Growing Up Tobacco Free Preventing Nicotine Addiction in Children and Youths (1994) / Chapter Skim
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2 THE NATURE OF NICOTINE ADDICTION
2 THE NATURE OF NICOTINE ADDICTION
Pages 29-68
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From page 29... ...
Nicotine addiction develops in the first few years of cigarette smoking, that is, for most people during adolescence or early adulthood. Most smokers begin smoking during childhood or adolescence: 89% of daily smokers tried their first cigarette by or at age 18, and 71% of persons who have ever smoked daily began smoking daily by age 18 (table 2-11.
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From page 30... ...
65. GENERAL ASPECTS OF NICOTINE ADDICTION The Daily Nicotine Addiction Cycle Given the pharmacologic properties of nicotine, a daily cycle of addiction can be described as follows.
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Pharmacologic Aspects of Nicotine The pharmacologic effects of nicotine are essential to sustaining cigarette smoking.4 Viewed another way, tobacco is used by people to deliver nicotine to TABLE 2-2 Criteria for drug dependence Primary criteria Highly controlled or compulsive use Psychoactive effects Drug-reinforced behavior Additional criteria Addictive behavior often involves the following: Stereotypic patterns of use Use despite harmful effects Relapse following abstinence Recurrent drug cravings Dependence-producing drugs often manifest the following: Tolerance Physical dependence Pleasant (euphoric) effects Source: Adapted from Centers for Disease Control.
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substance is taken to relieve or avoid withdrawal symptoms.
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When nicotine use is abruptly stopped, withdrawal symptoms emerge. The typical symptoms are listed below.
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From page 34... ...
By activating cholinergic receptors, nicotine enhances the release of other neurotransmitters and hormones including acetylcholine, norepinephrine, dopamine, vasopressin, serotonin, and beta-endorphin. The physiologic effects of nicotine include behavioral arousal and sympathetic neural activation.
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From page 35... ...
When nicotine is not available (such as when a smoker stops smoking) , the brain function becomes disturbed, resulting in a number of withdrawal symptoms, as mentioned above.
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The rate of metabolism is quite variable from person to person, so the same level of nicotine intake
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From page 37... ...
Thus, regular cigarette smoking results in continued exposure of the brain and body to nicotine. Addiction and the Light or Occasional Smoker Among adults the light or occasional smoker, that is, one who regularly smokes 5 or fewer cigarettes per day or who does not smoke every day, is in general less addicted than are daily smokers of more than 5 cigarettes per day.7 Smoking appears to be reinforced for light smokers by the direct pharmacologic effects of nicotine, as described above, as well as by behavioral aspects of tobacco use, as described below.
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From page 38... ...
Because of this compensatory smoking, having smokers switch to low-yield cigarettes reduces the risk of smoking to a much lesser degree, if at all, than suggested by the decreases in yield. Smoking Fewer Cigarettes The regulation of nicotine intake by daily smokers is also apparent when the number of cigarettes available to a smoker is restricted.
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From page 39... ...
There are various conceptualizations of the nature of the anticipatory response system. One is the conditioning model, in which learned associations between the effects of cigarette smoking and specific cues in the environment motivate smoking.
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Some items of this scale have been positively correlated with self-reported severity of nicotine withdrawal.22 Blood nicotine concentrations throughout the day are similar in regular smokers and people who also use smokeless tobacco.23 Plasma cotinine levels among regular users of smokeless tobacco are in many cases similar to those of cigarette smokers.24 Abstinence from smokeless tobacco use results in signs and symptoms of nicotine deprivation that are similar to those seen in smokers after they stop smoking.25 These symptoms are reversed by administration of tobacco or nicotine gum. Swedish oral snuff users report difficulty in quitting and many consider themselves to be addicted, reporting as much difficulty in giving up smokeless tobacco use as is reported by cigarette smokers trying to quit smoking.26 Finally, there is evidence that when deprived of snuff, regular snuff users will smoke cigarettes to satisfy their need for nicotine.27 The regular use of snuff or chewing tobacco by a child therefore increases the likelihood that subsequently the person will take up regular cigarette smoking.28 Comparison of Nicotine Addiction with Other Drug Addictions It is obvious that all drugs of dependence share psychoactivity, produce pleasure, and are shown to reinforce drug-taking behavior.
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From page 41... ...
For example, only 50% of smokers who suffer acute myocardial infarction quit smoking, despite a physician's admonition to do so.29 It has been argued that for many activities that entail risk, such as sex, sunbathing, and skiing, the individual assumes a risk and makes a free choice, and that the same is true of cigarette smoking. However, life-long smoking results in the premature death of one in three smokers and the disability of a great number of smokers from chronic lung disease, indicating a substantially different level of risk.
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From page 42... ...
It has been argued that a marked stereotypic syndrome occurs in a person after stopping use of heroin or alcohol, whereas the withdrawal symptoms after stopping smoking vary widely in nature and magnitude and, in one study, were not sufficiently present in 22% of quitters to constitute a diagnosis of withdrawal.34 Although it is true that smoking does not result in seizures or delirium tremens, withdrawal from smoking can be extremely disruptive to personal life. Nicotine withdrawal may be viewed as closer to that of withdrawal from other stimulants such as cocaine: the withdrawal syndrome is not life-threatening but it profoundly affects behavior and remains a strong impetus to recurrent drug use.
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Epidemiology and Natural History of Cigarette Smoking Data from the Youth Risk Behavior Survey for smoking initiation by high school youths in the United States are presented in table 2-4 (1990) and in table 2-5 (1991)
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. "Nicotine addiction" refers to regular smoking, usually every day, with an internally regulated need for nicotine.
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As the daily intake of nicotine increases, the development of physical dependence, that is, experiencing withdrawal symptoms between cigarettes or when cigarettes are not available, becomes established. Thus, there appears to be a progression over time from smoking initially for social reasons to smoking for pharmacologic reasons.
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~;.~,.. - FIGURE 2-3 Source: Data from 1990 Youth Risk Behavior Survey, presented in Escobedo, Luis G., Stephen E
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Average salivary cotinine levels were 103, 158, and 208 g/ml.39 The level of 208 ng/ml is similar to that of many adult daily smokers. The ratio of salivary cotinine per cigarette per day, an index
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Also of note in the study was that smokers who smoked at the time of all three surveys, as well as smokers who were occasional smokers or nonsmokers at the time of the first survey but who subsequently became daily smokers, showed escalation of cigarette consumption (figure 2-4) and saliva cotinine levels each year.
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"Subjective Effects of Cigarette Smoking in Adolescents." Psychopharmacology 92 ( 19871: 1 15-1 17. That youths experience pharmacologic elects of nicotine from tobacco smoke was reported in an earlier study by the same researchers.40 A smoking questionnaire asked a group of 170 British schoolgirls ages 11-17 about the five subjective effects of smoking specified in figure 2-5.
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From page 50... ...
was 22 ng/ml; 74% of the daily smokers and 47% of the occasional smokers experienced one or more of the six symptoms of nicotine withdrawal graphed in figure 2-6. The withdrawal score correlated significantly with salivary cotinine concentration and with weekly cigarette consumption.
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"Cigarette Withdrawal Symptoms in Adolescent Smokers." Psychopharmacology 90 (1986~: 533-536. stated that they probably or definitely would not be smoking in 5 years, as did 32% of those who smoked one pack per day or more (table 2-8~.
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From page 52... ...
Even those who smoke only a few cigarettes peer day during high school have a high risk of becoming heavy smokers as adults. These data are evidence' that nicotine addiction develops during adolescence, and that most adolescents who are daily cigarette smokers (as well as some who are occasional smokers)
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From page 53... ...
Distal factors are also powerful because, over time, they affect proximal factors as these influences become interpreted and internalized, particularly among adolescents as they try to shape a mature self-identity.47 The degree to which any of these risk factors influences smoking behavior varies for each risk factor and among research studies. The reader who wishes a de
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From page 54... ...
This section provides only an overview of those issues most pertinent to the policy questions addressed in this report. Initiation of cigarette smoking is influenced by several kinds of factors: environmental, behavioral, personal, and sociodemographic.48 Among the environmental factors that influence initiation of smoking is having friends who smoke, having a best friend who smokes, and/or having many friends who smoke strongly influences initiation.
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From page 55... ...
Evidence from studies of twins suggests a moderate genetic influence both on initiation and on maintenance of cigarette smoking.5i Possible mechanisms include genetically determined differences in the pharmacologic response to nicotine, differences in personality, and the presence or absence of an affective or other psychiatric disorder, particularly depression. There is a high concordance of cigarette smoking and alcoholism, and studies in twins suggest that these addictions share, to some extent, a common genetic determ~nant.52 Some proportion of the genetic predisposition to tobacco addiction thus appears to be specific, but some appears to be linked to alcoholism or to other drug addictions.
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From page 56... ...
was predicted by best friend being a smoker, feelings of-helplessness, and rapid progression to the second cigarette.53 These analyses support the idea that initiation of cigarette smoking is primarily a consequence of environmental factors, whereas progression appears to be more influenced: by personal a~d pharmacologic factors. SoGiodemographic factors that predispose youths to cigarette~smoking include low socioeconomic status, low level of parental education, and:theindividual's developmental state of adolescence.
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From page 58... ...
As noted earlier, smokeless tobacco use is a risk factor for cigarette smoking, and vice versa. The exchangeability of tobacco use supports the idea that nicotine addiction can be maintained by tobacco from any source.
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" With the exception of data for eighth and tenth grade students, all other data points for the Monitoring the Future Project survey reflect estimates for high school seniors. bGrades 9-12.
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Tobacco manufacturers -state 'that the mason Jerry JO extracted and then reapplied to tobacco is that nicotine in the nature t-stucco leaf exists fin very uneven concentrations. By extracting and re-~g Viscose, 'it is possible to provide a more consistent tobacco p - -A which movers a consistent amount of nicotine It has also been su.~ges~tl '~at the -mount of nicotine in tobacco is corn - ll0d ib as to ensure ~ level a-dequ-~ ~ maintain nicotine addiction.
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From page 61... ...
Thus, values for yields of tar, nicotine, and carbon monoxide~for each cigarette are reported from this type of testing procedure. Lowering the yields of tar and other toxic constituents of cigarettes smoke makes intuitive sense as a way to reduce~the health risks of cigarette smoking.
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From page 62... ...
do seem to make it more difficult for smokers to obtain levels of nicotine that they can from high-yield cigarettes.70 The observation that sales of these ultralow-yield cigarettes are relatively low suggests that there may be a threshold for nicotine delivery, below which nicotine addiction is not easily maintained. As typically smoked, low-yield cigarettes are not less harmful than higher-yield cigarettes.
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8. Among adults the prevalence of cigarette smoking has declined from 1966 to the present.
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From page 64... ...
"The Natural History of Cigarette Smoking: Predicting Young-Adult Smoking Outcomes from Adolescent Smoking Patterns. " Health Psychology 9:6 ( 1990)
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From page 65... ...
"Daily Intake of Nicotine During Cigarette Smoking`" CI`~B'bo`rmacology and Therapeutics 35 (1984)
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From page 66... ...
"Subjective Effects of Cigarette Smoking in Adolescents." Psychopharmacology 92:1 (1987)
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From page 67... ...
Biglan. "Longitudinal Changes in Adolescent Cigarette Smoking Behavior: Onset and Cessation." Journal of Behavioral Medicine 11:4 (1988)
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From page 68... ...
Slade, eds. Nicotine Addiction: Principles and Management.
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