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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 or vaporized products (pipes, cigars, bidis, hookah pipes, electronic cigarettes, vaping devices). Cigarette smoking increases the risk of cardiovascular disease (CVD; stroke, sudden death, heart attack), respiratory diseases (emphysema, asthma, chronic obstructive pulmonary disease), lung cancer, and other cancers. Smokeless tobacco products increase the risk of oral and neck cancers. Additionally, using vaporized nicotine products has been associated with an accelerated development of lung cancers. Screening with computed tomography (CT) scan is indicated for current and former smokers (<15 years since quit date) between the ages of 55 and 80 years with greater than a 30-pack year history.

Nicotine is a ganglionic agonist with pharmacologic effects that are dose-dependent. Pharmacologic effects include:

  • Central and peripheral nervous system stimulation and depression;

  • Respiratory stimulation;

  • Skeletal muscle relaxation;

  • Catecholamine release leading to:

    • 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 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. As part of the Healthy People initiative, a goal was established to reduce the harms of both smoking and exposure to second-hand smoke. The availability of prescription and over-the-counter medications offers an array of options 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 As each time they come in contact with a person who smokes (Table 67-1). The US Preventive Services Task Force (USPSTF) recommends asking adults about their smoking status at each point of contact with a health care provider.

TABLE 67-1The Five As of Smoking Cessation

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