Understanding And Addressing

Nicotine Addiction

A Science-Based Approach to Policy and Practice

October 2015

Nicotine is Not Harmless

• Increase in blood pressure, respiration, and heart rate

• Adversely affects nervous, cardiovascular, respiratory,

and reproductive systems

• May contribute to cancerous tumor development

• Can be lethal if orally ingested

• Associated with poor reproductive health outcomes

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Nicotine is Not Harmless

• Early exposure can produce lasting effects on brain and

lung development

• Early exposure is associated with cognitive, emotional,

and behavioral deficits

• Perpetuates the use of harmful tobacco products

• Increases the risk of nicotine addiction and alcohol and

other drug use and addiction

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Nicotine Addiction Among

Cigarette Smokers Overall, 37% of individuals aged 12 and older who reported

smoking cigarettes in the past 30 days had nicotine addiction

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Nicotine Addiction Linked to

Other Substance Use Disorders

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How Do People Become

Addicted to Nicotine?

• The mechanism is similar to how the other addictive

substances (e.g., stimulants) and highly rewarding

behaviors (e.g., gambling) produce addiction

• After entering the bloodstream, nicotine reaches the brain

within seconds and triggers a cascade of biochemical

reactions that are interpreted by the brain as rewarding

• Nicotine also acts on the adrenal glands, triggering the

release of natural stimulants including adrenaline

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How Do People Become

Addicted to Nicotine?

• Brain cells (neurons) stimulated by nicotine release

chemicals, such as dopamine, that produce feelings of

pleasure and that maintain or perpetuate those feelings

• Reactions along the brain pathways affected by nicotine

lead to changes in mood, increase concentration, and

decrease appetite

• After continued use, the body adjusts to the presence of

nicotine and increasing amounts are needed to produce the

same rewarding effects (i.e., tolerance) and to stave off the

negative effects of its absence (i.e., withdrawal)

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How Do People Become

Addicted to Nicotine? • Withdrawal symptoms--such as anxiety, depression, and cognitive

deficits--can occur within minutes of the last dose of nicotine,

increasing the risk of repeated use to avoid discomfort

• As tolerance develops, nicotine ingestion must occur more frequently

and at shorter intervals to alleviate withdrawal symptoms

• Even when not ingesting nicotine, someone addicted to nicotine can

experience craving and withdrawal symptoms merely by being exposed

to cues that are mentally linked with nicotine use, such as specific

times of day, cigarette packaging and lighters, or social situations

where nicotine use tends to occur

• People are particularly susceptible to these triggering cues when they

are experiencing stressful life events

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Symptoms of Nicotine Addiction A problematic pattern of use leading to clinically significant impairment/distress,

manifested by at least 2 of the following occurring within a 12-month period:

1. Tobacco taken in larger amounts or over a longer period than intended

2. Persistent desire or unsuccessful efforts to cut down or control use

3. A great deal of time spent in activities necessary to obtain or use

4. Craving, or a strong desire or urge to use

5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, home

6. Continued use despite having persistent or recurrent social or interpersonal problems

caused or exacerbated by the effects of tobacco

7. Important activities given up or reduced because of use

8. Recurrent use in physically hazardous situations

9. Continued use despite knowledge of having a persistent or recurrent physical or

psychological problem likely caused or exacerbated by tobacco

10. Tolerance

11. Withdrawal

Severity: Mild (2-3 symptoms), Moderate (4-5 symptoms), Severe (6 or more symptoms)

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Factors That Increase the Risk of

Nicotine Use and Addiction Genetics and Physiology

• Genetics play a greater role than environmental factors in

predicting nicotine addiction, e.g., by determining how the

body metabolizes or processes nicotine

• Biological factors related to how the brain produces and

reacts to dopamine are associated with the risk of developing

nicotine addiction

• Certain personality traits that have a strong genetic basis,

such as risk-taking, sensation seeking, and cognitive

difficulties, can increase the risk of nicotine use and addiction

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Factors That Increase the Risk of

Nicotine Addiction The Environment

• Prenatal exposure to nicotine

• Parents’ or peers’ nicotine product use

• Childhood trauma

• Use of products containing menthol

– Menthol is associated with an increased risk of smoking initiation, greater smoking

frequency, and nicotine addiction, and with decreased smoking cessation

– Menthol reduces the rate of nicotine metabolism (increasing exposure to nicotine) and

increases the reinforcing value of nicotine and the risk of addiction

– Menthol nicotine products disproportionately appeal to young people, blacks, and

women--groups historically singled out by the tobacco industry for targeted marketing

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Groups at Increased Risk

• Young people relative to adults

• Early initiators of nicotine use relative to later initiators

• People who use multiple nicotine products relative to a

single nicotine product, especially if cigarettes are one of

the products used

• People with mental illness or psychiatric symptoms

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Prevention

• The main way to prevent nicotine addiction is to prevent people from using products that contain nicotine

• Because most people who are addicted to nicotine began using nicotine products in adolescence or early adulthood, prevention strategies that are implemented early tend to work best

• Effective approaches are comprehensive and involve:

– Public education and awareness

– Research-based policies/regulations that curb access and availability

– Early detection of risk

– Health-based interventions that promote cessation

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Effective Policies and Regulations

• The 2009 Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration (FDA) the authority to regulate the manufacture, distribution, and marketing of certain tobacco products

• In 2016, the authority of the FDA was extended to all nicotine-containing products

• The FDA can prohibit the sale of cigarettes with “characterizing flavors” (except menthol); require bigger and more graphic warning labels on product packages and advertisements; prohibit “reduced harm” claims; and require FDA approval for new tobacco products

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Effective Policies and Regulations

• Taxes - Raising taxes on tobacco products increases their

cost, which has been associated with less smoking and more

smoking cessation, especially among youth

• Smoking Bans - Clean indoor/outdoor air laws

• Restrictions on Advertising – Extensive for cigarettes, limited

for non-cigarette nicotine products

• Warning Labels – Required on product packages and

advertisements

• Restricting Youth Access – Minimum legal purchase/sale age

for tobacco products

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Interventions and Treatment

• Brief interventions

• Smoking cessation quitlines

• Pharmaceutical therapies

– Nicotine replacement therapy (nicotine patches, gum, nasal spray, inhalers, lozenges, and sub-lingual tablets)

– Bupropion (a prescription antidepressant medication)

– Varenicline (reduces rewarding effects of smoking as well as craving and withdrawal symptoms)

• Psychosocial/behavioral therapies

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Recommendations for Policymakers Strengthen tobacco control regulations and policies and apply them to

all nicotine products:

• Prohibit the marketing of nicotine products in any way that targets or appeals to youth

• Restrict youth access to all nicotine-containing products

• Include appropriate health warnings on all nicotine-containing products

• Improve packaging to prevent accidental nicotine poisonings, especially by youth

• Protect non-users from exposure to secondhand or passive smoke or aerosol

• Increase pricing (through higher taxes) to help minimize youth initiation and use

• Ensure the transparency and consistency of ingredients, dosing, and functioning of products

• Reduce the addiction potential of nicotine-containing products

• Invest in quality research to fill gaps in knowledge

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Recommendations for Policymakers

Actions for state and local governments:

• Increase funding for comprehensive, evidence-based prevention and cessation programming

• Enforce tobacco tax and point-of-sale laws, control retail outlet density and location, and

promote responsible sale and distribution of nicotine products

• Increase enforcement of laws restricting the sale of nicotine products to minors

• Enact strong and comprehensive indoor and outdoor clean air laws that prohibit the use of all

nicotine products anywhere the use of cigarettes is prohibited

• Enact zoning laws that restrict the density of nicotine product retail outlets

• Raise the minimum legal purchasing age to 21 for all nicotine-containing products

• Increase taxes on all nicotine products to help prevent youth initiation and reduce use

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Recommendations for Practice

• Identify nicotine use through routine screening for all forms of

nicotine product use

• Provide or connecting those who use nicotine products with

evidence-based interventions

• Incorporate screening and interventions into routine health care

practice and educational health initiatives

• Ensure a health- rather than a punitive-based intervention approach

• All addiction treatment programs, as well as criminal justice and

social service settings, should be required to address addiction

comprehensively--banning nicotine product use and specifically

including treatment for nicotine addiction in their services

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Conclusion

Nicotine is a highly addictive substance that not only perpetuates tobacco use, the leading cause of preventable morbidity and mortality in the United States, but also has its own adverse effects.

Public health and policy efforts have been remarkably successful in reducing rates of cigarette smoking in the U.S. over the past few decades. However, we must not allow the growing use of non-cigarette nicotine products to undo decades of hard-won progress in reducing the health and financial costs of nicotine product use.

A rational and science-based approach to the regulation of these products is required.

Adequate attention must also be paid to preventing the use of all addictive substances, including nicotine, and providing effective treatments that reduce or eliminate harm to those with addiction.

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www.centeronaddiction.org