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Nicotine

This information on depression is for health and mental health professionals including:

  • psychologists
  • psychiatrists
  • psychotherapists
  • physicians
  • psychiatric nurses
  • clinical social workers

This information is for reference only.  Actual recommendations will depend on the needs of individual patients and resources available.

Prevelance
Cultural Factors Risk Factors and Symptoms
Diagnosis
Management

Prevelance

  • According to the American Lung Association, in 2002, nearly 13 million Americans over the age of 50 smoked. This number accounted for more than 28 percent of all adult smokers. Close to 10 percent of Americans over 65 years of age currently smoke.
  • Results from a national epidemiological survey indicated that among U.S. adults, 12.8% were nicotine dependent. Associations between nicotine dependence and specific Axis I and II disorders were all strong and statistically significant (p<.05) in the total population and among both men and women. Nicotine-dependent individuals with a co morbid psychiatric disorder made up 7.1% of the population, yet they consumed 34.2% of all cigarettes smoked in the United States.

National Center for Health Statistics. Raw Data from the National Health Interview Survey, U.S., 2000. [Analysis by the American Lung Association Research and Program Services Division, Using SPSS and SUDAAN]).

Nicotine dependence and psychiatric disorders in the United States: Results from the national epidemiological survey on alcohol and related conditions. Grant BF, Hasin DS, Chou SP, et al. Arch Gen Psychiatry. 2004 Nov; 61(11):1107-1115.

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Cultural Factors


  • African Americans and Hispanics suffer disproportionately from smoking-related illnesses such as asthma. In addition, barriers to smoking cessation include: a lack of a regular source for medical care, female sex, being nonmarried and employed, and lack of income and education.
  • Among older African American men, 22.1% between the age of 65-74 smoke and 12 % age 75 or older smoke.

American Lung Association: Lung Disease Data in Culturally Diverse Communities: 2005; and from Psychosocial correlates of smoking cessation among elderly ever-smokers in the United States. Honda K. Addict Behav. 2005 Feb; 30(2):375-381.

Centers for Disease Control and Prevention. Surveillance for five health risks among older adults -- United States, 1993-1997. Morbidity and Mortality Weekly Report 1999; 48: 89-130.

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Risk Factors and Symptoms


Risks associated with nicotine abuse include the development of:

  • Depression
  • Dementia and Alzheimer‘s disease
  • Pneumonia
  • Chronic-obstructive pulmonary disease (emphysema and chronic bronchitis)
  • Cancers of the mouth, tongue, throat, larynx, lung, esophagus, pancreas, bladder, and kidney
  • Coronary artery and peripheral artery disease
  • Stroke
  • Gangrene of the legs
  • Cataracts (the primary cause of loss of vision and blindness)

Symptoms of nicotine abuse

  • Dependence on nicotine
  • Jitters, anxiety

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Diagnosis


Screening Instruments

  • The Fagerstrom Test for Nicotine Dependence (FTND), a 6-item questionnaire that is useful in predicting the severity of nicotine craving and withdrawal, is the most widely used screening instrument.
  • The Heaviness of Smoking Index (HSI) is a 2-item screen that performs as well as the FTND and correlates with biochemical indices of nicotine intake. There is general consensus that persons who smoke at least 10 cigarettes per day or within 60 minutes of waking up are moderately nicotine dependent. Individuals who smoke at least 20 cigarettes per day or within 30 minutes of waking are highly dependent.

DSM-IV diagnostic criteria

No specific diagnostic criteria for nicotine dependence exists in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). However, the general criteria for substance dependence from the DSM can be applied:

Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve in-toxication or desired effect
    2. Markedly diminished effect with continued use of the same amount of the substance
  2. Withdrawal, as manifested by either of the following
    1. The characteristic withdrawal syndrome for the substance
    2. The same (or a closely related) substance is taken to relieve or avoid with-drawal symptoms
  3. The substance is often taken in larger amounts or over a longer period than was intended
  4. There is a persistent desire or unsuccessful efforts to cut down or control sub-stance use
  5. A great deal of time is spent in activities necessary to obtain the substance (e.g., driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
  6. Important social, occupational, or recreational activities are given up or reduced because of substance use
  7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

DSM-IV TR criteria: five axes

Evaluate patients using all five axes in the DSM-IV TR criteria:

  1. Axis I: Clinical Disorders, other conditions that may be a focus of clinical attention
  2. Axis II: Personality Disorders, borderline intellectual functioning or mental retardation
  3. Axis III: General Medical Conditions
  4. Axis IV: Psychosocial and Environmental Problems
  5. Axis V: Global Assessment of Functioning

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.


More specialized assessments

Some patients also require evaluation for:

  • Medical problems
  • Psychological issues
  • Substance abuse

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Management

According to the American Lung Association, older adults who quit smoking can improve their circulation and lung health. One study indicated that in a single year, the risk “of heart disease is cut almost in half, and risk of stroke, lung disease, and cancer diminish. Among smokers who quit at age 65, men gained 1.4 to 2.0 years of life and women gained 2.7 to 3.4 years.” (Taylor, DH, Hasselblad, V, Henley J, et al. Benefits of Smoking Cessation for Longevity. Am J Public Health 2002; 92: 990-996.)

Another study found that former smokers with mild or moderate chronic obstructive pulmonary disease breathed easier after quitting. After one year, the women who quit smoking had 2 times more improvement in lung function compared with the men who quit. (Connett, JE, Murray, RP, Buist, AS, et al., Changes in Smoking Status Affect Women More than Men: Results of the Lung Health Study, Am J Epidemiol 2003; 157: 973-979.)

Older adults who have a regular source of health care have the best chance of quitting smoking. Careful clinical evaluation and treatment are also important because nicotine withdrawal is linked to depression.

(Adapted from Psychosocial correlates of smoking cessation among elderly ever-smokers in the United States. Honda K. Addict Behav. 2005 Feb; 30(2):375-81.)

Treatment

The treatment of nicotine dependence can include pharmacotherapy, psychotherapy, and participation in smoking cessation programs. However, most patients will require an approach that combines multiple therapies.

Pharmacotherapy

Medications that can help with smoking cessation include:

  • Controlled-dose nicotine (nicotine replacement agents) in gums, candies, and liquids; inhalers and nasal sprays; and patches.
  • Agents such as silver nitrate that create aversion to nicotine.
  • Other drugs such as bupropion.

Psychotherapy

Immediately refer patients to a psychiatrist if they abuse nicotine and have any of the following conditions:

  • Severe anxiety or anorexia
  • Significant psychomotor agitation or retardation
  • Psychosis or mania
  • Suicidal or homicidal thinking

Consider referring patients to a psychiatrist if they abuse nicotine and have any of the following disorders:

  • Depression
  • Eating disorders
  • Post-traumatic stress or abuse
  • Obsessive compulsive disorders or personality disorders /li>

Smoking cessation programs. Older patients should be encouraged that they can quit smoking as successfully as younger patients can. Effective smoking-cessation programs:

  • Stress the risks of nicotine abuse.
  • Underscore the health benefits associated with quitting.
  • Establish a date for quitting.
  • Use sound behavioral modification techniques.
  • Provide strategies for stress management and relaxation.
  • Treat withdrawal symptoms
  • Provide regular and continuing follow-up.

(Adapted from Smoking cessation in the elderly. Appel DW, Aldrich TK. Clin Geriatr Med. 2003 Feb;19(1):77-100)

Adapted from: