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Nicotine dependence, also called tobacco dependence, is an addiction to tobacco products caused by the drug nicotine. Cigarette smoking is the most prevalent type of tobacco use; additional options include smokeless products (chew and snuff) and other smoke products (pipes, cigars, bidis, and hookah pipes). Cigarette smoking increases the risk of cardiovascular disease (stroke, sudden death, heart attack), respiratory diseases (emphysema, asthma, chronic obstructive pulmonary disease), lung cancer, and other cancers.

Nicotine is a ganglionic agonist with pharmacologic effects that are dose dependent. Pharmacologic effects include central and peripheral nervous systems stimulation and depression, respiratory stimulation, skeletal muscle relaxation, catecholamine release by the adrenal medulla, peripheral vasoconstriction, increased blood pressure, heart rate, cardiac output, and oxygen consumption. Nicotine dependence entails a physiologic and psychological process. Physiologic dependence: Nicotine stimulates the neurotransmitter dopamine activating the reward pathway in the brain. Initially, the person is rewarded for using tobacco with pleasure or a perceived relief from stress. However, the pleasurable effects diminish with continued use, but smoking continues to avoid nicotine withdrawal. Psychological addiction: In the absence of a physical reward for smoking, persons experience cravings with certain activities, stimuli, or times throughout the day. Unlike the physical component to addiction, the psychological component persists indefinitely. Therefore, there is always a chance of relapsing. Physiologic and psychological withdrawal processes manifest as a variety of symptoms lasting 2 to 4 weeks. Nicotine withdrawal symptoms may include: irritability, insomnia, hunger, fatigue, dizziness, difficulty in concentrating, depressed mood, and chest tightness. While nicotine replacement therapy (NRT) may diminish or alleviate nicotine withdrawal, symptoms may persist to some degree.


The best smoking cessation treatment is prevention through public health education and abstinence. However, the availability of prescription and over-the-counter medications offers an array of options for those attempting to quit tobacco. Additionally, cognitive behavioral therapy and increased provider contact increases the chance of quitting tobacco products. Health care providers should utilize the five A’s each time they come in contact with a person who smokes (Table 67-1).

TABLE 67-1The Five A’s of Smoking Cessation

NRT has proven successful for tobacco cessation. NRT is available in multiple dosage forms and delivery devices, allowing for various ...

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