Going nicotine free: Treating nicotine addiction

 

Tobacco smoking has devastating effects. More than half a million Americans die each year from smoking-related diseases. Those deaths are usually preceded by years of disability and discomfort from heart and lung disease, as well as a dozen different cancers. Twenty million people in the U.S. suffer every day with tobacco related disease.

 

Most of the smoking patients I see want to quit, and there are many products available to help them. The most important element, however, is their own motivation, because quitting smoking is really tough. This is a classic drug addiction to one of the most addictive substances on Earth, nicotine. 

 

That may seem like an exaggeration, but we know that smoking delivers nicotine to the deepest and most ancient parts of the brain. It stimulates the release of dopamine, a master neurotransmitter that plays a vital role in decision making, motor control, motivation and reward. After inhaling, smokers usually feel more relaxed, focused, energetic and free from hunger—but only for about 30 minutes. 

 

A smoker who consumes a pack of 20 cigarettes delivers about 200 spikes of dopamine to their nervous system. A pack-a-day smoker jolts the brain with 7,000 hits of dopamine every year. The brain responds to this onslaught by dialing back all dopamine production, including natural dopamine—produced by events like contact with friends and family, exercise, food, sunlight, sex and other enjoyable activities. As a result, most smokers spend the majority of their lives in a state of chronic dopamine withdrawal, leading to depression, anxiety, irritability and lack of focus.

 

Effective healthcare providers address tobacco use with their patients; 70% of smokers want to quit and have tried. Many people may not realize that smokers will, on average, try to quit seven times before they succeed. 

 

 

The most effective program to quit smoking includes three components: a motivated patient, ongoing tobacco counseling and some form of medicinal support for nicotine withdrawal. I often recommend a prescription medication called Chantix, or varenicline in its generic form. This drug was engineered to bind with dopamine receptors in the brain that block nicotine, while also stimulating a smaller release of dopamine to help the withdrawal symptoms. 

 

Another effective medication is Welbutrin, or bupriopion, which was originally prescribed as an anti-depressant that stimulates the dopamine receptors. Patients reported a reduction in their desire to smoke as an incidental benefit. 

 

Combining one of these medications with nicotine replacement therapy is often helpful. I’ll sometimes recommend using a prescription inhaler or nasal spray to provide more rapid delivery of nicotine for relief of withdrawal. We haven’t seen any long-term negative effects from the use of these nicotine replacement therapies but, over the long haul, nicotine in any form is probably not a great idea. 

 

For people who started smoking as teenagers, the effort to re-wire the brain is difficult. When a smoker quits, the nicotine is gone from the system within a week—if they aren’t using nicotine replacement. That first week off is often called the “golden week.” If a smoker can go completely clean for the entire week, the odds of staying off permanently are vastly increased. However, growing new brain connections in order to reexperience normal pleasure levels from natural events can take six months to a year, or longer. 

 

 

There’s been explosive media coverage about the more than 1,000 acute lung illnesses apparently brought on by using e-cigarettes (vaping). Many—about 30%—appear to be caused by vaping THC, the psychoactive ingredient in marijuana. 

 

The greatest concern should be for the 5 million middle school and high school kids who, according to the Centers for Disease Control, have taken up e-cigarettes. In addition, surveys of freshmen at Ohio State suggest that vaping is rampant on campus, so the number of young people addicting to nicotine could be closer to 10 million. The vast majority of these kids are using a new product, JUUL, which is a sleek, easily concealed device that delivers a high dose of nicotine in a flavored and easily palatable chemical form.

 

JUUL has been promoted as a positive alternative to smoking, even though there’s no evidence that its use is effective for cigarette cessation. In fact, most of the science suggests vaping discourages cessation. Smokers who use JUUL tend to keep smoking, and only use JUUL when they can’t smoke. The result is toxicity from both products.

 

The biggest problem is that for every smoker who uses JUUL to quit, about 80 kids start addicting to nicotine using JUUL. It seems likely that many or most will go on to higher impact nicotine delivery devices (cigarettes) and suffer their consequences. Even those who simply addict to JUUL will be at significantly increased risk for other substance abuse and mental illness.