Breaking the Tobacco Smoking Habit

 

We are now 100 years into an epidemic of avoidable, tobacco-induced health problems and over 50 years into the attempt to stop it, with more knowledge accumulating every year about the toll tobacco smoking takes on every part of the human body. Each year, smoking costs US society $130-170,000,000 in medical care, $150,000,000 in lost productivity and 400,000 lives lost prematurely. Over 160 million people live with serious, smoking related illnesses. Still, 20% of adults smoke regularly, and young people continue to join their ranks. If you never picked up the habit, be glad. If you have picked it up and managed to kick it, congratulations. You are part of a slow public health success story, and, by understanding the smoking habit, you may be able to help someone else quit.

The evolution of cigarettes

Tobacco was the first crop sold for profit by the American colonists, who introduced Europeans to pipe-smoking and tobacco chewing in the 1600s. However, the smoking habit did not begin in earnest until the invention of a cigarette rolling machine in 1883. By the 1940s smokers in the United States lit up 300 billion cigarettes per year and during WWII, soldiers’ ration kits included cigarettes. By the 1950s, 44% of US adults smoked regularly. Psychiatry texts in the 1960s urged doctors to light up with their patients and, by then, cigarette consumption topped 500 billion per year. Older adults today recall being raised in smoke-filled houses, driven around (without seatbelts) in smoke-filled cars, and sent to the corner store to buy cigarettes for their elders.

Recognition of the problem

Though the 1964 Surgeon General’s report confirmed what many people by then knew – that tobacco was bad for health, wrinkled skin prematurely and caused lung cancer, other lung problems and vascular disease  – cigarette consumption rates continued to climb well into the 1980s. But then decades of educational, political, legal and economic pressures on smokers began to work. By 2012, public places were largely free of tobacco smoke, ex-smokers outnumbered active smokers, and cigarette consumption rates had fallen back to the 1940’s levels. Anti-smoking advocates are rightly proud of their efforts, but the credit must also go, in great measure, to the individuals who did battle with the smoking habit and succeeded. Breaking the smoking habit is difficult, often requiring many attempts and relapses before the goal is achieved.

Nicotine is addictive

Smoking becomes a habit because tobacco contains nicotine, which changes the chemistry of the brain in a way that makes the tobacco user uncomfortable when the nicotine level falls. Tobacco companies have exploited the addictive qualities of nicotine by manufacturing their products to diminish negative physical effects and enhance addictive ones. Menthol soothes the smoke-irritated throat. Nicotine is added in just the right dose – not enough to provoke toxic symptoms like nausea, vomiting dizziness and diarrhea, but just enough to ensure the desire for more.

In addition to physical addiction, smokers develop psychological addiction, a learned desire or craving for smoking that arises from the association of smoking’s pleasure with certain situations such as social gatherings, meals, stressful or anxiety provoking circumstances or boredom. Sophisticated advertising techniques add to the social cachet of smoking and subtly enhance these psychological cravings. The combination of physical and psychological addiction means a two-pronged attack is often necessary to help a smoker who wants to quit.

Two-part attack on a two-part addiction

    Physical addiction to any substance produces withdrawal symptoms when the substance is no longer available to the body. In the case of tobacco, irritability, anxiety, insomnia, abdominal cramps and depression occur within hours of smoking cessation. These symptoms peak and begin to diminish within several days and will stop in a predictable period of time – about 2-4 weeks – after the last does of nicotine.

    Since nicotine can be delivered to the brain without the many carcinogenic chemicals in cigarette smoke, nicotine replacement therapy (NRT) is helpful to someone who is trying to stop a smoking habit, allowing time to deal with the psycho Nicotine is available in non-prescription gums, lozenges and skin patches. Nicotine inhalers and nasal sprays require a prescription. Eventually, though, the physical withdrawal symptoms will have to be suffered when the ex-smoker decides to give up the nicotine.

    E-cigarettes also deliver smoke-free nicotine, by vaporizing it in water. They are highly engineered products containing plastics, ceramics and metals and their long term risks are as yet unknown. Unlike the other nicotine delivery systems, e-cigarettes involve regular smoking behaviors and cannot be expected to help diminish the psychological cravings involved in the habit. 

    Psychological cravings that prompt smoking are often far longer lasting than physical withdrawal symptoms – and more responsible for relapse. In most studies of smoking cessation, behavioral therapy is key to long term cessation. Such intervention can take many forms, including one-on-one counseling, supportive group therapy and even online group participation. Many online resources are available to help smokers cope with this aspect of tobacco addiction. (see list below).

Two drugs are also commonly prescribed to help smokers quit. One, varenicline (Chantrix), attaches itself to nicotine receptors partially stimulating them and relieving withdrawal symptoms and at the same time blocking a sense of reward from inhaled nicotine. Another drug, Bupropion (Wellbutrin), is an antidepressant. These drugs improve smoking cessation rates slightly, and are more effective if used in conjunction with NRT. Both, however, are associated with some troublesome reports of behavioral changes, now noted in black box warnings on their packaging.

The cold turkey method- just as effective 

While public health measures have contributed significantly to decreasing smoking rates, breaking the smoking habit remains an individual project and the single most effective measure a smoker can take to improve health. One curious smoking cessation statistic confirms what many doctors have long observed – that cold-turkey quitting is as effective as any of the assisted methods. It appears that the whole-hearted decision to stop, once made without any reservations, could be the most important factor in long term success. This method has no unwanted side effects or risks and does not require withdrawal of nicotine replacements once the psychological smoking habit is tamed. Non-smokers can play a large role in aiding people whom they care about to make this final decision.

Resources for Smokers Who Want to Quit
http://smokefree.gov/
http://www.cdc.gov/tobacco/quit_smoking/how_to_quit/
http://www.lung.org/stop-smoking/how-to-quit/
http://www.nlm.nih.gov/medlineplus/quittingsmoking.html

The Opiate Epidemic: Why Now?

In the 1970s, doctors in inner city hospital saw many patients suffering complications of heroin use, but outside those communities there was no talk in the media about an epidemic of opiate abuse. Now, four decades later, the state of Kentucky is suing Purdue Pharma for the devastating effects of its opiate drug OxyContin on its citizens, the Governor of Vermont devoted his 2015 State of the union address to the problems of prescription opiate and heroin abuse in his state, and a California doctor was recently convicted of second degree murder in the narcotic overdose deaths of three patients. And these just a few of the news stories related to our current “opiate epidemic.” Is this a new problem, and if so, how did we get here?

What are opiates? 

Opiates are psychoactive substances that have been used for over 5000 years. They are derived from the poppy plant and ingested, smoked or injected to produce relaxation, pleasant euphoria and mild hallucinations. Medically speaking, they also alleviate pain, coughing and diarrhea. Opium, the general name for poppy plant extracts, is a complex mix of substances which include the alkaloid chemicals morphine and codeine. Morphine was isolated and named in Germany in 1805. Though very effective as a pain remedy, morphine was, by the end of the Civil War, termed a “hydra headed monster” that was “wrecking lives and home.” In a search for a non-addictive opiate, an English pharmacist created heroin in in 1874. Synthetic offshoots like Vicodin, Percodan and Percocet followed in the 20th century, and OxyContin debuted in the mid-1990s.

Dependence and addiction

Opiates alter the brain’s structure and chemistry. Normally, the brain produces “endogenous opioids” in response to activities that are pleasant and rewarding. In response to opiate drugs, the brain promptly lowers its own opioid production. If the drug supply is interrupted, the lack of internal production of opioids causes withdrawal symptoms – agitation, nervousness, high blood pressure, pain, nausea, vomiting and seizures. Opiate use has produced dependence on an external source. Its severity depends on dose and length of time opiate drugs have been used. When the next dose preoccupies thinking and drug seeking interferes with routine life, causing medical and social ills, dependence has become addiction.

Withdrawal symptoms are relieved by taking more opiate drugs, but over time the dose required to keep withdrawal symptoms at bay increases.  This is called tolerance. At the same time, however, the opiate dose that causes respiratory depression does not change and one of the side effects of progressively larger doses of opiates is respiratory depression – failure to breathe. Respiratory depression is the usual mechanism for death in someone who has overdosed on an opiate drug.

The road to heroin addiction

Since 1999, opiate overdose deaths have quadrupled in this country. Prescriptions for opiates have skyrocketed, as has heroin use. The US accounts for eighty percent of the opiates consumed in the world and an estimated 2.1 million Americans have opioid related substance abuse problems. Medically speaking, though, this is not an epidemic and it is not a new problem. The reasons for the hyperbolic use of epidemic language in the media are sociologic. We have entered a new era in which the pattern of use of heroin has changed dramatically, moving out of the lower socioeconomic strata into smaller cities, towns and wealthy suburbs and into the lives of children. In this story, the medical profession and pharmaceutical industry have played roles as large as those of innovative drug dealers from a small town in Mexico.

In the modern history of the poppy plant derivatives, heroin was a street drug and heroin users were typically found in decaying inner cities. The other opiates remained under the control of physicians, who were constrained in their prescription writing by the fact that these drugs fell under federal controlled substance laws. Use was restricted even in terminally ill cancer patients because of fear of addiction, a view that changed only after the advent of the hospice movement in the 1970s.

By the 1980s, buoyed by the good feelings of providing relief for cancer pain, doctors who dealt with other forms of chronic pain – typically orthopedic in nature, but also nerve pain and headaches – began to change their views about the use of narcotics. A short letter in the prestigious New England Journal of Medicine in 1976 stated that a review of hospitalized patients who had received opiates showed no evidence of significant risk of later addiction to the drugs. Though it was nothing of the kind, this letter was later described as a “landmark study” and used to support the view that, when used to treat pain, opiates did not cause addiction.

By the 1990s powerful opiates were flowing into the community in large quantities for routine treatment ankle sprains and dental work. In hospitals, pain became the “fifth vital sign,” measured subjectively by the patient on a 1-10 scale, and used in hospital satisfaction surveys used for quality control. Opiates flowed much more freely because patient satisfaction surveys counted for insurance reimbursement and discharge medications often included narcotic prescriptions.

OxyContin appears

While medical prescribing practices were changing, Purdue Pharma developed OxyContin. Heavily marketed as a product that could not cause addiction because the patented timed release would prevent the initial high and euphoria associated with the conventionally produced pills, the drug came in large doses. But people seeking a high soon learned to crush the continuous release pills. OxyContin quickly became a popular street drug, sold by the people who were getting prescriptions for the myriad pains that bring people to doctors’ offices. Pill mills popped up where drug seekers could find unethical doctors willing to write prescriptions with no requirements other than money.

Heroin is cheaper than OxyContin  

Heroin requires no doctor’s prescription, is far cheaper than stolen OxyContin sold on the streets, and satisfies the dependence, tolerance and addictions of people who have slipped into those traps with prescription drugs. Heroin overdoses are claiming teenagers in wealthy suburbs of Midwestern cities and in New England – because heroin has arrived there with young men who deliver small amounts directly to customers who contact them by phone. These dealers are salaried non-users, they provide reliable quality heroin, and they disappear back into Mexico after short term stays.

Rethinking

Solutions will have to come from objective study of the results of loosening the standards of prescribing addictive and mind-altering drugs for self-limited problems that can be adequately treated with lesser drugs. And while the care of the terminally ill and some patients with severe nerve pain may require opiates, there have been no controlled studies on risk vs benefit for the treatment of other chronic pain problems, ones which may benefit more from a comprehensive approach combining lifestyle changes, exercise and counselling such as had been provided in pain clinics in the past. Last but not least, doctors and patients could all benefit from a widespread educational campaign about signs of increasing tolerance to and dependence on brain altering drugs.

 

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