Disorders Due to Nicotine Use: Effects, Withdrawal & Treatment

The 6C4A of ICD-11 mentioned disorders due to the use of nicotine. The important entities in disorders due to: 

• The use of nicotine a single episode of harmful use of nicotine 
• Harmful patterns of use of nicotine. 

• Episodic 
• Continuous 
• Unspecified 
• The nicotine dependence can be:
  • Current use 
  • Sustained partial remission 
  • Sustained full remission 
  • Unspecified 
• ICD-11 considers nicotine intoxication in the diagnostic criteria. 

The Important Features of Nicotine Intoxication 

• Restlessness, psycho-motor agitation, anxiety, headache, palpitations or paresthesias, 
• GI symptoms such as nausea, vomiting, abdominal cramps, burning sensation in the mouth, and salivation. 
• The person may also report insomnia, bizarre dreams, and confusion. 
• In rare instances, the person may also have paranoid ideations, perceptual disturbances, convulsions, and even coma. 
• Nicotine intoxication most commonly occurs in naive or non-tolerant users or among those taking higher than accustomed doses. 
• It also mentions nicotine withdrawal, other specified disorders due to the use of nicotine, and disorders due to the use of nicotine unspecified. 

Clinical Features

• Behaviourally, nicotine has a stimulatory effect on the CNS. It causes improvement in attention, learning, reaction time, and problem-solving ability. 
• Cigarette smokers may also report mood uplifts, a decrease in tension, and lessening depressive feelings. 
• Short-term nicotine exposure increases cerebral blood flow without changing cerebral oxygen metabolism. 
• The long-term exposure causes a decrease in the overall cerebral blood flow. 
• Nicotine acts as a skeletal muscle relaxant.

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Assessment of Severity of Nicotine Dependence  

RTQ

• The revised Fagerstrom tolerance questionnaire (RTQ) has 10 10-item questionnaire
  • It is used to measure the severity of nicotine dependence. 

Fagerstrom's Test for Nicotine Dependence (FTND)

• One of the important assessments of nicotine dependence is the Fagerstrom test for nicotine dependence (FTND). 
• It consists of six items from the RTQ. The items included are:
  • The number of cigarettes smoked 
  • Smoking topography 
  • Smoking to relieve nicotine withdrawal 
  • Difficulty refraining from smoking
• FTND assesses the severity of nicotine dependence. It also assesses tolerance and withdrawal. 
• The total score is 10. 
• The first question is, how soon after you wake up do you smoke your first cigarette? The more quick use, the more severe the dependence. 
• Q. Do you find it difficult to refrain from smoking in places where it is forbidden? Which cigarette would you hate most to give up, i.e., first in the morning or any other? 
• Q. How many cigarettes per day do you smoke, i.e., 10 or less, 11 to 20, 21-30, or 30 or more? Do you smoke more frequently during the first hours after waking up than during the rest of the day? Do you smoke even if you are so ill that you are in bed most of the day? 
• The score is calculated:
  • A score between 0 and 2 suggests very low dependency. 
  • A score of 3–4 suggests low dependence. 
  • A score of 5 suggests medium dependence 
  • A score of eight to 10 is very high.

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Differential Diagnosis

• One important differential diagnosis is psychiatric disorders and adverse effects of psychiatric medications. 
• Many symptoms of tobacco withdrawal can mimic, exacerbate, or mask symptoms of psychiatric disorders or adverse effects of psychiatric medications.
  • For example, symptoms such as akathisia, anxiety, depression, irritability, insomnia, and weight gain. 
• The people who quit smoking may have increased psychiatric medication side effects or have caffeine intoxication due to metabolic changes in P450 1A2 isoenzyme due to stopping smoking. 
• Various chemicals in smoke stimulate the enzyme P450 1A2. A person is on certain psychiatric medication, and this enzyme metabolizes the psychiatric medication. Subsequently, the effect of the medication will decrease. 
• Stopping smoking and maintaining the same caffeine intake will increase the availability of caffeine and its effects on intoxication. 
• One should always try to investigate any change in the smoking status in case of a change in the mental state or increased medication side effects. 
• Some of the important points in decoding nicotine intoxication may appear as abdominal pain, dizziness, headache, nausea, pallor, sweating, palpitations, vomiting, and weakness. 
• The treatment of nicotine intoxication is usually supportive. 
• Children are at higher risk of nicotine intoxication. 

Course & Prognosis

• Death is the primary adverse effect of smoking, and individuals who smoke tend to die 10 years earlier than nonsmokers. 
• There are 7357 chemical compounds in cigarette smoke.
  • Many chemicals are respiratory irritants, such as acrolein and acetaldehyde. 
  • The damaging chemicals in the cardiovascular system are cyanide, arsenic, and cresols. 
  • They also have carcinogens such as other metals, nitrosamines, and polycyclic aromatic hydrocarbons; nearly 70 of these chemicals are carcinogenic.

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Smoking

• Smoking is the leading cause of death. 20% of all mortality is related to smoking.
  • 1/3 of the deaths occurred due to cardiovascular or cerebrovascular causes
  • 1/3 of deaths are due to cancer. 
  • 1/5th of the deaths are due to respiratory causes 
• 45% of the smokers die due to smoking-related disease. 
• Nicotine is a highly toxic alkaloid. 
• An average cigarette delivers around 1.5 milligrams of nicotine. 
• The fatal dose of nicotine in adults is 60 milligrams, and death is secondary to respiratory paralysis. In low doses, the signs and symptoms of nicotine toxicity are:
  • Nausea, vomiting, salivation 
  • Pallor due to peripheral vasoconstriction 
  • Weakness 
  • Abdominal pain due to peristalsis 
  • Diarrhea 
  • Dizziness, headache 
  • Increased blood pressure, tachycardia 
  • Tremors and cold sweats 
• It can also cause an inability to concentrate, confusion, and sensory disturbance.

Effects on Lungs 

• The cigarette toxicity in the lungs can cause:
  • Loss of cilia 
  • Hyperplasia 
  • Metaplasia 
  • Mucus plugging of the small airways   
  • Destruction of alveoli 
  • Reduced number of small arteries 
• The lung and respiratory sequelae of smoking are COPD, emphysema, and chronic bronchitis. The 3rd leading cause of death in the USA, with 90% of cases attributable to smoking. 
• Moreover, there is an increased risk of respiratory infections such as pneumonia, which can also trigger pneumonia. 

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Effects on Heart   

• 30% of the heart disease mortality is caused by smoking. 
• Smokers are at 2 to 4 times the risk of coronary artery disease, and women are affected more than men. 
• The acute effects of nicotine on the heart are:
  • Increase in systolic blood pressure, heart rate, cardiac output 
  • Vasoconstriction 
  • Carbon monoxide reduces the availability of oxygen to the heart. 
• The chronic effects of smoking are:
  • Increased inflammation 
  • Platelet activation or thrombosis 
  • Endothelial dysfunction 
  • Lead to atherosclerosis 
• Later in the inflammation process, there is destabilization of the plaques. It promotes the oxidation of low-density lipoproteins, leading to:
  • Reduced myocardial blood flow 
  • Reduced oxygen 
  • Artery occlusion 
• The end effects of cardiovascular disease are:
  • Myocardial infarctions 
  • Strokes 
  • Aortic aneurysms 
  • Impacts of peripheral vascular disease
• Nicotine is also arrhythmogenic. It increases serum catecholamines and is combined with the carboxyhemoglobin, lowering the threshold for ventricular fibrillation.
  • It can lead to sudden death in chronic smokers, but half of all the deaths are from coronary heart disease. 
• Quitting smoking reduces the risk of sudden death immediately and also in the long term. 
• The risk of myocardial infarction is dose-dependent; as few as one to four cigarettes per day raise the risk of death from ischemic heart disease. 
• The risk of heart disease is reduced by ½ after 1st year of cessation and falls to that of 'never-smokers' after 15 years of abstinence. 

Smoking & Cancer

• Nicotine is the single most lethal carcinogen in the USA.
• Cigarette smoke has carcinogens that can act as direct carcinogens, cocarcinogens, or tumor promoters or inhibitors. 
• Smoke, free radicals, and various other components can cause irritation, inflammation, cell proliferation, hyperplasia, oxidative stress damage, and decreased organ functions. 
• The health consequences of smoking: 50 Years of Progress 2014 Surgeon Generals report suggested that there is sufficient evidence to infer a causal relationship between smoking and cancers of the lung, larynx, oral cavity, pharynx, esophagus, pancreas, stomach, bladder, kidney, cervix, and acute myeloid leukemia. 
• Lung cancer and other cancers have dose-response, which means risk is associated with the number of cigarettes smoked per day. So, the higher the number of cigarettes, the higher the risk. 
• Smokers are 15–30 times more likely to develop lung cancer than non-smokers. 
• Lung cancer has surpassed breast cancer as the leading cause of cancer-related deaths in women. 
• Smoking is a major factor in lung cancer and COPD. 
• Nearly 75% of all deaths are due to these disorders.

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Other Common Smoking-related Diseases  

• Other common smoking-related diseases are low birth weight offspring, perinatal complications, other cancers, and ulcers. 
• Certain less common effects include worse wound healing, diabetes, impotence, and osteoporosis.

Smoking & Pregnancy

• In women, smoking can cause difficulty in becoming pregnant. 
• In men, smoking can affect sperm and sexual functioning. Therefore, it can decrease fertility. It also increases the risks of birth defects and miscarriages. 
• Women smoking during pregnancy can lead to preterm delivery, stillbirth, low birth weight, sudden infant death syndrome (SIDS), ectopic pregnancy, and orofacial clefts in infants. 
• It may also increase the risk of mental retardation, learning problems, and ADHD. 
• The course & prognosis of the health effects of tobacco use disorder worsen with comorbid disorder and exposure.
• The additive effect of environmental carcinogens such as radiation and asbestos exposure with smoking worsens cancer outcomes. 
• Alcohol can worsen the cancer outcomes with oral, laryngeal, and esophageal cancers. 
• The risk of larynx cancer is 75% higher in people who use tobacco and alcohol versus those exposed to either substance alone. 
• Smokers are less able to be physically active due to the deleterious effects on the cardiac and respiratory systems. 
• Moreover, there is an increased risk of many other comorbidities with smoke.

Environmental Tobacco Smoke 

• Environmental tobacco smoke is second-hand smoke. 
• Smokers often cohabitate with others, especially in psychiatric groups or extended living situations. 
• Even after separating smokers from non-smokers within the same air space, cleaning the air, opening windows, and ventilating buildings do not eliminate second-hand smoke exposure. 
• Secondhand smoke causes cardiovascular disease and lung cancer and increases the risk by 25 to 30 percent. 
• There is an association between exposure to second-hand smoke and risk of smoke. 
• Secondhand smoke causes 10% of smoking-related deaths. 
• It increases the risk of cancer and heart disease in spouses. 
• It also increases the incidence of respiratory and ear problems in children. 
• Secondhand smoke impacts the prognosis of tobacco use disorder and the likelihood of quitting when living with other smokers.

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Economic impact  

The important parameters used to assess the economic & public health burden of smoking are: 

• Smoking-attributable mortality (SAM) 
• Years of potential life lost (YPLL) 
• Productivity losses

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