Introduction to Tobacco Use​

• 15% of population smokes.  Higher rates in patients with other SUDs, mental illness, lower socioeconomic groups. 

• 30% of cancer deaths are due to tobacco.

• Nicotine is addicting and naturally occurring in tobacco leaves.  All forms of tobacco use (oral, smoked or vaped) are addicting because of nicotine.  Each cigarette contains typically 1mg of nicotine.  Vaping, chewing tobacco and pipes deliver even more nicotine than cigarettes.  

• Tobacco leaves naturally contain nitrosamines, a carcinogen.  Because of nitrosamines, all forms of tobacco use are a risk for cancer.  

• Cigarette smoke contains 7,000 compounds, some natural, some added, almost all toxic.  Including benzene, acetone, cyanide, formaldehyde and carbon monoxide.  

• Myth:  Smoking helps mental illness.  Fact is smoking worsens mental health disorders.  Quitting has been shown to improve anxiety and depression.  Stress and mood improve. May take a few weeks though to feel this improvement.  (Taylor 2014) 

• Harder for smokers to get hired in a job or to get housing. 

• Smoking is the #1 cause of lethal house fires. ​

Introduction to Tobacco Use Disorder (TUD)

• Tobacco Use Disorder is a substance use disorder under DSM-V.   Nicotine is a drug to the brain. 

• The vast majority of patients who smoke are addicted;  unlike other drugs like alcohol where lots of people drink alcohol but small numbers are addicted.    

• If no meds or counseling are used, only 5% of patients trying to quit tobacco are successful. 

• Smoking has the fastest ability to get drug effects to the brain.  Faster than IV.  Adds to the addicting properties. Massive uptake of drug occurs into the lung vasculature through inhaling and it's a short distance to the brain.  Smoking tobacco is highly addicting and reinforced.

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Severity of Illness:

• TTFC or Time to First Cigarette.  Ask the patient "When you wake up in the morning, how many minutes until you have your first smoke?"

  • Within 30 mins after waking is a moderate-severe TUD

  • If patient says they smoke within 5 minutes of awakening or they are awoken in the middle of the night with withdrawal symptoms, that is a sign of a severe TUD

• Because of the short duration of action (few hours), almost everyone who smokes wakes up in some degree of nicotine withdrawal. Some patients wake up in the middle of the night to smoke.    ​

• ​​Good effects of quitting smoking can be seen as quickly as 3 days with lower or normal levels of carbon monoxide (CO).  Lower levels of CO immediately lowers risk of MI, CVA and sudden death. 

• Severe TUD can be very hard to overcome.  Inform the patient this is the first step in a long road.

• Medications PLUS counseling increases chance of success.   California Smokers' Helplines listed below. 

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 Nicotine Withdrawal Symptoms

• Occurs within hours after last cigarette;  can last for 4 weeks.

• Withdrawal symptoms include depressed mood, insomnia, irritability, anger, frustration, anxiety, difficulty concentrating, restless, weight gain (nicotine suppresses appetite)

• Patients may feel that smoking helps with these symptoms;  explain these are symptoms of withdrawal, probably not an underlying condition.  Just an endless cycle of nicotine withdrawal and treating withdrawal symptoms with smoking.  

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 Medications for TUD

• Best treatment for Tobacco Use Disorder (TUD) includes daily medication and counseling.

• Patients may not have been successful in the past with meds for TUD because they didn't use a high enough dose or didn't use meds long enough. We now know patients may need to be on medications for months. You can't cure a 40-year addiction in a couple of weeks.