical establishment usually approaches such a task. Nevertheless, I am reasonably certain that the e-cigarette is far safer than a real cigarette.  

Most users will tell you that the slower uptake of nicotine requires more time spent "smoking" or "misting".  Nevertheless, people can use the e-cigarettes in more places so it may be a fair trade off.

People find e-cigarettes effective and if it works, that is fine, but I still prefer an NON ON-DEMAND approach with the hope that the addiction can be completely overcome.  In addition to patches there are several non-nicotine medications that are effective.

Buproprion is the active ingredient in Wellbutrin and Zyban.  It works by increasing dopamine levels in critical parts of the brain and has been found to be effective in curbing cravings.  About a third of patients benefit and stop smoking.   When combined with nicotine patches, almost 50% of smokers will stop smoking. Buproprion is also an anti-depressant and has the additional benefit of reducing appetite and weight gain sometimes seen with quitting smoking.  

Chantix is a chemical structurally similar to nicotine.  It sits in the nicotine and gives about 60% of the effect that nicotine does.  The less than maximal effect is important since a maximal effect would cause the Chantix to be addictive.  It stays in the body for up to twelve hours allowing steady stimulation  of the receptor and avoiding withdrawal.  It also blocks the receptor from nicotine should the patient smoke while on it.  For these reasons, it is considered a partial agonist/antagonist.  For those of you familiar with Suboxone, you will know it has the same effects and classification related to the opioid receptor.

Chantix is by far and away the most effective medication for terminating the tobacco habit.  I find a third of my patients stop smoking immediately and another third stop smoking eventually.  Many patients smoke on Chantix; however, the number of cigarettes smoked is reduced by over 75% and often the inhalations that are done on Chantix are fewer, more shallow and shorter.  When Chantix is stopped, there may be a very mild nicotine withdrawal; yet, I have numerous patient who have stopped the medication after a few months and have not returned to smoking. 

Chantix has other benefits.  Since it increases dopamine levels on a slow steady basis, it has broader benefits with impulse control disorders.  Alcohol use and cravings go down, so do those for cocaine. It reduces hunger and may lead to weight loss.  

A number of patients have side effects. Vivid dreams are likely and due to dopamine release during the REM state of our sleeping.  Some nausea is also common.  Irritability is seen but it is unclear if this is due to Chantix or not smoking.  Constipation, also reported,is likely due to not smoking as nicotine induces bowel movements.

Unfortunately, depression has gotten a lot of publicity as a complication of treatment.  Yet it is unclear that Chantix causes this as opposed to just failing to prevent it.  Nicotine is a stimulant. Any withdrawal of stimulants is associated with depression which is occasionally severe.  When a smoker, who is trying to quit, gets very depressed, they may grab a cigarette.  If Chantix is on board, the cigarette has no effect.  While I would not recommend unstable psychiatric patients to start this, I would not avoid it for stable patients.  Most patients do not get depressed.  Even the few that do become "
depressed" seemed to have overly anticipated the problem and quickly blame any bad feelings on Chantix-right or wrong.  Many just use the publicity as an excuse to avoid making any attempts to stop.

Other drugs that are not approved for nicotine addiction have been found to be useful in stimulant withdrawal use in general.  They include baclofen and low-dose zofran.  The also provide benefit.

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