A Seminar released on June 13, 2008 in The Lancet
discusses nicotine addiction, and the potential for reducing its
disease burden and death toll by improving public knowledge and using
treatments individual to patients. This includes the potential creation
of an antinicotine vaccine.
Nicotine is a stimulant classically found in tobacco, and its chronic
addiction is primary cause of habitual smoking. According to the
seminar, there are approximately 1.2 billion smokers and approximately
half of them will die from diseases directly caused by smoking.
Currently, about five million smokers die each year, and if present
trends continue this could increase to ten million each year by 2025.
More of these smokers are men than women, necessitating separate
studies by gender. For instance, of the world's male population, 92% of
them live in countries where more than 25% of all males smoke. In
contrast, in the world's female population, 10% live in countries where
female smoking frequency is above 24%. In the United Kingdom and the
United States, between 25-35% of all males smoke. In the female
population, however, there is some discrepancy, as in the USA 14-24% of
women smoke but more than 24% smoke in the UK.
The distribution of smokers varies by country, ranging from as little
to 5% of the population to over 55%. Some countries where male smoking
prevalence is above 55% include Russia and Kenya. The female
smoking frequencies are above 24% in Brazil, Germany, Spain, and the
UK.
Terminating an addiction to smoking is often recognized as a
significant challenge. In the USA, over 70% of the smoking population
want to quit every year and 45% attempt it. However, less than 5% of
the general population is successful in this endeavor.
Even simple advice from a health care professional can help improve
these rates. Following guidelines set forward recently in the US, the
Seminar first examines the role of counseling in quitting smoking,
addressing topics including problem solving, coping, and motivational
skills.
According to the Seminar, this rate of termination can be enhanced by
treatment for nicotine addiction itself. "Pharmacotherpaies for
nicotine dependence can enhance quit rates by about
two-three fold," state the authors. They discuss and evaluate a number
of nicotine-replacement therapies (NRTs) such as patches or nicotine
gum, non-nicotine products based on efficacy, side effects, and
precautions for each. Additionally, they examine improved rates of
success with combinations of the nicotine patch and other products such
as nicotine gum.
The authors of the Seminar examine not just the characteristics of
termination, but also the limited benefits of cigarette reduction,
which is also achieved with higher frequency with the use of NRTs. They
say, however, that these effects are counteracted by changes in the
habits of the smokers: "Smokers engage in substantial compensatory
smoking - deeper inhalation per cigarette - so that a reduction of
cigarette consumption of 50% or more results only in a 30% decrease in
biomarkers for toxicant exposure." Cigarette reduction's primary
benefit, therefore, may be that it acts as an intermediate step towards
quitting.
There are some new treatments in development. One example is a nicotine
vaccine which prompts the body's immune system to develop antibodies
against the substance, and for which preliminary trials are in
progress. Another is the drug rimonabant, which selectively blocks a
specific cannabinoid receptor, for which large, randomized
trials are being performed. Finally, pharmacogenetics, a field in which
treatment is matched to the patient based on his genetic profile, is
examined.
The authors conclude with comments about nicotine addiction: "Nicotine
or tobacco addiction should be treated as a chronic disorder. Treatment
can need persistent efforts to try to assist tobacco users in their
attempts at quitting. Relapse should be seen as a probable
event...Treatment can improve these outcomes...The most crucial
component of care is the actual delivery of such treatments."
Dr Kenneth Warner of School of Public Health, Ann Arbor, MI, USA, and
Dr Judith Longstaff Mackay, Bloomberg Initiative to Reduce Tobacco Use,
Hong Kong, China, contributed an accompanying Comment in which they
state the importance of The Framework Convention on Tobacco Control
(FCTC,) which has presently been ratified by 154 countries. They
indicate that the medical community should make a higher priority of
treatment of tobacco dependence, especially in every day practice, and
that they should lobby governments, who may have conflicts of interest
due to tobacco lobbies, to put this legislation into effect. "Here is
something simple, achievable, and unequivocally good that would relieve
the suffering of literally millions of human beings," they say.
Tobacco addiction
Dorothy K Hatsukami, Lindsay F Stead, Prakash C Gupta
Lancet 2008; 371: 2027-38
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Smoking cessation treatment in a public-health context
Kenneth E Warner, Judith Longstaff Mackay
Lancet 2008; 371: 1976-8
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Anna Sophia McKenney