Dr. L.R. KHAN
INTRODUCTION:
TOBACCO
Tobacco is used worldwide and is consumed by about 30 percent of the population in the form of cigarettes. Smoking has been implicated in a variety of illnesses, primarily lung cancer, lung disease, heart disease, and paralysis. There has been an increase in the use of chewing tobacco in the form of Gutkha and snuff among some segments of the population, primarily teenagers, and both have been implicated in throat cancer.
Pharmacology:
Nicotine is the active agent present in tobacco, it exerts effects on the central nervous system through receptors. Nicotine is highly toxic, and an overdose of 60 mg is fatal. The average cigarette contains 0.5 mg of nicotine. The physiological effects of nicotine include constriction of peripheral blood vessels, increased intestinal motility, stimulation of the hypothalamic pleasure center in brain ( which may account for the habitual use of the drug), decreased metabolic rate, rapid eye movement (REM) sleep changes, and tremor. Women who smoke are reported to have low-birth-weight babies. An occasional case of nicotine poisoning may be seen, consisting of excessive salivation, abdominal pain, vomiting, increased heart rate, mental confusion, and headache.
Nicotine Dependence:
Dependence on nicotine develops quickly. The average smoker uses 20 to 30 cigarettes a day. Dependence is also reinforced by psychological factors. For example, among adolescent girls, smoking is associated with being rebellious or often associated with pleasurable events, such as parties, diner, and sex. Other reinfrocers include smoking paraphernalia and advertising.
Nicotine Withdrawal:
The nicotine withdrawal syndrome develops in 90 to 120 minutes after the last cigarette smoked and peaks within the first 24 hours after cessation. It lasts for several weeks or months in some persons. The major symptom is an intense craving for a cigarette associated with tension and irritability. The person feels generally frustrated or angry, restless, and anxious; has difficulty concentrating, and is drowsy but has difficulty in sleeping. Decreased heart rate and blood pressure reduced motor performance, increased muscle contractions occur. Increased appetite and weight gain occur in most persons after they stop smoking.
Treatment:-
With smoking, the likely hood of the long term successful quitting of addiction is related to the severity of the dependence. Severity is measure by an index as total cigarettes smoked per day. Motivation is critical; those who seeks help only to please others generally do poorly. One finding on the smoking behavior is that the smokers� tendency to adjust or titrate nicotine level, switching to low tar, low nicotine brands of cigarettes or just cutting down does very little good. Most cigarettes smokers turn to puffing and inhalation patterns to compensate for changes in the nicotine delivered by their cigarettes. In smokers who switch brands, plasma nicotine levels decline only modestly and carbon monoxide level decline minimally. Only 25 percent of those who are initially successful are still nonsmokers at the end of the one year.
Aversion conditioning
techniques couple external stimuli or internal stimuli with the act of smoking. Electric shock are rarely used, but the rapid smoking method, when combined with other behavioral techniques, health advise, and emotional support, is now recognized as one of the most reliable and effective treatment of the tobacco dependence. Rapid smoking consists of having the patient inhale smoke from his or her own cigarette every 6 seconds. The procedure is carried out while the patient is being observed by trained therapist. The puffing continues until the patient is unwilling to take another puff. It usually takes about 10 to 15 minutes of puffing to reach this level. Repeating this procedure directly link smoking with negative effects. Although it at first postulated that the buildup of carbon monoxide and nicotine might be unsafe, it has been shown that the method can be used safely patients, a 50 percent abstinence rate at 12 year follow up has been reported
Acupuncture and hypnosis:- Acupuncture & hypnosis may be effective when combined with group therapy.
Commercial Programs:- This program generally involve multiple behavioral modification methods, group process and group support; for the most part, they focus on motivation of participants, teaching them about nicotine decondition craving. Although data are not easily obtained, these program are probably considerably more effective then the rapid smoking techniques in the hands of skilled therapist.
Pharmacological Intervention:- Nicotine in form of gum has been repeatedly demonstrated to increase likely-hood of successful tobacco abstinence in a variety of situations ranging from nicotine gum plus physicians advise to nicotine gum in the context of multicomponent behavioral treatment offered by an expert therapist. There has been one report that clonidine reduces craving for tobacco.
Now a days Bupropion is being used to reduce craving for tobacco leading to gradual decrease in its consumption. A few companies are offering mouth sprays & gurgles which cause bitter taste in mouth on using tobacco in any form ( e.g. Cigarette, Bidi, Gutkha, Zarda, etc.)
(Author is Consultant Psychiatrist at Raahat Hospital, Aurangabad.)
