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Saturday, June 14, 2008

Nicotine Addiction: Prevalence And Treatment

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. "Pharmacotherapies 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.

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