TOBACCO DEPENDENCE

Tobacco smoking could be defined as a pharmacologically-reinforced behaviour in which nicotine is responsible for the addiction. If smoking initiation is dependent upon sociological and cultural factors, smoking is maintained by a double dependency :
- Pharmacological dependence : smoking dependence is characterised by tolerance and withdrawal symptoms;
- Non-pharmacological dependence : smoking is maintained despite the smokers' knowledge about the health risks and despite the negative social and environmental pressure.
These two kinds of dependence may or may not coexist in one particular smoker, and may sometime be absent in others.

Criteria for tobacco smoking dependence
Two kinds of approaches are proposed to evaluate nicotine dependence : specific questionnaires and biological measures.

The Fagerström Test for Nicotine Dependence  relies on simple questions that allow one to evaluate the intensity of nicotine addiction by a score :
- Score < 4 : low dependence
- Score between 4 and 7 : intermediate dependence
- Score > 7 : high dependence
This questionnaire is the most valuable tool for nicotine dependence evaluation.

The DSM IV criteria are used to evaluate tobacco dependence. Items 1 and 2 are used to evaluate  physical dependence.

Biological markers. Carbon monoxide and plasma saliva and urine cotinine are useful to quantify tobacco smoking in different conditions, but are weakly correlated to dependence and are in some instances difficult to obtain (particularly for GP).

Recommendations:
Evaluation of tobacco dependence and its subtypes helps  to  distinguish   between  t different cessation strategies
- The Fagerström questionnaire is a simple clinical tool to evaluate nicotine dependence and to help to find the best individual approach to cessation;
- The use of biological markers is not necessary for dependence evaluation in usual clinical settings.
 

IS THE EXISTENCE OF A TOBACCO-RELATED DISEASE INFLUENCING THE MODALITIES OF SMOKING CESSATION?

The diagnosis of a tobacco-related disease or the appearance of an acute complication are teachable moments  for  smoking cessation. The maintenance of this motivation is also necessary in the medium and long term. Differences are observed between conditions in terms of smoking cessation rates.

The benefit from cessation on cardiovascular and respiratory functions is obtained rapidly. The tobacco dependence process may explain why, when the information is given, which is not always the case, these smokers have great difficulties to maintain abstinence. The use of adequate nicotine replacement therapy in the early phase is an important help to achieve maintenance of abstinence.
 

ARE THE PRESENCE OF ANXIETY, DEPRESSION, ALCOHOL ABUSE, FEAR OF WEIGHT GAIN, INFLUENCING THE MODALITIES OF SMOKING CESSATION ?

These specific conditions should be taken into account to obtain successful quitting.

Anxiety and Depression.  Several studies have shown an association between anxiety and tobacco smoking. The link seems obvious with agoraphobia, simple phobia and panic disorder. Evidence is weaker with social phobia and generalised anxiety. Smoking prevalence is high in depressed people, and they have more difficulties in quitting. The appearance of  a depressive episode during or after smoking cessation is mostly a risk in those with history of depression.

History of depression or anxiety disorder should be ascertained before every smoking cessation attempt in order to anticipate the reappearance of a new episode. Use of psychotropic drugs, anxiolytics or antidepressant, should be based on individual consideration.

Alcohol abuse. The literature is focused on alcohol dependence. There is a positive correlation between tobacco and alcohol consumption.

More than 80% of alcoholics are smokers. They usually are highly dependent and smoking cessation is more difficult for them.

Weight gain. The fear of weight gain is a barrier to smoking cessation that is often underestimated, particularly in women. Smoking cessation is frequently followed by a weight gain, that in the vast majority of women, is limited to 6 Kg. A psychological encouragement, with no excess, aiming at the valorisation of body image through smoking cessation is important. Physical activity  may be encouraged. Use of nicotine replacement therapy is useful to delay the weight gain.
 

DO SPECIAL SOCIAL SITUATIONS (DEPRIVATION, LOW EDUCATION OR SOCIAL LEVEL) INFLUENCE THE MODALITIES OF SMOKING CESSATION ?

Social and economical factors influence tobacco consumption. Cardiovascular risk associated to tobacco smoking is higher in deprived people, but mainly in men. On the contrary, tobacco smoking is higher in women of higher social level. However, smoking cessation attempts might not be linked to social or demographic factors.

Recommendations:
It does not seem wise to set up special programs for deprived people. This kind of approach may lead to opposite results than those expected, like increasing their social exclusion. However,  accessibility to health care system and reimbursement of NRT must be facilitated.
 

DOES ADOLESCENCE INFLUENCE THE MODALITIES OF SMOKING CESSATION ?

Some differences exist in the attitude of adolescents towards smoking, compared to adults:
- Identification to models is very important. Tobacco smoking attitudes of relatives, peers, and educators are influential ; tobacco smoking could be view as a rite of passage to adulthood.
- Economic  factors are frequently cited as a motivation for smoking cessation
- Use of health care system for smoking cessation is scarcely evoked.

It appears that health care offer is specifically oriented towards adults, and that it is poorly adapted to adolescents. Specific programs should be developed for them.
 

DOES  PREGNANCY INFLUENCETHE MODALITIES OF SMOKING CESSATION ?

Based on French polls, 25% of pregnant women are smoking, 40% of them quit during the first trimester, while 5% quit during the second or third trimester. A great number of pregnant women have difficulties in stopping smoking during their pregnancy and to stay abstinent after giving birth. For these women smoking cessation interventions before, during and after pregnancy increase the rate of cessation, which after all is relatively low (6% to 20%). Special individualised intervention on smoking cessation with explanations, information and occasionally an expired CO measurement is more efficacious than minimal intervention (individual or group) without follow-up.

Conception desire and post-partum follow-up are also good circumstances to motivate smoking cessation in women.
 

Recommendations:
Obstetrical and gynaecological services are privileged structures to motivate and encourage smoking cessation. These actions should include physicians, midwives and other health professionals. The risks for the foetus and the infant must be taught and recalled to parents.