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Treatment of Tobacco Dependence in Mental Health and Addictive Disorders (PDF) 

Conclusions and Recommendations

Our review highlights the advances during the last decade in the treatment of TD in people with MHA disorders. Much progress has been achieved. Treatment combining intensive CBT and multiple pharmacotherapy has shown the greatest efficacy. Among the many studies measuring changes in psy- chiatric symptoms during smoking treatment, most show improvements. Increasing the efficacy of these interventions may be achieved through extending the duration of treat- ment, providing them in the context of mental health care,60 and promoting reduction as an acceptable initial treatment goal. MET and CM as adjunctive interventions to increase readiness to quit, treatment usage, and smoking abstinence (or reduction) should also be evaluated in future studies, and CBT should be used as a part of relapse-prevention therapy. Experimental therapies, such as selegiline and nicotine vac- cine, among others, have yet to be tested in MHA smokers.95 An evidence-based algorithm for the general approach to smoking cessation in people with MHA disorders is displayed in Figure 1.

Additional recommendations include creating and establishing programs to raise the awareness and ability of mental health care professionals to identify and treat people with TD. . . .

With the exception of obsessive–compulsive disorder, all of the major MHA disorders are associated with a significantly higher prevalence of smoking than that found among the gen- eral US population.9 To date, there has been only one treat- ment study of smokers with BD, and none have targeted smokers with panic disorder. The evidence suggests that many of the patients with these disorders may be able to reduce their smoking or achieve abstinence if provided with treatment. Future research is needed for these MHA subgroups.

Lastly, there is a critical need for research aimed at identify- ing smoker characteristics that predict positive smoking ces- sation treatment outcomes (usage, reduction, and [or] abstinence) among smokers with MHA. For example, some studies have found that atypical antipsychotic medication is associated with short-term abstinence in treatment combin- ing MET and NRT or bupropion.6,49 To the extent that people with schizophrenia smoke to help alleviate pathophysiologic aspects of their condition, such as prefrontal cortical and information processing deficits, pharmacological treatments targeting these processes may lead to improved cessation out- comes.9,31 A similar approach is needed in treatment studies of smokers with other MHA diagnoses.

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Nicotine Creates Stronger Memories, Cues To Drug Use 

Ever wonder why former smokers miss lighting up most when they are in a bar or after a meal with friends?

Researchers at Baylor College of Medicine say nicotine, the addictive component in cigarettes, "tricks" the brain into creating memory associations between environmental cues and smoking behavior. The findings appear in the current issue of the journal Neuron.

"Our brains normally make these associations between things that support our existence and environmental cues so that we conduct behaviors leading to successful lives. The brain sends a reward signal when we act in a way that contributes to our well being," said Dr. John A. Dani, professor of neuroscience at BCM and co-author of the study. "However, nicotine commandeers this subconscious learning process in the brain so we begin to behave as though smoking is a positive action."

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• AUDIO: The link between smoking and darker skin  

new research says just how addictive smoking is for you depends on the color of your skin. "Living on Earth's" Ike Sriskandarajah filed this report.

Dr. Gary King from Pennsylvania State University studied nicotine -- the highly addictive stimulant that makes people crave cigarettes -- and melanin, a compound your body makes that determines how dark you are. And he found a connection.

According to Dr. King, the melanin is strongly attracted to nicotine, and the way it works is when you light up a cigarette, the tobacco and all the chemicals created when it burns into your mouth, into your lungs and the rest of your organs, including your biggest organ ... skin.

"Skin does react like every other organ in the body unto nicotine and the other 4,000 chemicals that are consumed when one actually smokes," said Dr. King. "And that binding process in and of itself may lead to greater dependence."

Inhaling thousands of chemicals is not a good idea. But it is especially bad for people with dark, melanin-rich skin. That's because melanin grabs and hangs onto the nicotine.

Greater dependence means it's much harder for darker skinned people to kick the habit. In fact white smokers on average are 15 percent better at quitting than blacks. . . .

Which is why Dr. King's next step is to survey dark and light skinned people all over the world. His findings are based on a pretty small sample -- 150 subjects, all of whom are African American.

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Professor: Nicotine does not cause cigarette addiction 

An ASU professor is challenging widely held conceptions about smoking, including challenging the view that nicotine is addictive.

Peter Killeen, emeritus professor of psychology in the College of Liberal Arts and Sciences, presented his research findings for the National Institute on Drug Abuse on the Tempe campus Wednesday afternoon.

The talk was called “Reefer Madness: There ain’t no such Thing as Addiction to Nicotine.”

NIDA initially invited Killeen to look into ways to improve scientific research on drug abuse, specifically nicotine addiction.

“I came up with a shocking discovery,” Killeen said. “There’s no such thing as nicotine addiction.”

“It’s time to get our heads straight,” Killeen said. “What causes the tremendously addicting power of cigarettes is the drug cocktail of nicotine,” he said, not nicotine itself.

Before he got into his findings, Killeen said he wanted to make clear that tobacco kills. . . .

“Studies have shown that none of the nicotine replacement therapies — chewing gum, inhalers, patches — none of those are addictive,” he said. “Nicotine is not addictive. So what’s going on?”

The cause of addiction is the release of monoamine oxidase inhibitors, or MAOIs, along with nicotine, Killeen said.

While nicotine affects the release of dopamine, or the “reward hormone” that affects emotions and movement, MAOIs help regulate dopamine levels, Killeen said.

“When you put together something that directly releases dopamine and another thing that helps the brain clean up excess dopamine, you’ve got a one-two punch,” he said. “It is my hypothesis that it’s a combination of nicotine with some of these other chemicals that causes the powerful addiction.”

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• Smoking Cessation During Substance Abuse Treatment 

Conclusions

Many individuals in substance abuse treatment are quite willing and able to quit smoking with the assistance of pharmacological and behavioral support. Although absolute quit rates tend to be lower for smokers who are in treatment than for those in recovery from alcohol and other substance use disorders, smoking cessation interventions are effective for both groups and do not appear to increase the risk of relapse to alcohol and other drug use.

Some individual and organizational barriers need to be overcome to improve smoking cessation outcomes among those in substance abuse treatment. However, the available research as well as our own experience suggest that quitting smoking during substance abuse treatment is indeed achievable--in other words, a mission possible.

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• Women and Smoking: An Interdisciplinary Examination of Socioeconomic Influences  

• Research shows temptation more powerful than individuals realize 

Whether it's highlighted in major news headlines about Argentinean affairs and Ponzi schemes, or in personal battles with obesity and drug addiction, individuals regularly succumb to greed, lust and self-destructive behaviors. New research from the Kellogg School of Management examines why this is the case, and demonstrates that individuals believe they have more restraint than they actually possess--ultimately leading to poor decision-making.

The study, led by Loran Nordgren, senior lecturer of management and organizations at the Kellogg School, examined how an individual's belief in his/her ability to control impulses such as greed, drug craving and sexual arousal influenced responses to temptation. . . .

In developing their case, the study's authors cited previous research demonstrating that people often have difficulty appreciating the power of impulsive states. People in a "cold state" (not experiencing hunger, anger, sexual arousal, etc.) tend to underestimate how a "hot," impulsive state will influence their behavior. To expand upon these findings, the study authors set out to test whether:

* People in a cold, non-impulsive state will overestimate their ability to control impulses

* People in a hot, impulsive state will have a more realistic view of their capacity for impulse control

* People who perceive they have a high capacity for impulse control will expose themselves to more temptation and will ultimately exhibit more impulsive behavior

To test their hypotheses, the researchers conducted four experiments focusing on hunger, addiction and mental fatigue. Each experiment resulted in significant "restraint bias."

For example, one experiment focused on cigarette addiction found those who overestimated their capacity for self-control were much more likely to smoke a cigarette after simply watching a movie about smoking. Another experiment centered on hunger. Results found a satiated group was significantly less likely to return snacks than a hungry group who limited their temptation by choosing less appealing snacks.

"A system which assumes people will control themselves is going to fall prey to this restraint bias; we expose ourselves to more temptation than is wise, and subsequently we have millions of people suffering with obesity, addictions and other unhealthy lifestyles," said Nordgren. "And, while our study focused on personal behaviors like smoking and eating, it is easy to apply our findings to a broader context. Understanding the power of temptation, you might also ask about the extent to which we need oversight or regulatory guidelines for business and political leaders."

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Lawmaker: Hands off anti-smoking programs targeting minorities  

Members of a legislative subcommittee that is scouring Arkansas’ tobacco settlement proceeds for extra money took notice of a $3 million fund balance in the master’s degree program on addiction studies at the University Arkansas at Pine Bluff.

But a Pine Bluff lawmaker says the little-known degree program and 17 community and school grants the university oversees should not be raided for funds to pay for other health-related programs because they and other minority health initiatives funded with tobacco settlement money are addressing a major problem — disparities in health services.

“It’s shocking. If you look at access to health care, you look at the demographics and minority residents, especially in the Delta, minorities don’t have sufficient health care,” Rep. Stephanie Flowers, D-Pine Bluff, said last week after meeting of a joint subcommittee of the House and Senate Public Health, Welfare and Labor committees.

During the meeting, members carefully examined the budget of the state Health Department’s Smoking Prevention and Cessation Program’s budget looking for any excess funds that could be shifted to other health-related programs, such as adult drug courts. “I think that is the wrong direction,” Flowers said. . . .

One of the few programs of its kind in the country, director Jerry Lewis told lawmakers it prepares students for intervention, prevention and treatment of those with alcohol, tobacco, drug and gambling addictions. Students also learn how to manage addiction facilities.

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Nicotine may have more profound impact than previously thought 

Nicotine isn't just addictive. It may also interfere with dozens of cellular interactions in the body, new Brown University research suggests.

Conversely, the data could also help scientists develop better treatments for various diseases. Pharmaceutical companies rely on basic research to identify new cellular interactions that can, in turn, serve as targets for potential new drugs.

"It opens several new lines of investigation," said lead author Edward Hawrot, professor of molecular science, molecular pharmacology, physiology and biotechnology at Brown University.

Hawrot's research is highlighted in a paper published April 3 in the Journal of Proteome Research. He and a team that included graduate students William Brucker and Joao Paulo set out to provide a more basic understanding of how nicotine affects the process of cell communication through the mammalian nervous system. . . .

The Brown University researchers looked specifically at the alpha-7 nicotinic acetylcholine receptor in mouse brain tissue. A very similar receptor exists in humans. The alpha-7 receptor is the most enigmatic of the so-called "nicotinic" receptors, so named because nicotine binds to them when it is introduced into the body. Most receptors are on the surface of cells and are sensitive to small signaling molecules such as the neurotransmitter acetylcholine, which is the naturally occurring signal the body uses to activate alpha-7 receptors.

Their discovery: 55 proteins were found to interact with the alpha-7 nicotinic receptor. Scientists had not previously known of those connections.

"This is called a "nicotinic" receptor and we think of it as interacting with nicotine, but it likely has multiple functions in the brain," Hawrot said. "And in various, specific regions of the brain this same alpha-7 receptor may interact with different proteins inside neurons to do different things." . . .

The new finding suggests that the alpha-7 receptors have a much broader role in the body than previously suspected and that the newly identified associated proteins could also be affected when nicotine binds to the alpha-7 receptor.

Nicotine may affect bodily processes -- and perhaps the actions of other commonly used drugs -- more broadly than was previously thought.

This advance could lead to the development of new treatments to combat smoking addiction. At the same time, the finding could also have future implications for diseases such as schizophrenia, Hawrot said.

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• Defeating nicotine's double role in lung cancer 

A lung cancer treatment that inhibits nicotine receptors was shown to double survival time in mice, according to Italian researchers.

The results of the early phase animal model study were reported in the June 15 issue of the American Journal of Respiratory and Critical Care Medicine.

Changes in genes encoding nicotine receptors are strongly associated not only with the tendency to smoke, but with susceptibility to lung cancer. Nicotine exposure also heightens the expression of the nicotine receptors, which leads to increased cell proliferation and inhibition of apoptosis, further setting the stage for cancer. . . .

John Heffner, M.D., past president of the ATS stated that "this research clearly has profound clinical implications regarding the role of nicotine in stimulating lung cancer and nicotine receptor antagonists in treating the disease. The highly addictive nature of nicotine, however, complicates patients' ability to quit smoking and avoid ongoing nicotine exposure."

"This [addictive nature of nicotine] underscores the importance of potential FDA regulation of nicotine in tobacco products to limit exposure to this drug that promotes tumor growth," wrote Dr. Spindel.

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Drug and Alcohol Dependence : The role of temperament in the relationship between early onset of tobacco and cannabis use: The TRAILS study 

Background

While temperamental characteristics have been related to the onset of cannabis use, it is not clear at what point(s) along the trajectory from early onset of tobacco use (EOT) to early onset of cannabis use (EOC) these characteristics exert their impact. This study examined if (1) temperamental characteristics predispose to EOT that on its turn predisposes to EOC, and (2) temperament moderates the importance of EOT on the progression to EOC.

Methods

Data from 1848 (83%) participants in the TRacking Adolescents’ Individual Lives Survey (TRAILS), a prospective population study of Dutch adolescents, were analyzed. We used parent-reports on the Early Adolescent Temperament Questionnaire to assess the dimensions of high-intensity pleasure, frustration, effortful control, shyness and fearfulness at age 10–12. EOT and EOC were defined as use at least once before the ages of 12 and 13 years, respectively, assessed by means of self-reports. We performed mediation and moderation analyses in Mplus.

Results

High levels of high-intensity pleasure predisposed to entrance in the trajectory from EOT to EOC. Once tobacco use had been initiated at early age, low levels of shyness and high levels of high-intensity pleasure increased the risk of progression to EOC.

Conclusions

Besides a common liability for EOT and EOC based on temperament, the risk of transition from tobacco to cannabis use is modified by temperamental characteristics. Differences in interplay with other risk factors may explain the impact of temperament on distinct points along the substance use trajectory.

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An addiction as bad as any other 

She paused in her story to assert, "I am not a stupid woman," though that was already obvious to this listener, who, noticing a patch behind her ear, inquired, "Are you trying to quit smoking?"

Her name is Laura. She's 45 and continues to "cheat," even though her surgeon has assured her that failing to quit will put her on a collision course with esophageal cancer.

"I've now had four major surgeries, including one where they sealed up the top of my stomach.

"I obviously wasn't smoking while I was in the hospital, and I was OK with that. In fact, while I was there this past April my sister came to visit me and when she leaned down to give me a kiss I said, 'Wow, do you stink!'

"Then right after I got out, while I was riding in the car with her, I borrowed her cigarette, 'just for a puff.' That's how it started, and now I'm back at it again." . . .

"I know, it's smokers' logic," she said. "It's just that alcoholism is almost accepted in this country while we're treated like junkies. And our habit might be the hardest one of all to kick."

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What's new in Nicotine & Tobacco Research? ($$) 

Innovative delivery systems are needed to reach, motivate, and treat adolescent and young adult smokers, who often don’t respond to advice from health professionals or nicotine replacement therapy. One promising medium is individualized counseling via cell phone "texting."

Haug et al. (p. 915) pilot-tested such a system among 171 young adult smokers recruited at a German university and randomized to receive one or three weekly text messages tailored to their baseline and weekly assessments or no intervention. They also could use a texting helpline to overcome cravings.

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• Table of Contents (August 2009, 11 [8]) 

Table of Contents (July 2009, 11 [7])