Substance Abuse: Nicotine Dependence
Nicotine dependence is the most common substance use disorder in the USA and increases morbidity and mortality more than any other substance use disorders. In the USA about 25% of the population is addicted to tobacco. Tobacco use has serious health consequences for the user, family members and others who inhale secondhand environmental tobacco smoke or are exposed during pregnancy. Treatment can be effective. There are six FDA-approved medica-tions for use in tobacco addiction treatment, including bupropion and five nicotine replacement medications (patch, gum, spray, in-haler and lozenge). Behavioral psychosocial therapies are also as effective as medications, however, treatment providers do not often this approach. Integrated medication and behavioral therapy is ef-fective in helping smokers quit in about 45% of cases. About 44% of all cigarettes consumed in the USA are by individuals with mental illness or addiction, and specialized treatments can help this heavy smoker population. The diagnosis of Nicotine Dependence follows the DSM-IV TR criteria for substance dependence found on p. 476.
The DSM-IV nicotine withdrawal syndrome describes a charac-teristic set of symptoms that develops after abrupt cessation or a reduction in the use of nicotine products after at least several weeks of daily use and is accompanied by four of the following signs and symptoms: 1) dysphoria or depressed mood; 2) insomnia; 3) irrita-bility, frustration, or anger; 4) anxiety; 5) difficulty concentrating; 6) restlessness or impatience; 7) decreased heart rate; and 8) in-creased appetite or weight gain (American Psychiatric Association, 1994). The withdrawal symptoms must also cause clinically sig-nificant distress or impairment in social, occupational, or other im-portant areas of functioning and must not be secondary to a general medical condition or be accounted for by another mental disorder.
Other symptoms that may be associated with nicotine withdrawal include craving for nicotine, a factor thought to be significant in relapse; a desire for sweets; and impaired perform-ance on tasks requiring vigilance. To some extent, the degree of physiological dependence predicts severity of the withdrawal syndrome and difficulty stopping smoking.
The prevalence of cigarette smoking is higher at lower so-cioeconomic levels. Slightly more males than females smoke, al-though more males than females are successful in stopping smok-ing. There is evidence that the number of cigarettes per smoker is increasing, leaving a more hard-core and potentially more de-pendent group of smokers. There has also been a recent increase in the rate of smoking among adolescents, particularly in the number of teenage girls smoking. This increased smoking rate amongst adolescents is particularly alarming, as smokers typi-cally start smoking at an early age, with more than 60% of smok-ers beginning by age 14 years and nearly all by age 18 years.