Varenicline: progress in smoking cessation treatment

Varenicline is the first pharmacological aid for smoking cessation treatment to be approved in almost a decade. Varenicline is an alpha4beta2 nicotinic acetylcholine receptor partial agonist. It may assist those who wish to quit smoking by producing partial activation at nicotinic receptors to ease craving and withdrawal symptoms; and by simultaneously blocking the effects of nicotine from cigarettes smoked, thereby reducing the satisfaction of continued smoking. The effectiveness of varenicline as an aid for smoking cessation has been demonstrated in several clinical trials versus placebo and sustained release bupropion. In addition, varenicline is well tolerated and has an acceptable safety profile. As an aid for smoking cessation, varenicline offers progress in the treatment of tobacco dependence.

Lesões pulmonares provocadas pela nicotina por via subcutânea em ratos

OBJETIVO: Estudo com o objetivo de observar a influência da nicotina, aplicada pela via subcutânea, em pulmões de ratos. MÉTODOS: Foram utilizados 20 ratos Wistar pesando 235± 35g, separados aleatoriamente em 2 grupos iguais. O grupo I (n=10) recebeu nicotina na dose de 2 mg/Kg/dia pela via subcutânea durante 20 dias e o grupo II (n=10) recebeu placebo pela mesma via de administração. RESULTADOS: Os resultados mostraram que no grupo I ocorreu broncopneumonia em 3 (30%) ratos, leucocitose alveolar em 10 (100%) e leucocitose septal em 7 (70%). Atelectasia foi encontrada em 2 (20%). Transformados em escores, os dados totalizaram 52 pontos. Os escores das alterações observadas nos pulmões do grupo II atingiram 11 pontos (p<0,05). CONCLUSÃO: Os dados permitiram concluir que o uso da nicotina por via subcutânea contribuiu para o aparecimento de lesões pulmonares em ratos, em número e intensidade significativamente maiores do que nos animais considerados controles.

Initial tobacco use episodes in children and adolescents: current knowledge, future directions

Approximately three-quarters of adult tobacco users report that their first tobacco use occurred between ages 11 and 17, while many adults who do not regularly use tobacco report that they experimented with it as adolescents. Surprisingly little is known about the effects of these initial tobacco use episodes and their influence on adult tobacco use patterns. In particular, understanding the role that nicotine plays in these early tobacco use experiences may be important in understanding the development of regular tobacco use and concomitant nicotine dependence. One goal of this review is to summarize current knowledge regarding the effects of initial tobacco use episodes in adolescents and to discuss nicotine exposure in initial tobacco use episodes. Another goal is to outline a research agenda designed to learn more about initial tobacco use episodes and the effects of nicotine in children. An ethical rationale and some potential methods for this research agenda are presented.

Smokeless tobacco: an addicting drug

In 1986, the Surgeon General concluded that smokeless tobacco is an addictive drug sharing many qualities with other drugs of abuse such as morphine and cocaine. Smokeless tobacco can be used to deliver psycho-active and dependence-producing levels of nicotine. Tolerance develops with repeated use, causing the user to increase nicotine dosing through increased use and/or switching to products with higher nicotine yields. Clinical signs of nicotine withdrawal develop upon cessation of use. Recent data show that smokeless tobacco products vary widely in their nicotine dosing capabilities. Low-dose products tend to be those commonly marketed toward, and used by, young people without previous smokeless tobacco experience. Many of these people develop dependence and switch to high-dose products. The present article discusses each of these qualities of smokeless tobacco in greater detail. The article also discusses qualities of smokeless tobacco that make it an effective nicotine delivery device that leads to addiction.

Personality differences related to smoking and adult attention deficit hyperactivity disorder

Tridimensional Personality Questionnaire (TPQ) scores are compared for three groups of adults: (a) current smokers with Attention Deficit Hyperactivity Disorder (ADHDSmk, n = 14); (b) current smokers without ADHD (NonADHDSmk, n = 21); and (c) ADHD never smokers (ADHDNevSmk, n = 17). The ADHASmk participants started smoking at a significantly younger age than NonADHDSmk participants. On the TPQ Novelty Seeking (NS) scale, all groups scored more than a standard deviation above the norm, and ADHDSmk participants scored significantly higher than NonADHDSmk participants. The earlier onset of smoking in ADHD adults suggests that smoking prevention efforts may be particularly important for ADHD children. Previous studies have reported that both smokers and ADHD patients have elevated NS scores; this study suggests an additive effect for smokers with ADHD. This exaggerated tendency towards thrill seeking in ADHDSmk participants may complicate smoking-cessation treatment in this population, because the health consequences of smoking may be of less concern to ADHD smokers.

Depressive symptomatology and smoking among persons with diabetes

The purpose of this study was to determine whether (a) symptoms of depression are more prevalent and severe among diabetic smokers than diabetic nonsmokers, (b) smoking is related to depressive symptomatology among diabetic patients, and (c) there is a positive relationship between number of cigarettes smoked and severity of depressive symptoms. Diabetic non-smokers (n = 103) and diabetic smokers (n = 83) were surveyed regarding symptoms of depression as measured by the Beck Depression Inventory (BDI). Depressive symptomatology was more prevalent and severe among smokers than nonsmokers. Smoking was significantly associated with depressive symptomatology. Among smokers, the number of cigarettes smoked per day was independently associated with cognitive symptoms of depression.

Nicotine-related brain disorders: the neurobiological basis of nicotine dependence

1. This paper was written at a moment when the dependence liability of nicotine, the psychoactive component from tobacco, was the center of a dispute between the tobacco manufacturing companies and the scientific community (Nowak, 1994a-c). Without being comprehensive, it tries to summarize evidence compiled from several disciplines within neuroscience demonstrating that nicotine produces a true psychiatric disease, behaviorally expressed as dependence to the drug (American Psychiatric Association, 1994). Nicotine dependence has a biological substratum defined as "neuroadaptation to nicotine." 2. The first part of the article defines terms such as "abuse," "tolerance," "dependence," and "withdrawal." It discusses clinical and experimental facts at the whole-organism level, showing that animals and humans will seek and self-administer nicotine because of its rewarding properties. 3. The second part discusses the neurobiological basis of neuroadaptation to nicotine. It presents information on neuroanatomical circuits which may be involved in nicotine-related brain disorders, such as the mesocorticolimbic pathway and the basal forebrain-frontal cortex pathway. It also discusses work from several laboratories, including our own, that support the notion of a molecular basis for neuroadaptative changes induced by nicotine in the brain of a chronic smoker. 4. Although still under experimental scrutiny, the hallmark of neuroadaptation to nicotine is up-regulation of nicotinic receptors, possibly due to nicotine-induced desensitization of their function (Marks et al., 1983; Schwartz and Kellar, 1985). A correlation between these plastic changes and the behavioral data obtained from animal and human experiments is still needed to understand dependence to nicotine fully.

Sensation seeking, nicotine dependence, and smoking motivation in female and male smokers

Sensation-seeking scores in female (n = 36) and male (n = 60) French smokers were compared with those for a control group of female (n = 23) and male (n = 45) nonsmokers. The findings clearly show that smokers of both sexes are higher in sensation seeking than their nonsmoking counterparts: they score higher on the Disinhibition, Experience Seeking, and Boredom Susceptibility components of sensation seeking. Smoking women were particularly high on Experience Seeking. The relationships among the sensation-seeking components, nicotine dependence, and motives for smoking were assessed in the smokers. Disinhibition and Experience Seeking moderately correlated with nicotine dependence in females, as assessed by the Fagerström questionnaire and the Addictive factor of the Russell Classification of Smoking by Motives. Women high in Experience Seeking may be at particular risk for smoking and possibly for dependence. Further research is needed to state that the high sensation seeker is a person who might be expected to be particularly sensitive to the stimulating reward of smoking, and thus particularly vulnerable to becoming a dependent smoker.

Pharmacological and non-pharmacological smoking motives: a replication and extension

Cigarette smokers (n = 387) completed a questionnaire measure of smoking motives, and subgroups of this sample provided external validation information. Seven factors emerged from a principal components' analysis: automatic, sedative, addictive, stimulation, psychosocial, indulgent and sensorimotor manipulation. A higher-order principal components analysis revealed the presence of two second-order factors. Inspection of the pattern of correlations between factor scores and criterion variables clearly indicated that the first four factors above and their underlying second-order factor are more closely related to nicotine pharmacology and mood-altering effects of nicotine than the latter three motives and their underlying second-order factor. Moreover, the positive correlations between these pharmacological motives and age, coupled with a negative relationship between age and the non-pharmacological motives, support the description of the smoking career as a progressive transfer of reward from non-pharmacological to pharmacological factors. These findings suggest that self-reported reasons for smoking represent more than bias in verbal report.

Nicotine dependence and alcoholism epidemiology and treatment

Nicotine dependence in alcohol-involved adults is a long-ignored treatment problem. The absence of its discussion in the literature is difficult to defend in light of medical and epidemiological data on the cost and prevalence of this dual addition. Most descriptive studies of alcohol abusers published in the past 20 years have reported tobacco use rates of at least 90%. There is a crucial need to educate treatment professionals and their clients about the additional health risks associated with joint nicotine dependence and alcoholism. Historically, certain barriers to active intervention have existed in drug abuse treatment facilities, including (1) concerns that urging clients to quit smoking might have an adverse effect on their maintenance of sobriety, (2) a tendency to minimize the strength and severity of nicotine addition, (3) a lack of informative data on how best to treat smoking in recovering alcoholics, and (4) financial issues related to marketing and insurance compensation. Recent data obtained from recovering alcoholics who have tried to quit smoking and anecdotal reports from alcoholism treatment centers that have begun addressing nicotine addiction are now challenging these barriers. Education, role modeling, environmental control, and development of staff expertise can be incorporated into standard alcoholism treatment programs to jointly treat these paired addictions.

Nurses and smoking: review and implications

An analysis of smoking behavior among nurses shows unacceptably high levels of smoking, despite some evidence of a downward trend. In this article, the nature of tobacco dependence is examined, and an extensive review of demographic and causative factors associated with the smoking behavior of nurses is presented. The impact of smoking on the practice of nurses, particularly related to their ability to serve as health educators and role models, is critically examined. Areas for potential research and inquiry, along with some overall strategies for intervention, are identified.

The role of nicotine in tobacco use

The 1988 US Surgeon General's Report titled "Nicotine Addiction", is cited frequently in the literature as having established the "fact" that nicotine derived from cigarette smoke is addictive in the same sense as "classic" addicting drugs such as heroin and cocaine. This manuscripts critically evaluates key research findings used in support of this claim and identifies shortcomings in the data that seriously question the logic of labeling nicotine as "addictive". In addition, the manuscript argues that the role of nicotine in tobacco use is not like the role of cocaine in coca leaf use as argued by the 1988 Surgeon General's Report, but is, in fact, more like the role of caffeine in coffee drinking as concluded in the 1964 US Surgeon General's Report.

Cardiac output and the blood pressure increase in deoxycorticosterone acetate-salt hypertension after nicotine infusion

We wished to determine if nicotine exaggerates the blood pressure increase in deoxycorticosterone (DOCA)-salt hypertension. Uninephrectomized, male Sprague-Dawley rats were implanted with DOCA pellets (75 mg) and placed on a 5.2% salt diet for sixteen days and then infused with nicotine (DOCA-Nicotine; 2.4 mg/kg/day) or vehicle (DOCA-Sham). Control animals were treated with vehicle (Control) or nicotine (Control-Nicotine). The DOCA-Nicotine group had significantly greater tail-cuff blood pressures than the DOCA-Sham group by one week of nicotine infusion. At 2.5 weeks of nicotine infusion the DOCA-Nicotine rats had significantly greater tail-cuff blood pressures, direct arterial blood pressures, and cardiac outputs compared to the DOCA-Sham animals. Renal blood flows were similar in the two groups. Control-Nicotine animals demonstrated no response to nicotine during 2.5 weeks of infusion. We conclude that in the DOCA-salt rat nicotine induces an exaggerated rise in blood pressure and that the mechanism involves an increase in cardiac output.

Smoking, cessation, and the diabetes health care team

Cigarette smoking is a major risk factor in diabetes and contributes to the development of microvascular and macrovascular complications. Despite this, approximately one third of patients with diabetes smoke. Nicotine is physically and psychologically addictive, with multiple factors contributing to the initiation and continuation of the habit. Cessation is a process in which the smoker progresses through several stages of change, including precontemplation, contemplation, action, maintenance, and relapse. Knowledge of this process is needed for the diabetes health care team to effectively individualize smoking prevention and cessation strategies. This stepped care approach includes preventive, behavioral, and pharmacologic strategies as a component of routine diabetes education.

Involvement of tobacco in alcoholism and illicit drug use

Survey data from the United States indicate that tobacco use is associated with the initiation of use of other addicting substances, and that increasing levels of tobacco use are associated with increasing levels of use of other psychoactive substances. Furthermore, factors affecting initiation, abstinence, and relapse to the use of tobacco, alcohol, and opioids are similar in nature. In addition, there are similarities in the addictive process underlying the use of these substances. Taken together, these data suggest that tobacco use is involved, possibly more than by simple association, in the use of other substances containing psychoactive chemicals. In the present paper we discuss the involvement of tobacco in the use of alcohol, opioids, cocaine, and other substances, as well as some of the implications of these observations for researchers and clinicians. One such implication is that it may be possible to use tobacco and nicotine as models for phenomena of interest to other substance use researchers. For example, drug abuse treatment and prevention strategies could be explored using tobacco use as a target behavior, and biological phenomena such as the development of tolerance and physical dependence may be more readily studied with nicotine than with many other drugs. Certain pharmacologic differences across substances are also discussed in light of their implications for development of treatment and drug control policies.

Desensitization of central cholinergic mechanisms and neuroadaptation to nicotine

This review focuses on neuroadaptation to nicotine. The first part of the paper delineates some possible general mechanisms subserving neuroadaptation to commonly abused drugs. The postulated role of the mesocorticolimbic neuroanatomical pathway and drug-receptor desensitization mechanisms in the establishment of tolerance to, dependence on, and withdrawal from psychoactive drugs are discussed. The second part of the review deals with the pharmacological effects of nicotine at both pre- and postsynaptic locations within the central nervous system, and the still-perplexing upregulation of brain nicotine-binding sites seen after chronic nicotine administration. A special emphasis has been put on desensitization of presynaptic cholinergic mechanisms, and postsynaptic neuronal nicotinic-receptor function and its modulation by endogenous substances. A comparison with the inactivation process occurring at peripheral nicotinic receptors is also included. Finally, a hypothesis on the possible connections between desensitization of central cholinergic mechanisms and neuroadaptation to nicotine is advanced. A brief comment on the necessity of fully understanding the effects of nicotine on the developing nervous system closes this work.

Tertiary-level interventions for hard-core smokers

It has become more commonplace to find that today's smokers fit into one of four target populations: (1) persons with a history of cessation failures; (2) persons with a history of other addictive disorders; (3) persons with smoking-related diseases; and (4) persons with a history of psychiatric impairment. This article addresses the need to expand and create a new methodology for smoking cessation to suit these patients. Interventions geared toward a tertiary level of treatment are offered. This article also examines treatment within the context of phase-specific interventions.

Nicotine dependence and alcoholism epidemiology and treatment

Nicotine dependence in alcohol-involved adults is a long-ignored treatment problem. The absence of its discussion in the literature is difficult to defend in light of medical and epidemiological data on the cost and prevalence of this dual addiction. Most descriptive studies of alcohol abusers published in the past 20 years have reported tobacco use rates of at least 90%. There is a crucial need to educate treatment professionals and their clients about the additional health risks associated with joint nicotine dependence and alcoholism. Historically, certain barriers to active intervention have existed in drug abuse treatment facilities, including (1) concerns that urging clients to quit smoking might have an adverse effect on their maintenance of sobriety, (2) a tendency to minimize the strength and severity of nicotine addiction, (3) a lack of informative data on how best to treat smoking in recovering alcoholics, and (4) financial issues related to marketing and insurance compensation. Recent data obtained from recovering alcoholics who have tried to quit smoking and anecdotal reports from alcoholism treatment centers that have begun addressing nicotine addiction are now challenging these barriers. Education, role modeling, environmental control, and development of staff expertise can be incorporated into standard alcoholism treatment programs to jointly treat these paired addictions.

Physiologic effects of nicotine polacrilex

Nicotine is the pharmacologically active agent in tobacco responsible for the maintenance of cigarette smoking behavior. Paradoxically, nicotine also offers the most promise in the successful treatment of cigarette smoking when it is delivered to the central nervous system in a safer and more manageable form. By transferring the physiologic dependence from nicotine contained in tobacco to nicotine bound in a polacrilex, the behavioral aspects associated with cigarette smoking can be removed with a minimal amount of discomfort or risk of relapse. Nicotine bound to a polacrilex and administered as a chewing gum is currently the replacement of choice since many of the systemic effects of nicotine delivered via this route are similar to the effects of nicotine delivered in cigarette smoke without the accompanying exposure to carbon monoxide and tar. Factors such as administered dose, schedule of dosing, and rate and vigor of chew, however, can significantly alter the desired effects. This paper provides a summary of the physiologic changes which may affect the effectiveness of nicotine gum as a pharmacologic adjunct in the treatment of tobacco dependence.

Implications for the practicing physician of the psychosocial dimensions of smoking

The multifaceted nature of smoking includes its physiologic, social, and psychologic dimensions and its career features. It develops over time, through phases such as experimentation or conditioning. It also is given up over time, often after several unsuccessful attempts. Several repetitions of a sequence of considering cessation, attempting to quit, and relapsing are likely to precede permanent cessation. Those who are not ready to commit themselves to quitting may be reached by low-key information more than by too forceful exhortation. Those who are ready to quit may select from among a range of approaches, including group clinics, "self-help" manuals, and physician counseling. Maintenance requires as much attention as does cessation. Cooperation from those around the quitter, reminders to use skills for coping with stressors or temptations, and continued encouragement from the physician may all encourage long-term abstinence. Owing to the multifaceted nature of smoking and quitting and the multiple approaches to cessation and its maintenance, the physician may best be viewed as a catalyst for nonsmoking. If appropriate to his or her practice, this may include extended patient counseling, but those unable to provide this may still make great contributions through brief information on why it is important to quit, encouragement to do so, timely referral to other staff or to materials and programs available in the community, and continued expression of interest in the patient's efforts and/or success. All these may catalyze quitting without demanding excessive time or skills beyond those commonly employed by the physician. In catalyzing nonsmoking, the physician can also be an effective proponent of community or voluntary agency programs as well as institutional and governmental policies to limit smoking in health care facilities and public places. The American College of Chest Physicians' policy encouraging nonsmoking among its Fellows and in their offices is an excellent example of this catalyst role.