The 2002 Official Patient's Sourcebook on Nicotine Dependence: A Revised and Updated Directory for the Internet Age

THE 2002 OFFICIAL PATIENT’S SOURCEBOOK

on

NICOTINE

DEPENDENCE J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

ii

ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The 2002 Official Patient’s Sourcebook on Nicotine Dependence: Revised and Updated for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83259-5 1. Nicotine Dependence-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

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Dedication To the healthcare professionals dedicating their time and efforts to the study of nicotine dependence.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to nicotine dependence. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

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About ICON Health Publications In addition to nicotine dependence, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Alcoholism

·

The Official Patient's Sourcebook on Anabolic Steroid Dependence

·

The Official Patient's Sourcebook on Club Drug Dependence

·

The Official Patient's Sourcebook on Cocaine Dependence

·

The Official Patient's Sourcebook on Dextromethorphan Dependence

·

The Official Patient's Sourcebook on Dissociative Drug Dependence

·

The Official Patient's Sourcebook on Ghb Dependence

·

The Official Patient's Sourcebook on Hepatitis C

·

The Official Patient's Sourcebook on Heroin Dependence

·

The Official Patient's Sourcebook on Inhalants Dependence

·

The Official Patient's Sourcebook on Ketamine Dependence

·

The Official Patient's Sourcebook on Lsd Dependence

·

The Official Patient's Sourcebook on Marijuana Dependence

·

The Official Patient's Sourcebook on Mdma Dependence

·

The Official Patient's Sourcebook on Methamphetamine Dependence

·

The Official Patient's Sourcebook on Pcp Dependence

·

The Official Patient's Sourcebook on Prescription Cns Depressants Dependence

·

The Official Patient's Sourcebook on Prescription Drug Dependence

·

The Official Patient's Sourcebook on Prescription Opioids Dendedence

·

The Official Patient's Sourcebook on Prescription Stimulants Dependence

·

The Official Patient's Sourcebook on Rohypnol Dependence

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION ................................................................................................................................. 1 Overview ....................................................................................................................................... 1 Organization ................................................................................................................................. 3 Scope.............................................................................................................................................. 3 Moving Forward............................................................................................................................ 4 PART I: THE ESSENTIALS ............................................................................................................. 7 CHAPTER 1. THE ESSENTIALS ON NICOTINE DEPENDENCE: GUIDELINES ...................................... 9 Overview ....................................................................................................................................... 9 What Is Nicotine?........................................................................................................................ 12 Is Nicotine Addictive? ................................................................................................................. 13 What Is the Extent and Impact of Tobacco Use? ......................................................................... 15 What Happens When Nicotine Is Taken for Long Periods of Time? ........................................... 17 What Are the Medical Consequences of Nicotine Use?............................................................... 18 Smoking and Pregnancy: What Are the Risks?........................................................................... 19 Are There Effective Treatments for Nicotine Addiction? ............................................................ 20 Are There Gender Differences in Tobacco Smoking? .................................................................. 22 Cigarettes and Other Nicotine Products INFOFAX .................................................................. 23 Health Hazards............................................................................................................................ 24 Promising Research ..................................................................................................................... 26 Extent of Use ............................................................................................................................... 28 More Guideline Sources .............................................................................................................. 29 Vocabulary Builder...................................................................................................................... 36 CHAPTER 2. SEEKING GUIDANCE ................................................................................................... 41 Overview ..................................................................................................................................... 41 Associations and Nicotine Dependence ....................................................................................... 41 Finding Drug Treatment and Alcohol Abuse Treatment Programs ........................................... 43 Finding Doctors........................................................................................................................... 45 Selecting Your Doctor ................................................................................................................. 46 Working with Your Doctor ......................................................................................................... 47 Broader Health-Related Resources .............................................................................................. 48 CHAPTER 3. CLINICAL TRIALS AND NICOTINE DEPENDENCE ...................................................... 49 Overview ..................................................................................................................................... 49 Recent Trials on Nicotine Dependence........................................................................................ 51 Benefits and Risks........................................................................................................................ 58 Keeping Current on Clinical Trials ............................................................................................. 61 General References....................................................................................................................... 62 Vocabulary Builder...................................................................................................................... 63 PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL ........................... 65 CHAPTER 4. STUDIES ON NICOTINE DEPENDENCE ........................................................................ 67 Overview ..................................................................................................................................... 67 The Combined Health Information Database .............................................................................. 67 Federally-Funded Research on Nicotine Dependence.................................................................. 80 E-Journals: PubMed Central ....................................................................................................... 96 The National Library of Medicine: PubMed................................................................................ 96 Vocabulary Builder...................................................................................................................... 97 CHAPTER 5. PATENTS ON NICOTINE DEPENDENCE .................................................................... 101 Overview ................................................................................................................................... 101 Patents on Nicotine Dependence ............................................................................................... 102 Keeping Current ........................................................................................................................ 104

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Vocabulary Builder.................................................................................................................... 104 CHAPTER 6. BOOKS ON NICOTINE DEPENDENCE ........................................................................ 105 Overview ................................................................................................................................... 105 Book Summaries: Federal Agencies ........................................................................................... 105 Book Summaries: Online Booksellers ........................................................................................ 110 The National Library of Medicine Book Index........................................................................... 110 Chapters on Nicotine Dependence............................................................................................. 114 General Home References .......................................................................................................... 121 Vocabulary Builder.................................................................................................................... 121 CHAPTER 7. MULTIMEDIA ON NICOTINE DEPENDENCE ............................................................. 123 Overview ................................................................................................................................... 123 Bibliography: Multimedia on Nicotine Dependence.................................................................. 123 Vocabulary Builder.................................................................................................................... 125 CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES .............................................................. 127 Overview ................................................................................................................................... 127 NIH Guidelines ......................................................................................................................... 127 NIH Databases .......................................................................................................................... 128 Other Commercial Databases .................................................................................................... 134 The Genome Project and Nicotine Dependence......................................................................... 135 Specialized References ............................................................................................................... 139 Vocabulary Builder.................................................................................................................... 140 CHAPTER 9. DISSERTATIONS ON NICOTINE DEPENDENCE.......................................................... 141 Overview ................................................................................................................................... 141 Dissertations on Nicotine Dependence...................................................................................... 141 Keeping Current ........................................................................................................................ 142 Vocabulary Builder.................................................................................................................... 142 PART III. APPENDICES .............................................................................................................. 143 APPENDIX A. RESEARCHING YOUR MEDICATIONS ..................................................................... 145 Overview ................................................................................................................................... 145 Your Medications: The Basics ................................................................................................... 145 Learning More about Your Medications ................................................................................... 147 Commercial Databases............................................................................................................... 149 Contraindications and Interactions (Hidden Dangers)............................................................. 150 A Final Warning ....................................................................................................................... 151 General References..................................................................................................................... 151 Vocabulary Builder.................................................................................................................... 152 APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ............................................................... 153 Overview ................................................................................................................................... 153 What Is CAM? .......................................................................................................................... 153 What Are the Domains of Alternative Medicine? ..................................................................... 154 Can Alternatives Affect My Treatment?................................................................................... 157 Finding CAM References on Nicotine Dependence .................................................................. 158 Additional Web Resources......................................................................................................... 163 General References..................................................................................................................... 170 Vocabulary Builder.................................................................................................................... 171 APPENDIX C. RESEARCHING NUTRITION..................................................................................... 173 Overview ................................................................................................................................... 173 Food and Nutrition: General Principles .................................................................................... 173 Finding Studies on Nicotine Dependence ................................................................................. 178 Federal Resources on Nutrition................................................................................................. 179 Additional Web Resources......................................................................................................... 180 Vocabulary Builder.................................................................................................................... 182 APPENDIX D. FINDING MEDICAL LIBRARIES ............................................................................... 185

Contents

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Overview ................................................................................................................................... 185 Preparation ................................................................................................................................ 185 Finding a Local Medical Library ............................................................................................... 186 Medical Libraries Open to the Public ........................................................................................ 186 APPENDIX E. PRINCIPLES OF DRUG ADDICTION TREATMENT .................................................... 193 Overview ................................................................................................................................... 193 Principles of Effective Treatment .............................................................................................. 193 What Is Drug Addiction?.......................................................................................................... 196 Frequently Asked Questions ..................................................................................................... 197 Drug Addiction Treatment in the United States ...................................................................... 204 General Categories of Treatment Programs .............................................................................. 205 Treating Criminal Justice-Involved Drug Abusers and Addicts .............................................. 208 Scientifically-Based Approaches to Drug Addiction Treatment ............................................... 209 Resources ................................................................................................................................... 217 Selected NIDA Educational Resources on Drug Addiction Treatment .................................... 217 Vocabulary Builder.................................................................................................................... 221 ONLINE GLOSSARIES ............................................................................................................... 223 Online Dictionary Directories................................................................................................... 227 NICOTINE DEPENDENCE GLOSSARY ................................................................................. 229 General Dictionaries and Glossaries ......................................................................................... 240 INDEX.............................................................................................................................................. 242

Introduction

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INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don't know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

2

Nicotine Dependence

Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor's offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Nicotine Dependence has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to nicotine dependence, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on nicotine dependence. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on nicotine dependence should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on

Introduction

3

appropriate options is always up to the patient in consultation with their physician and healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching nicotine dependence (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to nicotine dependence. It also gives you sources of information that can help you find a doctor in your local area specializing in treating nicotine dependence. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with nicotine dependence. Part II moves on to advanced research dedicated to nicotine dependence. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on nicotine dependence. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with nicotine dependence or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with nicotine dependence. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with nicotine dependence.

Scope While this sourcebook covers nicotine dependence, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that nicotine dependence is often considered a synonym or a condition closely related to the following: ·

Chewing Tobacco

·

Cigar Smoking

4

Nicotine Dependence

·

Cigarette Abuse

·

Cigarette Addiction

·

Cigarette Dependence

·

Ciragette Smoking

·

Nicotine

·

Nicotine Abuse

·

Nicotine Addiction

·

Tobacco Abuse

·

Tobacco Addiction

·

Tobacco Dependence

·

Tobacco Smoking

In addition to synonyms and related conditions, physicians may refer to nicotine dependence using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world's illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for nicotine dependence:4 ·

305.1 tobacco use disorder

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to nicotine dependence. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson's approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and 4 This list is based on the official version of the World Health Organization's 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

5

highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with nicotine dependence will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with nicotine dependence is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of nicotine dependence, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

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PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on nicotine dependence. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your doctor or healthcare provider may have already explained the essentials of nicotine dependence to you or even given you a pamphlet or brochure describing nicotine dependence. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Seeking Guidance

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CHAPTER 1. THE ESSENTIALS ON NICOTINE DEPENDENCE: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on nicotine dependence. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on nicotine dependence can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on nicotine dependence. Originally founded in 1887, the NIH is one of the world's foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world's most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.

5

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

10 Nicotine Dependence

There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with nicotine dependence and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute on Drug Abuse (NIDA); guidelines on abused drugs at http://www.nida.nih.gov/DrugAbuse.html

Among these, the National Institute on Drug Abuse is particularly noteworthy.6 NIDA was established in 1974, and in October 1992 it became part of the National Institutes of Health, Department of Health and Human Services. The Institute is organized into divisions and offices, each of which plays an important role in programs of drug abuse research. NIDA's mission is to lead the Nation in bringing the power of science to bear on drug abuse and addiction. This charge has two critical components. The first is the strategic support and conduct of research across a broad range of disciplines. The second is to ensure the rapid and effective dissemination and use of the results of that research to significantly improve drug abuse and addiction prevention, treatment, and policy. NIDA supports over 85 percent of the world's research on the health aspects of drug abuse and addiction. NIDA supported science addresses the most fundamental and essential questions about drug abuse, ranging from the molecule to managed care, and from DNA to community outreach research. NIDA is not only seizing upon unprecedented opportunities and technologies to further understanding of how drugs of abuse affect the brain and behavior, but also working to ensure the rapid and effective transfer of scientific data to policy makers, drug abuse practitioners, other health care practitioners and the general public. The NIDA web page is an important part of this effort (http://www.nida.nih.gov/). Before citing NIDA's most

The section is reproduced or adapted from the NIDA: http://www.nida.nih.gov/NIDAWelcome.html#Mission. For the remainder of this book, “adapted” signifies attributed “reproduction” with formatting and other minimal editorial changes. 6

Seeking Guidance 11

recent guideline on nicotine dependence, the discussion below reproduces NIDA's general overview of drug abuse and addiction. Understanding Drug Abuse and Addiction7 Many people view drug abuse and addiction as strictly a social problem. Parents, teens, older adults, and other members of the community tend to characterize people who take drugs as morally weak or as having criminal tendencies. They believe that drug abusers and addicts should be able to stop taking drugs if they are willing to change their behavior. These myths have not only stereotyped those with drug-related problems, but also their families, their communities, and the health care professionals who work with them. Drug abuse and addiction comprise a public health problem that affects many people and has wide-ranging social consequences. It is NIDA's goal to help the public replace its myths and long-held mistaken beliefs about drug abuse and addiction with scientific evidence that addiction is a chronic, relapsing, and treatable disease. Addiction does begin with drug abuse when an individual makes a conscious choice to use drugs, but addiction is not just “a lot of drug use.” Recent scientific research provides overwhelming evidence that not only do drugs interfere with normal brain functioning creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity. At some point, changes occur in the brain that can turn drug abuse into addiction, a chronic, relapsing illness. Those addicted to drugs suffer from a compulsive drug craving and usage and cannot quit by themselves. Treatment is necessary to end this compulsive behavior. A variety of approaches are used in treatment programs to help patients deal with these cravings and possibly avoid drug relapse. NIDA research shows that addiction is clearly treatable. Through treatment that is tailored to individual needs, patients can learn to control their condition and live relatively normal lives. Treatment can have a profound effect not only on drug abusers, but on society as a whole by significantly improving social and psychological functioning, decreasing related criminality and violence, and reducing the spread of AIDS. It can also dramatically reduce the costs to society of drug abuse. 7

Adapted from http://165.112.78.61/Infofax/understand.html.

12 Nicotine Dependence

Understanding drug abuse also helps in understanding how to prevent use in the first place. Results from NIDA-funded prevention research have shown that comprehensive prevention programs that involve the family, schools, communities, and the media are effective in reducing drug abuse. It is necessary to keep sending the message that it is better to not start at all than to enter rehabilitation if addiction occurs. A tremendous opportunity exists to effectively change the ways in which the public understands drug abuse and addiction because of the wealth of scientific data NIDA has amassed. Overcoming misconceptions and replacing ideology with scientific knowledge is the best hope for bridging the “great disconnect” - the gap between the public perception of drug abuse and addiction and the scientific facts. The National Institutes of Health has recently published the following guideline for nicotine dependence:

What Is Nicotine?8 Nicotine, one of more than 4,000 chemicals found in the smoke from tobacco products such as cigarettes, cigars, and pipes, is the primary component in tobacco that acts on the brain. Smokeless tobacco products such as snuff and chewing tobacco also contain many toxins as well as high levels of nicotine. Nicotine, recognized as one of the most frequently used addictive drugs, is a naturally occurring colorless liquid that turns brown when burned and acquires the odor of tobacco when exposed to air. There are many species of tobacco plants; the tabacum species serves as the major source of tobacco products today. Since nicotine was first identified in the early 1800s, it has been studied extensively and shown to have a number of complex and sometimes unpredictable effects on the brain and the body. Cigarette smoking is the most prevalent form of nicotine addiction in the United States. Most cigarettes in the U.S. market today contain 10 milligrams (mg) or more of nicotine. Through inhaling smoke, the average smoker takes in 1 to 2 mg nicotine per cigarette. There have been substantial increases in the sale and consumption of smokeless tobacco products also, and more recently, in cigar sales.

Adapted from The National Institute on Drug Abuse: http://165.112.78.61/ResearchReports/Nicotine/Nicotine.html.

8

Seeking Guidance 13

Nicotine is absorbed through the skin and mucosal lining of the mouth and nose or by inhalation in the lungs. Depending on how tobacco is taken, nicotine can reach peak levels in the bloodstream and brain rapidly. Cigarette smoking, for example, results in rapid distribution of nicotine throughout the body, reaching the brain within 10 seconds of inhalation. Cigar and pipe smokers, on the other hand, typically do not inhale the smoke, so nicotine is absorbed more slowly through the mucosal membranes of their mouths. Nicotine from smokeless tobacco also is absorbed through the mucosal membranes.

Is Nicotine Addictive? Yes, nicotine is addictive. Most smokers use tobacco regularly because they are addicted to nicotine. Addiction is characterized by compulsive drugseeking and use, even in the face of negative health consequences, and tobacco use certainly fits the description. It is well documented that most smokers identify tobacco as harmful and express a desire to reduce or stop using it, and nearly 35 million of them make a serious attempt to quit each year. Unfortunately, less than 7 percent of those who try to quit on their own achieve more than 1 year of abstinence; most relapse within a few days of attempting to quit. Other factors to consider besides nicotine's addictive properties include its high level of availability, the small number of legal and social consequences of tobacco use, and the sophisticated marketing and advertising methods used by tobacco companies. These factors, combined with nicotine's addictive properties, often serve as determinants for first use and, ultimately, addiction.

14 Nicotine Dependence

Trends in percent of adolescents reporting current* cigarette use *Individual who reports smoking one or more cigarettes during the previous 30 days. Source: CDC, MMWR, 2000; 49(33): 755-758 Recent research has shown in fine detail how nicotine acts on the brain to produce a number of behavioral effects. Of primary importance to its addictive nature are findings that nicotine activates the brain circuitry that regulates feelings of pleasure, the so-called reward pathways. A key brain chemical involved in mediating the desire to consume drugs is the neurotransmitter dopamine, and research has shown that nicotine increases the levels of dopamine in the reward circuits. Nicotine's pharmacokinetic properties have been found also to enhance its abuse potential. Cigarette smoking produces a rapid distribution of nicotine to the brain, with drug levels peaking within 10 seconds of inhalation. The acute effects of nicotine dissipate in a few minutes, causing the smoker to continue dosing frequently throughout the day to maintain the drug's pleasurable effects and prevent withdrawal. What people frequently do not realize is that the cigarette is a very efficient and highly engineered drug-delivery system. By inhaling, the smoker can get nicotine to the brain very rapidly with every puff. A typical smoker will take 10 puffs on a cigarette over a period of 5 minutes that the cigarette is lit. Thus, a person who smokes about 1-1/2 packs (30 cigarettes) daily, gets 300 “hits” of nicotine to the brain each day. These factors contribute considerably to nicotine's highly addictive nature. Scientific research is also beginning to show that nicotine may not be the only psychoactive ingredient in tobacco. Using advanced neuroimaging technology, scientists can see the dramatic effect of cigarette smoking on the brain and are finding a marked decrease in the levels of monoamineoxidase

Seeking Guidance 15

(MAO), an important enzyme that is responsible for breaking down dopamine. The change in MAO must be caused by some tobacco smoke ingredient other than nicotine, since we know that nicotine itself does not dramatically alter MAO levels. The decrease in two forms of MAO, A and B, then results in higher dopamine levels and may be another reason that smokers continue to smoke - to sustain the high dopamine levels that result in the desire for repeated drug use.

What Is the Extent and Impact of Tobacco Use? According to the 1999 National Household Survey on Drug Abuse, an estimated 57.0 million Americans were current smokers and 7.6 million used smokeless tobacco, which means that nicotine is one of the most widely abused substances. In addition, in 1998 each day in the United States more than 2,000 people under the age of 18 began daily smoking. According to the Centers for Disease Control and Prevention (CDC), the prevalence of cigarette smoking among U.S. high school students increased from 27.5 percent in 1991 to 36.4 percent in 1997 before declining to 34.8 percent in 1999. NIDA's own Monitoring the Future Study, which annually surveys drug use and related attitudes of America's adolescents, also found the prevalence rates for smoking among youth declined from 1999 to 2000. Since 1975, nicotine in the form of cigarettes has consistently been the substance the greatest number of high school students use daily. Percentage of high school students who currently use cigarettes, smokeless tobacco, or cigars, by gender, race/ethnicity, and grade: Category

Cigarettes

Smokeless

Cigars

34.7% 34.9%

14.2% 1.3%

25.4% 9.9%

38.6% 38.2% 39.1% 19.7% 21.8% 17.7% 32.7% 34.0% 31.5%

10.4% 18.8% 1.5% 1.3% 2.5% 0.2% 3.9% 6.1% 1.8%

18.8% 28.3% 8.6% 13.7% 16.0% 11.6% 16.7% 21.9% 11.6%

Gender Male Female

Race/Ethnicity White, non-Hispanic Male Female Black, non-Hispanic Male Female Hispanic Male Female

16 Nicotine Dependence

Grade 9 10 11 12

27.6% 34.7% 36.0% 42.8%

Total % Surveyed 34.8%

6.8% 7.1% 8.4% 8.9%

13.7% 17.8% 18.2% 22.0%

7.8%

17.7%

Source: Centers for Disease Control and Prevention, CDC Surveillance Summaries, June 9, 2000. MMWR 49, SS-5, 2000. The impact of nicotine addiction in terms of morbidity, mortality, and economic costs to society is staggering. Tobacco kills more than 430,000 U.S. citizens each year-more than alcohol, cocaine, heroin, homicide, suicide, car accidents, fire, and AIDS combined. Tobacco use is the leading preventable cause of death in the United States. Economically, an estimated $80 billion of total U.S. health care costs each year is attributable to smoking. However, this cost is well below the total cost to society because it does not include burn care from smoking-related fires, perinatal care for low-birth-weight infants of mothers who smoke, and medical care costs associated with disease caused by secondhand smoke. Taken together, the direct and indirect costs of smoking are estimated at $138 billion per year.

How Does Nicotine Deliver Its Effect? Nicotine can act as both a stimulant and a sedative. Immediately after exposure to nicotine, there is a “kick” caused in part by the drug's stimulation of the adrenal glands and resulting discharge of epinephrine (adrenaline). The rush of adrenaline stimulates the body and causes a sudden release of glucose as well as an increase in blood pressure, respiration, and heart rate. Nicotine also suppresses insulin output from the pancreas, which means that smokers are always slightly hyperglycemic. In addition, nicotine indirectly causes a release of dopamine in the brain regions that control pleasure and motivation. This reaction is similar to that seen with other drugs of abuse-such as cocaine and heroin- and it is thought to underlie the pleasurable sensations experienced by many smokers. In contrast, nicotine can also exert a sedative effect, depending on the level of the smoker's nervous system arousal and the dose of nicotine taken.

Seeking Guidance 17

What Happens When Nicotine Is Taken for Long Periods of Time? Chronic exposure to nicotine results in addiction. Research is just beginning to document all of the neurological changes that accompany the development and maintenance of nicotine addiction. The behavioral consequences of these changes are well documented, however. Greater than 90 percent of those smokers who try to quit without seeking treatment fail, with most relapsing within a week. Repeated exposure to nicotine results in the development of tolerance, the condition in which higher doses of a drug are required to produce the same initial stimulation. Nicotine is metabolized fairly rapidly, disappearing from the body in a few hours. Therefore some tolerance is lost overnight, and smokers often report that the first cigarettes of the day are the strongest and/or the “best.” As the day progresses, acute tolerance develops, and later cigarettes have less effect. Cessation of nicotine use is followed by a withdrawal syndrome that may last a month or more; it includes symptoms that can quickly drive people back to tobacco use. Nicotine withdrawal symptoms include irritability, craving, cognitive and attentional deficits, sleep disturbances, and increased appetite and may begin within a few hours after the last cigarette. Symptoms peak within the first few days and may subside within a few weeks. For some people, however, symptoms may persist for months or longer. An important but poorly understood component of the nicotine withdrawal syndrome is craving, an urge for nicotine that has been described as a major obstacle to successful abstinence. High levels of craving for tobacco may persist for 6 months or longer. While the withdrawal syndrome is related to the pharmacological effects of nicotine, many behavioral factors also can affect the severity of withdrawal symptoms. For some people, the feel, smell, and sight of a cigarette and the ritual of obtaining, handling, lighting, and smoking the cigarette are all associated with the pleasurable effects of smoking and can make withdrawal or craving worse. While nicotine gum and patches may alleviate the pharmacological aspects of withdrawal, cravings often persist.

18 Nicotine Dependence

What Are the Medical Consequences of Nicotine Use? The medical consequences of nicotine exposure result from effects of both the nicotine itself and how it is taken. The most deleterious effects of nicotine addiction are the result of tobacco use, which accounts for one-third of all cancers. Foremost among the cancers caused by tobacco is lung cancer-the number one cancer killer of both men and women. Cigarette smoking has been linked to about 90 percent of all lung cancer cases. In addition to lung cancer, smoking also causes lung diseases such as chronic bronchitis and emphysema, and it has been found to exacerbate asthma symptoms in adults and children. Smoking is also associated with cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, ureter, and bladder. The overall rates of death from cancer are twice as high among smokers as among nonsmokers, with heavy smokers having rates that are four times greater than those of nonsmokers. Cigarette smoking is the most important preventable cause of cancer in the United States.

430,000 annual deaths are attributable to cigarette smoking Source: CDC, MMWR 1997; 46; 448-51 In addition to its ability to cause cancer, a relationship between cigarette smoking and coronary heart disease was first reported in the 1940s. Since that time, it has been well documented that smoking substantially increases the risk of heart disease, including stroke, heart attack, vascular disease, and aneurysm. It is estimated that nearly one-fifth of deaths from heart disease are attributable to smoking.

Seeking Guidance 19

While we often think of medical consequences that result from direct use of tobacco products, passive or secondary smoke also increases the risk for many diseases. Environmental tobacco smoke (ETS) is a major source of indoor air contaminants; secondhand smoke is estimated to cause approximately 3,000 lung cancer deaths per year among nonsmokers and contributes to as many as 40,000 deaths related to cardiovascular disease. Exposure to tobacco smoke in the home increases the severity of asthma for children and is a risk factor for new cases of childhood asthma. ETS exposure has been linked also with sudden infant death syndrome. Additionally, dropped cigarettes are the leading cause of residential fire fatalities, leading to more than 1,000 such deaths each year. At higher doses, such as the nicotine that can be found in some insecticide sprays, nicotine can be extremely toxic, causing vomiting, tremors, convulsions, and death. Nicotine poisoning has been reported from accidental ingestion of insecticides by adults and ingestion of tobacco products by children and pets. Death usually results in a few minutes from respiratory failure caused by paralysis. Laboratory research indicates that cigarette smoking causes toxic cardiovascular effects. For this reason, nicotine replacement medicines such as nicotine gum and the patch have been extensively evaluated for cardiovascular toxicity, especially for patients with cardiac disease. These trials suggest that use of nicotine replacements for smoking cessation does not increase cardiovascular risk. These findings are consistent with the generally slower and lower doses of nicotine obtained from the medicines as compared to tobacco products, and to the absence of carbon monoxide and numerous other toxins in tobacco smoke.

Smoking and Pregnancy: What Are the Risks? In pregnant women, carbon monoxide (a lethal gas) and the high doses of nicotine obtained when they inhale tobacco smoke interferes with oxygen supply to the fetus. Nicotine readily crosses the placenta, and nicotine concentrations in the fetus can be as much as 15 percent higher than maternal levels. It appears that nicotine is concentrated in fetal blood, amniotic fluid, and breast milk. Another ingredient of tobacco smoke, carbon monoxide, has been shown to inhibit the release of oxygen into fetal tissues. These factors, combined, likely account for the developmental delays commonly seen in the fetuses and infants of smoking mothers.

20 Nicotine Dependence

Women who smoke during pregnancy are at greater risk than nonsmokers for premature delivery, and there is a risk of lower birth weight for infants carried to term. In the United States it is estimated that 20 percent or more of pregnant women smoke throughout their pregnancies. The adverse effects of smoking may occur in every trimester of pregnancy; they range from spontaneous abortions in the first trimester to increased premature delivery rates and decreased birth weights in the final trimester. The decreased birth weights seen in infants of mothers who smoke reflects a dose-dependent relationship: the more the woman smokes during pregnancy, the greater the reduction of infant birth weight. Conversely, women who give up smoking early in pregnancy have infants of similar weight to those of nonsmokers.

Are There Effective Treatments for Nicotine Addiction? Yes, extensive research has shown that behavioral and pharmacological treatments for nicotine addiction do work. For those individuals motivated to quit smoking, a combination of behavioral and pharmacological treatments can increase the success rate approximately twofold over placebo treatments. Furthermore, smoking cessation can have an immediate positive impact on an individual's health; for example, a 35-year-old man who quits smoking will, on the average, increase his life expectancy by 5.1 years.

Nicotine Replacement Treatments Nicotine was the first pharmacological agent approved by the Food and Drug Administration (FDA) for use in smoking cessation therapy. Nicotine replacement therapies, such as nicotine gum, the transdermal patch, nasal spray, and inhaler, have been approved for use in the United States. They are used to relieve withdrawal symptoms, because they produce less severe physiological alterations than tobacco-based systems, and generally provide users with lower overall nicotine levels than they receive with tobacco. An added benefit is that these forms of nicotine have little abuse potential since they do not produce the pleasurable effects of tobacco products. Nor do they contain the carcinogens and gases associated with tobacco smoke. The FDA's approval of nicotine gum in 1984 marked the availability (by prescription) of the first nicotine replacement therapy on the U.S. market. In 1996, the FDA approved gum (Nicorette®) for over-the-counter sales. Whereas nicotine gum provides some smokers with the desired control over dose and ability to relieve cravings, others are unable to tolerate the taste and chewing demands. In 1991-1992, FDA approved four transdermal

Seeking Guidance 21

nicotine patches, two of which became over-the-counter products in 1996, thus meeting the needs of many additional tobacco users. Since the introduction of nicotine gum and the transdermal patch, estimates based on FDA and pharmaceutical industry data indicate that more than 1 million individuals have been successfully treated for nicotine addiction. In 1996 a nicotine nasal spray, and in 1998 a nicotine inhaler, became available by prescription. All the nicotine replacement products- gum, patch, spray and inhaler- appear to be equally effective. In fact, the over-the-counter availability of many of these medications, combined with increased messages to quit smoking in the media, has produced about a 20 percent increase in successful quitting each year.

Non-Nicotine Therapies Although the major focus of pharmacological treatments of nicotine addiction has been nicotine replacement, other treatments are being developed for relief of nicotine withdrawal symptoms. For example, the first non-nicotine prescription drug, bupropion, an antidepressant marketed as Zyban®, has been approved for use as a pharmacological treatment for nicotine addiction. In December 1996, a Federal advisory committee recommended that the FDA approve bupropion to become the first drug to help people quit smoking that could be taken in pill form, and the first to contain no nicotine.

Behavioral Treatments Behavioral interventions can play an integral role in nicotine addiction treatment. Over the past decade, this approach has spread from primarily clinic-based, formal smoking-cessation programs to application in numerous community and public health settings, and now to telephone and written formats as well. In general, behavioral methods are employed to (a) discover high-risk relapse situations, (b) create an aversion to smoking, (c) develop self-monitoring of smoking behavior, and (d) establish competing coping responses. Other key factors in successful treatment include avoiding smokers and smoking environments and receiving support from family and friends. The single most important factor, however, may be the learning and use of coping skills for both short- and long-term prevention of relapse. Smokers

22 Nicotine Dependence

must not only learn behavioral and cognitive tools for relapse prevention but must also be ready to apply those skills in a crisis. Although behavioral and pharmacological treatments can be extremely successful when employed alone, science has taught us that integrating both types of treatments will ultimately be the most effective approach. More than 90 percent of the people who try to quit smoking relapse or return to smoking within 1 year, with the majority relapsing within a week. There are, however, an estimated 2.5 to 5 percent who do in fact succeed on their own. It has been shown that pharmacological treatments can double the odds of their success. However, a combination of pharmacological and behavioral treatments further improves their chances. For example, when use of the nicotine patch is combined with a behavioral approach, such as group therapy or social support networks, the efficacy of treatment is significantly enhanced.

Are There Gender Differences in Tobacco Smoking? Several avenues of research now indicate that men and women differ in their smoking behavior and that differences in nicotine sensitivity may be the root cause. Studies of smoking behavior seem to indicate that women smoke fewer cigarettes per day, tend to use cigarettes with lower nicotine content, and do not inhale as deeply as men. Whether this is because of differences in sensitivity to nicotine is an important research question. Some researchers are finding that women may be more affected by factors other than nicotine, such as the sensory aspects of the smoke or social factors, than they are by nicotine itself. The number of smokers in the United States declined in the 1970s and 1980s, but has been relatively stable throughout the 1990s. Because this decline of smoking was greater among men than women, the prevalence of smoking is only slightly higher for men today than it is for women. Several factors appear to be contributing to this trend, including increased initiation of smoking among female teens and, more critically, women being less likely than men to quit smoking. Large-scale smoking-cessation trials show that women are less likely to initiate quitting and may be more likely to relapse if they do quit. In cessation programs using nicotine replacement methods, such as the patch or gum, the nicotine does not seem to reduce craving as effectively for women as for men. Other factors that may contribute to women's difficulty with

Seeking Guidance 23

quitting are that the withdrawal syndrome may be more intense for women and that they appear more likely than men to gain weight upon quitting. It is important for women entering smoking cessation programs to be aware that standard treatment regimens may have to be adjusted to compensate for gender differences in nicotine sensitivity.

Where Can I Get Further Scientific Information about Nicotine Addiction? To learn more about nicotine and other drugs of abuse, contact the National Clearinghouse for Alcohol and Drug Information (NCADI) at 1-800-7296686. Information specialists are available to assist you in locating needed information and resources. Fact sheets on health effects of drug abuse and other topics can be ordered free of charge, in English and Spanish, by calling NIDA INFOFAX at 1-888NIH-NIDA (1-888-644-6432) or 1-888-TTY-NIDA (1-888-889-6432) for the hearing impaired. Information can also be accessed through various Web sites, such as: ·

NIDA: http://www.drugabuse.gov

·

NCADI: http://www.health.org

·

Society for Research on Nicotine and Tobacco: http://www.srnt.org/

·

NicNet: http://www.nicnet.org/

·

Centers for Disease Control and Prevention: http://www.cdc.gov/tobacco

·

National Cancer Institute: http://www.cancer.gov

·

The Robert Wood Johnson Foundation: http://www.rwjf.org

·

Join Together Online: http://www.quitnet.org

Cigarettes and Other Nicotine Products INFOFAX9 In addition to the guideline above, NIDA also publishes shorter guidelines in the form of INFOFAXs. The INFOFAX below is one recently dedicated to cigarettes and other nicotine products:

9

Adapted from http://165.112.78.61/Infofax/tobacco.html.

24 Nicotine Dependence

Nicotine is one of the most heavily used addictive drugs in the United States. Cigarette smoking has been the most popular method of taking nicotine since the beginning of the 20th century. In 1998, 60 million Americans were current cigarette smokers (28 percent of all Americans aged 12 and older), and 4.1 million were between the ages of 12 and 17 (18 percent of youth in this age bracket). In 1989, the U.S. Surgeon General issued a report that concluded that cigarettes and other forms of tobacco, such as cigars, pipe tobacco, and chewing tobacco, are addictive and that nicotine is the drug in tobacco that causes addiction. In addition, the report determined that smoking was a major cause of stroke and the third leading cause of death in the United States.

Health Hazards Nicotine is highly addictive. It is both a stimulant and a sedative to the central nervous system. The ingestion of nicotine results in an almost immediate “kick” because it causes a discharge of epinephrine from the adrenal cortex. This stimulates the central nervous system, and other endocrine glands, which causes a sudden release of glucose. Stimulation is then followed by depression and fatigue, leading the abuser to seek more nicotine. Nicotine is absorbed readily from tobacco smoke in the lungs, and it does not matter whether the tobacco smoke is from cigarettes, cigars, or pipes. Nicotine also is absorbed readily when tobacco is chewed. With regular use of tobacco, levels of nicotine accumulate in the body during the day and persist overnight. Thus, daily smokers or chewers are exposed to the effects of nicotine for 24 hours each day. Nicotine taken in by cigarette or cigar smoking takes only seconds to reach the brain but has a direct effect on the body for up to 30 minutes. Research has shown that stress and anxiety affect nicotine tolerance and dependence. The stress hormone corticosterone reduces the effects of nicotine; therefore, more nicotine must be consumed to achieve the same effect. This increases tolerance to nicotine and leads to increased dependence. Studies in animals have also shown that stress can directly cause relapse to nicotine self-administration after a period of abstinence.

Seeking Guidance 25

Other studies have shown that animals cannot discriminate between the effects of nicotine and the effects of cocaine. Studies have also shown that nicotine self-administration sensitizes animals to self-administer cocaine more readily. Addiction to nicotine results in withdrawal symptoms when a person tries to stop smoking. For example, a study found that when chronic smokers were deprived of cigarettes for 24 hours, they had increased anger, hostility, and aggression, and loss of social cooperation. Persons suffering from withdrawal also take longer to regain emotional equilibrium following stress. During periods of abstinence and/or craving, smokers have shown impairment across a wide range of psychomotor and cognitive functions, such as language comprehension. Women who smoke generally have earlier menopause. If women smoke cigarettes and also take oral contraceptives, they are more prone to cardiovascular and cerebrovascular diseases than are other smokers; this is especially true for women older than 30. Pregnant women who smoke cigarettes run an increased risk of having stillborn or premature infants or infants with low birthweight. Children of women who smoked while pregnant have an increased risk for developing conduct disorders. National studies of mothers and daughters have also found that maternal smoking during pregnancy increased the probability that female children would smoke and would persist in smoking. Adolescent smokeless tobacco users are more likely than nonusers to become cigarette smokers. Behavioral research is beginning to explain how social influences, such as observing adults or other peers smoking, affect whether adolescents begin to smoke cigarettes. Research has shown that teens are generally resistant to many kinds of anti-smoking messages. In addition to nicotine, cigarette smoke is primarily composed of a dozen gases (mainly carbon monoxide) and tar. The tar in a cigarette, which varies from about 15 mg for a regular cigarette to 7 mg in a low-tar cigarette, exposes the user to a high expectancy rate of lung cancer, emphysema, and bronchial disorders. The carbon monoxide in the smoke increases the chance of cardiovascular diseases. The Environmental Protection Agency has concluded that secondhand smoke causes lung cancer in adults and greatly increases the risk of respiratory illnesses in children and sudden infant death.

26 Nicotine Dependence

Promising Research Research has shown that nicotine, like cocaine, heroin, and marijuana, increases the level of the neurotransmitter dopamine, which affects the brain pathways that control reward and pleasure. Scientists now have pinpointed a particular molecule (the beta 2 subunit of the nicotine cholinergic receptor) as a critical component in nicotine addiction. Mice that lack this molecule fail to self-administer nicotine, implying that without the b2 molecule, the mice do not experience the positive reinforcing properties of nicotine. This new finding identifies a potential site for targeting the development of antinicotine addiction medications. Other new research found that individuals have greater resistance to nicotine addiction if they have a genetic variant that decreases the function of the enzyme CYP2A6. The decrease in CYP2A6 slows the breakdown of nicotine and protects individuals against nicotine addiction. Understanding the role of this enzyme in nicotine addiction gives a new target for developing more effective medications to help people stop smoking. Medications might be developed that can inhibit the function of CYP2A6, thus providing a new approach to preventing and treating nicotine addiction. Another study found dramatic changes in the brain's pleasure circuits during withdrawal from chronic nicotine use. These changes are comparable in magnitude and duration to similar changes observed during the withdrawal from other abused drugs such as cocaine, opiates, amphetamines, and alcohol. Scientists found significant decreases in the sensitivity of the brains of laboratory rats to pleasurable stimulation after nicotine administration was abruptly stopped. These changes lasted several days and may correspond to the anxiety and depression experienced by humans for several days after quitting smoking “cold turkey.” The results of this research may help in the development of better treatments for the withdrawal symptoms that may interfere with individual's attempts to quit smoking.

Treatment Research suggests that smoking cessation should be a gradual process because withdrawal symptoms are less severe in those who quit gradually than in those who quit all at once. Rates of relapse are highest in the first few weeks and months and diminish considerably after 3 m-onths. Studies have shown that pharmacological treatment combined with psychological treatment, including psychological support and skills training to overcome

Seeking Guidance 27

high-risk situations, results in some of the highest long-term abstinence rates. Behavioral economic studies find that alternative rewards and reinforcers can reduce cigarette use. One study found that the greatest reductions in cigarette use were achieved when smoking cost was increased in combination with the presence of alternative recreational activities. Nicotine chewing gum is one medication approved by the Food and Drug Administration (FDA) for the treatment of nicotine dependence. Nicotine in this form acts as a nicotine replacement to help smokers quit the smoking habit. The success rates for smoking cessation treatment with nicotine chewing gum vary considerably across studies, but evidence suggests that it is a safe means of facilitating smoking cessation if chewed according to instructions and restricted to patients who are under medical supervision. Another approach to smoking cessation is the nicotine transdermal patch, a skin patch that delivers a relatively constant amount of nicotine to the person wearing it. A research team at NIDA's Division of Intramural Research studied the safety, mechanism of action, and abuse liability of the patch that was consequently approved by FDA. Both nicotine gum and the nicotine patch, as well as other nicotine replacements such as sprays and inhalers, are used to help people fully quit smoking by reducing withdrawal symptoms and preventing relapse while undergoing behavioral treatment. Another tool in treating nicotine addiction is a medication that goes by the trademark Zyban. This is not a nicotine replacement, as are the gum and patch. Rather, this works on other areas of the brain, and its effectiveness is in helping to make controllable nicotine craving or thoughts about cigarette use in people trying to quit. In the future, a nicotine vaccine may be an effective method for preventing and treating tobacco addiction. The vaccine would prevent nicotine from reaching the brain so as to reduce its effects and help keep people from becoming addicted. Scientists recently developed an experimental nicotine vaccine consisting of a nicotine derivative attached to a large protein. The scientists injected a single dose of nicotine into vaccinated rats and found that the amount of nicotine reaching the brain was reduced by 64%. Further, the researchers found that administering doses of nicotine antibodies similar to those that are ordinarily produced by the vaccine greatly reduced the rise in blood

28 Nicotine Dependence

pressure produced by a nicotine injection. The antibodies also completely prevented the increased movements ordinarily seen when rats are injected with nicotine. The next steps will be to conduct additional safety studies, followed by clinical trials with the vaccine in human volunteers. These clinical trials are currently scheduled to begin in early 2002.

Extent of Use Monitoring the Future Study (MTF) The MTF survey is conducted by the University of Michigan's Institute for Social Research and is funded by National Institute on Drug Abuse, National Institutes of Health; it has tracked 12th graders' illicit drug use and related attitudes since 1975. In 1991, 8th and 10th graders were added to the study. For the 1999 study, 45,000 students were surveyed from a representative sample of 433 public and private schools nationwide. The latest survey data are available at NIDA's website, http://www.drugabuse.gov, and at the University of Michigan website, http://www.MonitoringTheFuture.org. Prevalence rates for smoking among young people remain high, in spite of the demonstrated health risk associated with smoking. Since 1975, cigarettes have consistently been the substance the greatest number of high school students use daily. Between 1998 and 1999, however, past month smoking decreased significantly among 8th graders, from 19.1 percent to 17.5 percent, and rates of use were stable or slightly decreased for 10th graders (25.7 percent) and seniors (34.6 percent). Lifetime and daily use also leveled off in 1999 among all grades, as did use of smokeless tobacco. “Lifetime” refers to use at least once during a respondent's lifetime. “Past year” refers to an individual's drug use at least once during the year preceding their response to the survey. “Past month” refers to an individual's drug use at least once during the month preceding their response to the survey.

Seeking Guidance 29

Cigarette Use by Students, 1999 Monitoring the Future Study 8th-Graders

10th-Graders

12th-Graders

Ever Used#

44.1%

57.6%

64.6%

Used in Past Month#

17.5

25.7

34.6

Pack + per Day#

3.3

7.6

13.2

National Household Survey on Drug Abuse (NHSDA) NHSDA is an annual survey conducted by the Substance Abuse and Mental Health Services administration. Copies of the latest survey are available from the National Clearinghouse for Alcohol and Drug Information at 1-800-7296686. Each year, the NHSDA reports on the nature and extent of drug use among the American household population aged 12 and older. In 1998, an estimated 60 million Americans, or 28 percent of all Americans aged 12 and older, were current smokers. Approximately 18 percent (4.1 million) of youths 12 to 17 years old were current smokers in 1998. The 1998 survey shows that current smokers are more likely to drink heavily and use illicit drugs than non-smokers.

More Guideline Sources The guideline above on nicotine dependence is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to nicotine dependence. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with nicotine dependence. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly. Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this

30 Nicotine Dependence

Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you can either search using the alphabetical index or browse by broad topic areas. If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at the following:http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patientoriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.

The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on nicotine dependence and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is http://chid.nih.gov/. To search this database, go to http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive: ·

Staying Stopped: A Smoke Stoppers Program for Today's Smoker Source: Waterford, CT, Bureau of Business Practice, 125-page participant manual, single-fold descriptive brochure, program description and order sheets, packet of aids including an audiotape and a 14-page booklet, 1995. Contact: Bureau of Business Practice, 24 Rope Ferry Road, Waterford, CT 06386. (203) 442-4365. Summary: Staying Stopped: A Smoke Stoppers Program for Today's Smoker, can be used in classroom settings, for one-on-one programs, or as a self-help program to guide smokers through the quitting process. The program is designed for individuals who are thinking about quitting, ready to quit, concerned about possible relapse, using nicotine replacement therapy, or working and/or living in a smoke-free environment. The Staying Stopped program has three stages: (1) Promotion, which begins at least 4 weeks before the first session, and

Seeking Guidance 31

consists of brochures, fliers, and posters; (2) session topics, which consist of five, 30- to 60-minute sessions held once a week; and (3) data collection, which involves collecting and evaluating abstinence rates and satisfaction surveys at the end of treatment and 12 months posttreatment. The program is made up of five independent modules: (1) Developing a Plan, which involves making the commitment to quit smoking, keeping track of the cigarettes smoked, calculating the lifetime cost of smoking, and preparing for quit day; (2) Changing Your Behavior, which describes smoking cessation techniques to help fight off tobacco urges, such as keeping busy, saying the word stop to oneself to interrupt an urge to smoke, and not getting hungry, angry, lonely, or tired (HALT); (3) Managing Stress, which helps participants recognize and manage stress; (4) Watching Your Weight and Physical Activity, which teaches participants how to eat well, enjoy physical activity, and control their weight; and (5) Staying Stopped for Good, which provides information on relapse prevention and helps participants become comfortable as nonsmokers. Additional information is provided in the form of a nicotine dependency test and a course evaluation. The information package also contains an audiotape with relaxation exercises, a rubber band, a binder clip, a package of sugarless chewing gum, a magnet with the saying The Urge for a Cigarette Will Go Away Whether or Not You Smoke, a pin that reads Staying Stopped: The Choice is Mine, and a booklet that can help a friend know how to support the new nonsmoker. ·

What Do these Words Have in Common?: Gum Disease, Nicotine, Stained Teeth, Cancer, Bad Breath Source: Timonium, MD: American Lung Association of Maryland. 1993. 2 p. Contact: Available from American Lung Association of Maryland. 1840 York Road, Timonium, MD 21093. (800) 492-7527 (in Maryland) or (410) 560-2120. Also available from local American Lung Association chapters. Price: Single copy free. Stock Number 0606 8/93. Summary: This brochure, aimed at young adolescents, provides facts that encourage readers to avoid the use of smokeless tobacco. The brochure notes the different names used for smokeless tobacco and stresses that tobacco in any form is still tobacco, with the accompanying risks. Topics discussed include nicotine addiction, cancer, problems with bad breath, the impact of tobacco on the taste buds, and cost factors. The brochure includes a section of questions and answers on topics including: why some sports stars chew tobacco; the myth that smokeless tobacco is safer than smoking cigarettes; tobacco company ads; and legislation and warning labels on smokeless tobacco. The brochure concludes with a

32 Nicotine Dependence

section of replies that young readers can use when someone offers them a chaw of tobacco. The brochure is illustrated with line drawings of young male adolescents and smokeless tobacco products. ·

Tobacco abuse: A message to parents and teens Source: Elk Grove Village, IL: American Academy of Pediatrics. 1990. 1 p. Contact: Available from Publications Department, American Academy of Pediatrics, 141 Northwest Point Boulevard, P.O. Box 927, Elk Grove Village, IL 60009-0927. Telephone: (847) 228-5005 or (800) 433-9016 / fax: (847) 228-5097 / e-mail: [email protected] / Web site: http://www.aap.org. $15.00 for 100 copies, members; $20.00, nonmembers. Minimum order: 100 copies. Summary: This brochure discusses the harmful effects of passive smoking in children, points out the dangers of smokeless tobacco to adolescents, and encourages adult smokers to break the habit.

·

Tobacco Cessation Resource Kit Source: Chicago, IL: American Dental Association (ADA). 199x. (information packet). Contact: Available from American Dental Association (ADA). Council on Access, Prevention and Interprofessional Relations, 211 East Chicago Avenue, Chicago, IL 60611-2678. (312) 440-2879. Price: Single copy free. Summary: This resource kit, from the American Dental Association, provides brochures and journal articles about tobacco cessation. Two brochures provide a general overview of smoking and oral health and describe the oral health team's view of what smoking does to the oral cavity (including full-color photographs). The journal articles are grouped in three categories: clinical interventions for tobacco cessation; nicotine replacement therapies for tobacco cessation; and general information on tobacco cessation, including demographic data, consequences of tobacco use, and community interventions. Specific topics include the National Cancer Institute's (NCI) educational support services for dental action, implementing a tobacco cessation program in clinical practice, helping patients remain tobacco-free for life, dentists' attitudes regarding tobacco issues, the respiratory health effects of passive smoking, dental hygienists' role in reducing tobacco use, tobacco use cessation curricula in dental schools and dental hygiene programs, tobacco dependence and the nicotine patch, transdermal and transmucosal nicotine delivery systems, the use of nicotine polacrilex (Nicorette), preventing tobacco use among young people, the benefits of tobacco cessation, and the neurochemistry of nicotine addiction. Other

Seeking Guidance 33

materials include a list of NCI publications for health professionals, a list of resource organizations for more information, and a detailed booklet describing the Indiana University School of Dentistry's smoking cessation program for the dental office.

The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “nicotine dependence” or synonyms. The following was recently posted: ·

Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Source: Centers for Disease Control and Prevention/Task Force on Community Preventive Services.; 2001; 6 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1840&sSearch_string=nicotine+dependence

·

Smoking and diabetes. Source: American Diabetes Association.; 1999 October (republished 2002 Jan); 2 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 2360&sSearch_string=nicotine+dependence

·

Smoking cessation. Source: University of Michigan Health System.; 1998 September (updated 2001 Feb); 9 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 2184&sSearch_string=nicotine+dependence

·

Tobacco use cessation in the primary care setting. Source: Department of Defense/Veterans Health Administration.; 1999 May; Various pagings http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1802&sSearch_string=nicotine+dependence

34 Nicotine Dependence

·

Treating tobacco use and dependence. A clinical practice guideline. Source: Public Health Service (U.S.).; 2000 June; Various pagings http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1586&sSearch_string=nicotine+dependence

·

Treatment for stimulant use disorders. Source: Substance Abuse and Mental Health Services Administration (U.S.).; 1999; Various pagings http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1766&sSearch_string=nicotine+dependence

Healthfinder™ Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines. The following was recently found in this database: ·

Now Available Without a Prescription Summary: For those who yearn to break their cigarette addiction but don't fancy a trip to the doctor's office, the ability to get the nicotine patch without a physician's prescription may be just what the Source: Office of Consumer Affairs, U.S. Food and Drug Administration http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=1104

·

Smoking Cessation/Tobacco Abuse - NetWellness Summary: This web site presents a general overview of the adverse effects of smoking, other tobacco abuses and nicotine addiction. Source: Nonprofit/Professional Entity--Follow the Resource URL for More Information http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=4879

Seeking Guidance 35

·

You Can Quit Smoking: A Consumer Guide Summary: This consumer version of the Clinical Practice Guideline No.18 addresses methods for quitting smoking and overcoming nicotine addiction. Source: Agency for Healthcare Research and Quality http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=5044

The NIH Search Utility After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to nicotine dependence. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm

·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/

·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

36 Nicotine Dependence

·

WebMDÒHealth: http://my.webmd.com/health_topics

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: Abortion: 1. the premature expulsion from the uterus of the products of conception - of the embryo, or of a nonviable fetus. The four classic symptoms, usually present in each type of abortion, are uterine contractions, uterine haemorrhage, softening and dilatation of the cervix, and presentation or expulsion of all or part of the products of conception. 2. premature stoppage of a natural or a pathological process. [EU] Amphetamine: A powerful central nervous system stimulant and sympathomimetic. Amphetamine has multiple mechanisms of action including blocking uptake of adrenergics and dopamine, stimulation of release of monamines, and inhibiting monoamine oxidase. Amphetamine is also a drug of abuse and a psychotomimetic. The l- and the d,l-forms are included here. The l-form has less central nervous system activity but stronger cardiovascular effects. The d-form is dextroamphetamine. [NIH] Aneurysm: A sac formed by the dilatation of the wall of an artery, a vein, or the heart. The chief signs of arterial aneurysm are the formation of a pulsating tumour, and often a bruit (aneurysmal bruit) heard over the swelling. Sometimes there are symptoms from pressure on contiguous parts. [EU]

Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU] Bronchial: Pertaining to one or more bronchi. [EU] Bronchitis: Inflammation of one or more bronchi. [EU] Bupropion: A unicyclic, aminoketone antidepressant. The mechanism of its therapeutic actions is not well understood, but it does appear to block dopamine uptake. The hydrochloride is available as an aid to smoking cessation treatment. [NIH] Carcinogens: Substances that increase the risk of neoplasms in humans or animals. Both genotoxic chemicals, which affect DNA directly, and

Seeking Guidance 37

nongenotoxic chemicals, which induce neoplasms by other mechanism, are included. [NIH] Cardiac: Pertaining to the heart. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Cerebrovascular: Pertaining to the blood vessels of the cerebrum, or brain. [EU]

Cholinergic: Resembling acetylcholine in pharmacological stimulated by or releasing acetylcholine or a related compound. [EU]

action;

Chronic: Persisting over a long period of time. [EU] Cocaine: An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons; the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. [NIH] Contraceptive: conception. [EU]

An agent that diminishes the likelihood of or prevents

Convulsion: A violent involuntary contraction or series of contractions of the voluntary muscles. [EU] Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Cortex: The outer layer of an organ or other body structure, as distinguished from the internal substance. [EU] Craving: A powerful, often uncontrollable desire for drugs. [NIH] Dopamine: A neurotransmitter present in regions of the brain that regulate movement, emotion, motivation, and feeling of pleasure. [NIH] Emphysema: A lung disease in which tissue deterioration results in increased air retention and reduced exchange of gases. The result is difficult breathing and shortness of breath. It is often caused by smoking. [NIH] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Epinephrine:

The active sympathomimetic hormone from the adrenal

38 Nicotine Dependence

medulla in most species. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. It is used in asthma and cardiac failure and to delay absorption of local anesthetics. [NIH] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Homicide: The killing of one person by another. [NIH] Hormone: A chemical substance formed in glands in the body and carried in the blood to organs and tissues, where it influences function, structure, and behavior. [NIH] Ingestion: The act of taking food, medicines, etc., into the body, by mouth. [EU]

Inhalation: The drawing of air or other substances into the lungs. [EU] Insecticides: Pesticides designed to control insects that are harmful to man. The insects may be directly harmful, as those acting as disease vectors, or indirectly harmful, as destroyers of crops, food products, or textile fabrics. [NIH]

Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Larynx: An irregularly shaped, musculocartilaginous tubular structure, lined with mucous membrane, located at the top of the trachea and below the root of the tongue and the hyoid bone. It is the essential sphincter guarding the entrance into the trachea and functioning secondarily as the organ of voice. [NIH] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Menopause: Cessation of menstruation in the human female, occurring usually around the age of 50. [EU]

Seeking Guidance 39

Neurotransmitter: Chemical compound that acts as a messenger to carry signals or stimuli from one nerve cell to another. [NIH] Nicotine: An alkaloid derived from the tobacco plant that is responsible for smoking's psychoactive and addictive effects; is toxic at high doses but can be safe and effective as medicine at lower doses. [NIH] Opiate: A remedy containing or derived from opium; also any drug that induces sleep. [EU] Pancreas: A mixed exocrine and endocrine gland situated transversely across the posterior abdominal wall in the epigastric and hypochondriac regions. The endocrine portion is comprised of the islets of langerhans, while the exocrine portion is a compound acinar gland that secretes digestive enzymes. [NIH] Paralysis: Loss or impairment of motor function in a part due to lesion of the neural or muscular mechanism; also by analogy, impairment of sensory function (sensory paralysis). In addition to the types named below, paralysis is further distinguished as traumatic, syphilitic, toxic, etc., according to its cause; or as obturator, ulnar, etc., according to the nerve part, or muscle specially affected. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Perinatal: Pertaining to or occurring in the period shortly before and after birth; variously defined as beginning with completion of the twentieth to twenty-eighth week of gestation and ending 7 to 28 days after birth. [EU] Placenta: A highly vascular fetal organ through which the fetus absorbs oxygen and other nutrients and excretes carbon dioxide and other wastes. It begins to form about the eighth day of gestation when the blastocyst adheres to the decidua. [NIH] Poisoning: A condition or physical state produced by the ingestion, injection or inhalation of, or exposure to a deleterious agent. [NIH] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. [NIH] Psychiatry: The medical science that deals with the origin, diagnosis, prevention, and treatment of mental disorders. [NIH] Psychomotor: Pertaining to motor effects of cerebral or psychic activity. [EU] Pulmonary: Pertaining to the lungs. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface

40 Nicotine Dependence

receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Sedative: 1. allaying activity and excitement. 2. an agent that allays excitement. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Stimulant: 1. producing stimulation; especially producing stimulation by causing tension on muscle fibre through the nervous tissue. 2. an agent or remedy that produces stimulation. [EU] Tolerance: A condition in which higher doses of a drug are required to produce the same effect as during initial use; often is associated with physical dependence. [NIH] Toxic: Causing temporary or permanent effects that are detrimental to the functioning of a body organ or group of organs. [NIH] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Transdermal: Entering through the dermis, or skin, as in administration of a drug applied to the skin in ointment or patch form. [EU] Tremor: An involuntary trembling or quivering. [EU] Ureter: One of a pair of thick-walled tubes that transports urine from the kidney pelvis to the bladder. [NIH] Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses, or rickettsiae), administered for the prevention, amelioration or treatment of infectious diseases. [EU] Vascular: Pertaining to blood vessels or indicative of a copious blood supply. [EU] Withdrawal: A variety of symptoms that occur after chronic use of some drugs is reduced or stopped. [NIH]

Seeking Guidance 41

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with nicotine dependence. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.10 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with nicotine dependence. The chapter ends with a discussion on how to find a doctor that is right for you.

Associations and Nicotine Dependence As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.11 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 11 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 10

42 Nicotine Dependence

your expectations, and how well you cope with your condition can all influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information, by consulting all of them, you will have nearly exhausted all sources for patient associations. The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about nicotine dependence. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “nicotine dependence” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations.

The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “nicotine dependence”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred

Seeking Guidance 43

language and the format option “Organization Resource Sheet.” By making these selections and typing in “nicotine dependence” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with nicotine dependence. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “nicotine dependence” (or a synonym) in the search box.

Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site: http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective. The following internet links may be of particular interest: ·

WhyQuit.com http://whyquit.com/

·

QuitSmokingSupport.com http://www.quitsmokingsupport.com/intro.htm

Finding Drug Treatment and Alcohol Abuse Treatment Programs To find the right drug abuse treatment program or alcohol abuse treatment program for you, two useful resources are available.

44 Nicotine Dependence

National Drug and Treatment Referral Routing Service12 The U.S. Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Administration's (SAMHSA) National Drug and Treatment Referral Routing Service provides a toll-free telephone number for alcohol and drug information/treatment referral assistance. The number is: 1-800-662-HELP. When you call the toll-free number, a recorded message gives you the following options: 1 - Printed materials on alcohol and drug information or 24-hour substance abuse treatment referral information in your area (Additional options guide you through information and referral choices, including a Spanish language message.) 2 - Location of a Substance Abuse Treatment Office in your State

Substance Abuse Treatment Facility Locator13 Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), this searchable directory of drug and alcohol treatment programs shows the location of facilities around the country that treat alcoholism, alcohol abuse and drug abuse problems (http://findtreatment.samhsa.gov/). The Locator includes more than 11,000 addiction treatment programs, including residential treatment centers, outpatient treatment programs, and hospital inpatient programs for drug addiction and alcoholism. Listings include treatment programs for marijuana, cocaine, and heroin addiction, as well as drug and alcohol treatment programs for adolescents, and adults. SAMHSA endeavors to keep the Locator current. All information in the Locator is completely updated each year, based on facility responses to SAMHSA's National Survey of Substance Abuse Treatment Services. New facilities are added monthly. Updates to facility names, addresses, and telephone numbers are made monthly, if facilities inform SAMHSA of changes. The search site is: http://findtreatment.samhsa.gov/facilitylocatordoc.htm.

12 13

Adapted from NIAAA: http://www.niaaa.nih.gov/other/referral.htm. Adapted from SAMHSA: http://findtreatment.samhsa.gov/.

Seeking Guidance 45

Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with nicotine dependence must go through the process of selecting a physician. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:14 ·

If you are in a managed care plan, check the plan's list of doctors first.

·

Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals.

·

Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital. The services do not have information on the quality of care that these doctors provide.

·

Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide.

Additional steps you can take to locate doctors include the following: ·

Check with the associations listed earlier in this chapter.

·

Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors.

·

The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at http://www.abms.org/newsearch.asp.15 You can also contact the ABMS by phone at 1-866-ASK-ABMS.

·

You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA's Web site: http://www.amaassn.org/aps/amahg.htm.

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. While board certification is a good measure of a doctor's knowledge, it is possible to receive quality care from doctors who are not board certified.

14 15

46 Nicotine Dependence

If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

Selecting Your Doctor16 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: ·

Give me a chance to ask questions about nicotine dependence?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

·

Make me feel comfortable?

·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for nicotine dependence?

·

Spend enough time with me?

Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.

16 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

Seeking Guidance 47

Working with Your Doctor17 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: ·

You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know.

·

It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable.

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your doctor about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don't, your doctor will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

·

Ask your doctor to draw pictures if you think that this would help you understand.

·

Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first.

·

Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you.

This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

17

48 Nicotine Dependence

·

After leaving the doctor's office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your physician.

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:18 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

18

49

CHAPTER 3. DEPENDENCE

CLINICAL

TRIALS

AND

NICOTINE

Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your physician has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning nicotine dependence.

What Is a Clinical Trial?19 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for nicotine dependence is to try it on patients in a clinical trial.

What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases: ·

Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely.

·

Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on nicotine dependence.

·

Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for nicotine dependence compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve

The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm.

19

50 Nicotine Dependence

hundreds, perhaps thousands, of people--can also compare new treatments with no treatment. How Is a Clinical Trial Conducted? Various organizations support clinical trials at medical centers, hospitals, universities, and doctors' offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All doctors and researchers who take part in the study on nicotine dependence carefully follow a detailed treatment plan called a protocol. This plan fully explains how the doctors will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on nicotine dependence. In other clinical trials, where a new surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham treatment.” This treatment, like a placebo, has no effect on nicotine dependence and does not harm patients. Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither doctors nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or doctors will not affect the study results.

51

Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how nicotine dependence develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for nicotine dependence. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a disease or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific disease or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of disease or disorder, as well as, the age and previous treatment history of the patient. You or your doctor can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your doctor must contact one of the trial's investigators and provide details about your diagnosis and medical history. If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.

Recent Trials on Nicotine Dependence The National Institutes of Health and other organizations sponsor trials on various diseases and disorders. Because funding for research goes to the

52 Nicotine Dependence

medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to nicotine dependence.20 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your physician who can help you determine if you might benefit from participation. ·

Behavioral Economics of Human Drug Self-Administration Condition(s): Drug Dependence Study Status: This study is currently recruiting patients. Sponsor(s): National Center for Research Resources (NCRR) Purpose - Excerpt: The objective of this protocol is to examine the utility of behavioral economics for understanding reinforcer interactions as they pertain to drug self-administration. In a series of 6 experiments, the researchers will attempt to quantify the effects of qualitatively different reinforcers (money, cigarettes, alcohol, nicotine gum) and their interactions. This work represents a continuation of research by this investigator in the area of addiction and pharmacology. Study Type: Observational Contact(s): Warren Bickel, Ph.D. 1-802-656-6916; Vermont; University of Vermont, Burlington, Vermont, 05401, United States; Recruiting; Warren Bickel, Ph.D. 802-656-6916 Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00005765;jsessionid=B054526 8E66372B858A288D48433D0D5

·

Behavioral/Drug Therapy for Alcohol-Nicotine Dependence Condition(s): Alcoholism; Smoking Study Status: This study is currently recruiting patients. Sponsor(s): National Institute on Alcohol Abuse and Alcoholism (NIAAA) Purpose - Excerpt: This study will develop a behavioral and drug relapse prevention program for individuals who are dependent on both alcohol

20

These are listed at www.ClinicalTrials.gov.

53

and tobacco. The study's goal is to show that individuals receiving nicotine replacement therapy and naltrexone (Revia) with behavior therapy will have higher rates of abstinence from both smoking and drinking than individuals who do not receive the drug therapies. Individuals will be placed in a 12-week outpatient treatment program with followup assessments 1, 3, and 6 months after treatment. Phase(s): Phase IV Study Type: Interventional Contact(s): Texas; Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, Texas, 77030, United States; Recruiting; Dr. Joy Schmitz 713-500-2874 Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000447;jsessionid=B054526 8E66372B858A288D48433D0D5 ·

Naltrexone and Patch for Smokers Condition(s): Smoking Study Status: This study is currently recruiting patients. Sponsor(s): Department of Veterans Affairs Medical Research Service Purpose - Excerpt: The aim of this study is to investigate the effects of naltrexone, alone and combined with nicotine patch, on responses of smokers to smoking cues after 10 hours of tobacco deprivation. Smokers who are not seeking treatment will be assigned to one of six conditions: They will receive either 50 mg of naltrexone or a placebo pill, and also will wear a nicotine patch that has 0, 21, or 42 mg of nicotine during the tobacco deprivation period. Both the day before the medication and deprivation and at the end of 10 hours of deprivation all will be exposed to lit cigarette cues in the laboratory. Effects of the medications will be assessed on withdrawal measures, urge to smoke, psychophysiological measures, and the topography of smoking three test cigarettes. Studies such as these can help to identify potential interventions for tobacco cessation or withdrawal, and thereby could result in less suffering and mortality. Study Type: Interventional Contact(s): Rhode Island; VA Medical Center, Providence, Rhode Island, 02908, United States; Recruiting; Regina M. Correa-Murphy 401-457-3066 3478 [email protected]; Damaris Rohsenow, Principal Investigator Web Site:

54 Nicotine Dependence

http://clinicaltrials.gov/ct/gui/show/NCT00018213;jsessionid=B054526 8E66372B858A288D48433D0D5 ·

Quit Smoking Condition(s): Smoking Study Status: This study is currently recruiting patients. Sponsor(s): Department of Veterans Affairs Medical Research Service Purpose - Excerpt: This protocol evaluates the efficacy of combining pharmacologic treatments for smoking cessation, entailing the use of the nicotine skin patch with the nicotinic antagonist mecamylamine, with a specific behavioral therapy designed to inhibit the smoking urge. Phase(s): Phase II Study Type: Interventional Contact(s): North Carolina; Veterans Affairs Medical Center, Durham, North Carolina, 27705, United States; Recruiting; Jed E. Rose, Ph.D. 919416-1515; Jed E. Rose, Principal Investigator. Study chairs or principal investigators: Eric C Westman, M.D. Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00018161;jsessionid=B054526 8E66372B858A288D48433D0D5

·

Smoking Cessation in Alcoholism Treatment Condition(s): Alcoholism; Smoking Study Status: This study is currently recruiting patients. Sponsor(s): National Institute on Alcohol Abuse and Alcoholism (NIAAA) Purpose - Excerpt: This study is designed to increase understanding of the processes that affect the treatment outcome of individuals with both alcohol and nicotine dependence. Treatment outcome methodology will be combined with a computerized self-monitoring methodology to examine the extent to which smoking serves as a cue for alcohol craving and/or as a response to alcohol craving in treated alcoholics. Subjects will be veterans participating in the Substance Abuse Day Programs at the Newington and West Haven campuses of the VA Connecticut Healthcare System. Nonveteran women will be recruited from the community and enrolled in the day program. Subjects will be randomly assigned to one of the following two conditions: (1) intensive smoking cessation therapy (counseling plus nicotine replacement using nicotine

55

patches) concurrent with alcohol treatment, or (2) brief smoking cessation advice concurrent with alcohol treatment. Phase(s): Phase IV Study Type: Interventional Contact(s): Connecticut; Substance Abuse Treatment Center, VA Medical Center, West Haven, Connecticut, 06516, United States; Recruiting; Dr. Ned Cooney 203-937-4806 Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000454;jsessionid=B054526 8E66372B858A288D48433D0D5 ·

Tobacco Dependence in Alcoholism Treatment Condition(s): Alcoholism; Smoking Study Status: This study is currently recruiting patients. Sponsor(s): National Institute on Alcohol Abuse and Alcoholism (NIAAA) Purpose - Excerpt: The purpose of this study is to determine the effectiveness of naltrexone (Revia) in reducing drinking and smoking in patients with both nicotine and alcohol dependence. Individuals will be randomly assigned to a 12-week trial of a fixed daily dose of either naltrexone (Revia) and nicotine replacement patch or placebos. All individuals will receive weekly coping skills and smoking-cessation behavioral therapy. Followup interviews will be conducted 3 and 6 months after treatment to determine smoking and drinking status and persistence of any dependence symptoms. Phase(s): Phase IV Study Type: Interventional Contact(s): Florida; Department of Psychiatry, University of Miami School of Medicine, Miami, Florida, 33136, United States; Recruiting; Dr. Barbara Mason 305-243-4644 Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000437;jsessionid=B054526 8E66372B858A288D48433D0D5

·

Role of Metabolites in Nicotine Dependence (1) Condition(s): Tobacco Use Disorder Study Status: This study is completed.

56 Nicotine Dependence

Sponsor(s): National Institute on Drug Abuse (NIDA); University of Minnesota Purpose - Excerpt: To determine the effects of continine with or without a transdermal nicotine replacement on tobacco withdrawal symptoms. Phase(s): Phase II Study Type: Treatment Contact(s): Joni Jensen 2701 University Ave, S.E. Minneapolis, Minnesota, 55414-0392, United States 1-612-627-4903; Minnesota; University of Minnesota, Twin Cities Minneapolis, Minnesota, 55455, United States; Joni Jensen 1-612-627-4903. Study chairs or principal investigators: Dorothy Hatsukami, Principal Investigator; University of Minnesota Twin Cities Minneapolis, Minnesota, 55455, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000284;jsessionid=B054526 8E66372B858A288D48433D0D5 ·

Role of Metabolites in Nicotine Dependence (2) Condition(s): Tobacco Use Disorder Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Minnesota Purpose - Excerpt: To determine the effects of varying doses of cotinine on cigarette self-administration. Phase(s): Phase II Study Type: Treatment Contact(s): Joni Jensen 2701 University Ave, S.E. Minneapolis, Minnesota, 55414-0392, United States 1-612-627-4903; Minnesota; University of Minnesota, Twin Cities Minneapolis, Minnesota, 55455, United States; Joni Jensen 1-612-627-4903. Study chairs or principal investigators: Dorothy Hatsukami, Principal Investigator; University of Minnesota Twin Cities Minneapolis, Minnesota, 55455, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000288;jsessionid=B054526 8E66372B858A288D48433D0D5

·

Role of Metabolites in Nicotine Dependence (3) Condition(s): Tobacco Use Disorder

57

Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Minnesota Purpose - Excerpt: To determine the effects of various doses of ondansetron transdermal nicotine replacement on tobacco withdrawal symptoms. Phase(s): Phase II Study Type: Treatment Contact(s): Joni Jensen 2701 University Ave, S.E. Minneapolis, Minnesota, 55414-0392, United States 1-612-627-4903; Minnesota; University of Minnesota, Twin Cities Minneapolis, Minnesota, 55455, United States; Joni Jensen 1-612-627-4903. Study chairs or principal investigators: Dorothy Hatsukami, Principal Investigator; University of Minnesota Twin Cities Minneapolis, Minnesota, 55455, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000289;jsessionid=B054526 8E66372B858A288D48433D0D5 ·

Role of Metabolites in Nicotine Dependence (4) Condition(s): Tobacco Use Disorder Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Minnesota Purpose - Excerpt: To determine the effects of continine with or without a transdermal nicotine replacement on tobacco withdrawal symptoms. Phase(s): Phase II Study Type: Treatment Contact(s): Joni Jensen 2701 University Ave, S.E. Minneapolis, Minnesota, 55414-0392, United States 1-612-627-4903; Minnesota; University of Minnesota, Twin Cities Minneapolis, Minnesota, 55455, United States; Joni Jensen 1-612-627-4903. Study chairs or principal investigators: Dorothy Hatsukami, Principal Investigator; University of Minnesota Twin Cities Minneapolis, Minnesota, 55455, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000296;jsessionid=B054526 8E66372B858A288D48433D0D5

58 Nicotine Dependence

Benefits and Risks21 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: ·

A new treatment could be more effective than the current treatment for nicotine dependence. Although only half of the participants in a clinical trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over.

·

If the treatment is effective, then it may improve health or prevent diseases or disorders.

·

Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over.

·

People who take part in trials contribute to scientific discoveries that may help other people with nicotine dependence. In cases where certain diseases or disorders run in families, your participation may lead to better care or prevention for your family members. The Informed Consent

Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial's risks and benefits, the researcher’s expectations of you, and your rights as a patient.

What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you receive may cause side effects that are serious enough to require medical attention. This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f291. 21

59

How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital's Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, doctors will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent.

What Are a Patient's Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: ·

Information on all known risks and benefits of the treatments in the study.

·

Know how the researchers plan to carry out the study, for how long, and where.

·

Know what is expected of you.

·

Know any costs involved for you or your insurance provider.

·

Know before any of your medical or personal information is shared with other researchers involved in the clinical trial.

·

Talk openly with doctors and ask any questions.

After you join a clinical trial, you have the right to: ·

Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study.

·

Receive any new information about the new treatment.

·

Continue to ask questions and get answers.

60 Nicotine Dependence

·

Maintain your privacy. Your name will not appear in any reports based on the study.

·

Know whether you participated in the treatment group or the control group (once the study has been completed).

What about Costs? In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don't have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Questions Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: ·

What is the purpose of the clinical trial?

·

What are the standard treatments for nicotine dependence? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?

·

What tests and treatments will I need? Will I need surgery? Medication? Hospitalization?

·

How long will the treatment last? How often will I have to come back for follow-up exams?

·

What are the treatment's possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects?

·

Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long?

·

How will my health be monitored?

·

Where will I need to go for the clinical trial? How will I get there?

61

·

How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover?

·

Will I be able to see my own doctor? Who will be in charge of my care?

·

Will taking part in the study affect my daily life? Do I have time to participate?

·

How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?

Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has developed ClinicalTrials.gov to provide patients, family members, and physicians with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “nicotine dependence” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: ·

For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/

·

For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html

·

For drug abuse trials, visit and search the Web site sponsored by the National Institute on Drug Abuse: http://www.nida.nih.gov/CTN/Index.htm

62 Nicotine Dependence

General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

A Guide to Patient Recruitment : Today's Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001), CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinterna

·

A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinterna

·

The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinterna

·

The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinterna

·

Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinterna

·

Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinterna

·

Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293; http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinterna

63

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Deprivation: Loss or absence of parts, organs, powers, or things that are needed. [EU] Mecamylamine: A nicotinic antagonist that is well absorbed from the gastrointestinal tract and crosses the blood-brain barrier. Mecamylamine has been used as a ganglionic blocker in treating hypertension, but, like most ganglionic blockers, is more often used now as a research tool. [NIH] Metabolite: process. [EU]

Any substance produced by metabolism or by a metabolic

Naltrexone: Derivative of noroxymorphone that is the N-cyclopropylmethyl congener of naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. The FDA has approved naltrexone for the treatment of alcohol dependence. [NIH] Ondansetron: A competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and it has reported anxiolytic and neuroleptic properties. [NIH] Placebos: Any dummy medication or treatment. Although placebos originally were medicinal preparations having no specific pharmacological activity against a targeted condition, the concept has been extended to include treatments or procedures, especially those administered to control groups in clinical trials in order to provide baseline measurements for the experimental protocol. [NIH]

65

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on nicotine dependence. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on nicotine dependence. In Part II, as in Part I, our objective is not to interpret the latest advances on nicotine dependence or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with nicotine dependence is suggested.

Studies 67

CHAPTER 4. STUDIES ON NICOTINE DEPENDENCE Overview Every year, academic studies are published on nicotine dependence or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on nicotine dependence. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on nicotine dependence and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and nicotine dependence, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the

68 Nicotine Dependence

format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “nicotine dependence” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: ·

Efficacy of Computer-tailored Smoking Cessation Material as a Supplement to Nicotine Patch Therapy Source: Drug and Alcohol Dependence. 64(1):35-46, September 1, 2001. Summary: Researchers examined the efficacy of computer-tailored cessation materials as a supplement to nicotine patch therapy. The program, Committed Quitters Program (CQP), is a computer-tailored set of printed behavioral support materials offered free to purchasers of NicoDerm patches as a supplement to the nicotine patch and the standard brief User Guide (UG) and audiotape. Potential participants for the program were United States purchasers of NicoDerm patches and were recruited when they called a toll free number that offered free behavioral support materials. Eligible callers had to meet the following criteria: (1) Have a target quit date that was within 7 days from the enrollment call date; (2) had not already quit for longer than 1 day; (3) were trying to stop smoking; (4) had been smoking more than 10 cigarettes per day; (5) had purchased NicoDerm CQ Step 1 (a patch containing 21 milligrams of nicotine indicated for those who smoke more than 10 cigarettes/day); (6) agreed to be contacted for followup calls at 6 and 12 weeks; and (7) were at least 18 years old. The toll-free number received 20,696 calls. Of these, 6,426 callers met the eligibility criteria and 3,683 agreed to participate. Of these, 1,854 were randomly assigned to receive the CQP and 1,829 to receive only the UG (control participants). CQP program usage was defined in terms of (1) the amount of the program materials read; (2) frequency of referring to the materials; and (3) perceived helpfulness of, and satisfaction with, the materials. Across all participants, 80.1 percent used their assigned materials. Utilization rates were significantly higher for CQP than for UG participants, 84.1 versus 76.8 percent. Abstinence rates did not differ significantly between all CQP and UG participants at either time point. Among the 80.1 percent of participants who reported using their assigned materials, abstinence rates were significantly higher among CQP than among UG participants at both 6 weeks (38.8 versus 30.7 percent) and 12 weeks (18.2 versus 11.1 percent). Researchers conclude that among those who used it, the CQP

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proved to be an effective behavioral treatment for improving smoking cessation rates. 5 tables, 29 references. ·

Is Telephone Counselling a Useful Addition to Physician Advice and Nicotine Replacement Therapy in Helping Patients to Stop Smoking? A Randomized Controlled Trial Source: Canadian Medical Association Journal. 160(11):1577-1581, June 1, 1999. Summary: Canadian researchers evaluated the benefits of telephone counseling by nurses in addition to physician advice, nicotine replacement therapy, and self-help material for helping patients quit smoking. They recruited volunteers age 18 or older who smoked at least 15 cigarettes daily during the past year, and who wanted to quit smoking within 30 days. At a screening session, the participants received advice on the importance of smoking cessation, gave a medical and smoking history, and had a physical examination. The researchers stratified the participants by age and nicotine dependence, then randomized them to either a usual care group or a usual care group plus telephone counseling. Usual care included (1) nicotine replacement therapy, (2) selfhelp materials, and (3) physician advice. Telephone counseling by trained nurses occurred at 2 weeks, 6 weeks, and 13 weeks after the target quit date. All participants received questionnaires at 4 weeks, 12 weeks, 26 weeks, and 52 weeks after the target quit date to assess abstinence. Of 453 persons who responded to recruitment attempts, 396 participated, of which 199 were in the control group and 197 were in the intervention group. Results showed that (1) baseline characteristics and participation rates of the participants did not differ significantly between groups; (2) of 337 participants contacted 1 year after the target quit date, 94 reported not smoking; (3) overall quit rates were 45.9 percent at 4 weeks, 36.1 percent at 12 weeks, 28.5 percent at 26 weeks, and 23.8 percent at 52 weeks; and (4) the quit rates did not differ between groups at 52 weeks. The researchers concluded that (1) the addition of three telephone counseling sessions with a nurse did not increase smoking quit rates beyond the 23.7 percent achieved with brief physician advice and nicotine replacement therapy, (2) brief intervention by physicians can have a positive impact on heavy smokers, and (3) more research may show that telephone counseling may help smokers receiving little or no help from physicians. 1 figure, 3 tables, 34 references.

·

Nicotine Dependence Among Adolescent Smokers Source: Archives of Pediatrics and Adolescent Medicine. 152(2):151-156, February 1998.

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Summary: Researchers conducted a cross-sectional survey of 2,197 10th grade students in 6 San Jose, California, high schools to assess nicotine dependence among adolescent smokers. Students completed a questionnaire that measured (1) cigarette use within the last 30 days; (2) history of attempts to quit smoking; (3) nicotine dependence, using modified questions from the Fagerstrom Tolerance Questionnaire (mFTQ); (4) subjective withdrawal symptoms; and (5) symptoms of depression, using the Center for Epidemiologic Studies Depression Scale (CES-D). Researchers determined saliva cotinine levels and body mass index (BMI). Of the 485 students who reported smoking at least part of 1 cigarette during the past 30 days, 249 reported a previous attempt to quit smoking. Students who had tried to quit in the past reported withdrawal symptoms, which included (1) craving (45.5 percent), (2) nervous and tense (32.8 percent), (3) restless (29.4 percent), (4) irritable (28.7 percent), (5) hungry (25.3 percent), (6) unable to concentrate (21.7 percent), (7) miserable and sad (15.3 percent), and (8) trouble sleeping (12.8 percent). Students who reported strong cravings during a previous attempt to quit had significantly higher mFTQ scores, higher CES-D scores, and higher saliva cotinine levels. Researchers found no significant differences between males and females in the reporting of specific withdrawal symptoms. BMI was not associated with nicotine dependence. Smokers who attempted to quit had higher CES-D scores than nonsmokers, and CES-D scores were significantly associated with the number of reported withdrawal symptoms. Female smokers who attempted to quit had significantly higher CES-D scores. The researchers conclude that use of mFTQ scores, withdrawal symptoms, CES-D scores, and saliva cotinine levels may be helpful in designing smoking cessation programs for adolescents. 1 figure, 2 tables, 37 references. ·

Nicotine Dependence and Smoking Topography Among Black and White Women Source: Research in Nursing and Health. 20(6):505-514, December 1997. Summary: Researchers characterized the multidimensional aspects of nicotine dependence and cigarette smoking behaviors among 37 black and white women smokers age 19-59 years. They recruited participants from the Columbus, Ohio, metropolitan area via newspaper ads and postings at worksites. Of the 18 black and 19 white women, half of each group smoked regular and half smoked menthol cigarettes. Participants were admitted as outpatients to the General Clinical Research Center. Approximately 2 minutes before smoking their usual brand cigarette, researchers obtained a carbon monoxide (CO) in an expired air sample. At 1 minute prior to smoking, researchers drew a blood sample for

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plasma nicotine and baseline cotinine levels. As the participant smoked her cigarette, the researchers measured puffing and respiratory topography. At 1 minute after completion of smoking, the researchers obtained a second blood sample. At 2 minutes post-cigarette, they measured CO in expired air. The researchers also obtained self-reported time since last cigarette smoked prior to admission. To characterize the multidimensional aspects of nicotine dependence, researchers measured perceived nicotine dependence, time to first cigarette of the day, perceived benefits of smoking, baseline cotinine level, and cotinine per self-reported cigarette ratio. Data analysis indicated that plasma cotinine to cigarette ratio significantly related to total puff duration, total cigarette time, and CO boost (increase as a result of smoking a given cigarette). Black women had higher nicotine dependence as measured by plasma cotinine and by cotinine per cigarette ratio than did white women, although they smoked a similar number of cigarettes per day. This indicates that self-reported number of cigarettes smoked per day alone is not a complete assessment of nicotine dependence. Whereas puffing and respiratory data were similar between groups, black women had higher cigarette smoke exposure as measured by CO boost. Time to first cigarette was shorter in black women than white women. Longer cigarette time correlated with higher perceived benefits of smoking, indicating smoking behaviors congruent with beliefs about its positive effects. There was an association between perceived benefits and perceived dependence. The researchers conclude that these findings underscore the importance of understanding the multidimensional nature of cigarette smoking. They note that because black women experience greater lung damage and less lung function recovery than white women, it is imperative that there be concerted smoking cessation intervention efforts for this group. 2 tables, 53 references. ·

Nicotine Patch and Self-Help Video for Cigarette Smoking Cessation Source: Journal of Consulting and Clinical Psychology. 65(4):663-672, August 1997. Summary: Researchers conducted a 2 x 2 factorial design experiment comparing the efficacy of nicotine replacement therapy with a self-help video program for cigarette smoking cessation. They randomized 424 male and female smokers to a pharmacologic intervention (a nicotine or placebo patch) or to a self-help intervention (a video-enhanced manual or the manual alone). They assessed several variables prior to the interventions and at various intervals up to 12 months following initiation of the intervention. Logistic analysis revealed significantly higher levels of abstinence among those who used the nicotine patch

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compared to those who used placebo patches; no other significant differences between treatment groups were identified. A Cox proportional hazards analysis examining time to relapse demonstrated that those receiving the nicotine patch were significantly less likely to relapse in the short term than those receiving placebo patches; these differences grew less pronounced over time. Only 44 percent of those using nicotine patches and 22 percent of those using placebo patches reported being fully compliant. Cox proportional hazards analysis also indicated that compliance, independent of patch treatment condition, had an important effect on relapse. Subjects receiving nicotine patches reported significantly lower levels of cravings at 24 hours and 1 week after initiation of the intervention; no significant differences between groups were seen after 1 month. An analysis of variables predicting response to treatment was conducted using data only from participants assigned to the nicotine patch. Only the level of nicotine dependence was associated with relapse. Seventy-five percent of the subjects receiving nicotine patches correctly guessed their treatment assignment at the 6month follow up compared with 64 percent of those in the placebo condition. The researchers conclude that these data partially support the hypothesis that the nicotine patch produces significantly higher abstinence rates than a placebo patch and do not support the hypothesis that a video-enhanced self-help intervention produces higher abstinence rates than a print-based self-help treatment manual. 4 figures, 2 tables, 45 references. ·

How Effective is Nicotine Replacement Therapy in Helping People to Stop Smoking? Source: British Medical Journal. 308(6920):21-26, January 1, 1994. Summary: Hoping to determine the efficacy of nicotine replacement therapy in helping people stop smoking, researchers systematically analyzed 40 randomized controlled trials. In 20 trials, subjects referred themselves by responding to advertisements or attending anti-smoking clinics. In another 20 trials, general practitioners invited subjects to participate. Therapists in self-referred trials generally had experience in helping people stop smoking, but therapists in the invited trials tended not to have such experience. However, the trials did not permit distinction between the effects of subject motivation and the experience of the therapist. Researchers defined efficacy as the difference in percentages of treated and control subjects who had stopped smoking at 1 year. For both nicotine gum and patch, efficacy was highly significant (P less than 0.001). The 28 trials using 2 mg nicotine gum had an overall efficacy of 6 percent, with rates of 11 percent for self-referred subjects and

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3 percent for invited subjects. Efficacy depended on the extent of dependence on nicotine as assessed by a brief questionnaire. Highdependence smokers had efficacy rates of 16 percent, but no significant effect existed for low-dependence smokers. In six trials comparing 4 mg gum to 2 mg gum or placebo or both, four trials showed the superiority of the 4 mg gum in high-dependence smokers. The efficacy of the transdermal nicotine patch in six trials comparing it to placebo patches (9 percent) did not depend as much on nicotine dependence. Findings suggest that nicotine gum and the transdermal patch both effectively aid in smoking cessation for smokers, with the efficacy variations due to degree of nicotine dependence. 1 figure, 7 tables, 54 references. ·

Effect of Cost on the Self-administration and Efficacy of Nicotine Gum: A Preliminary Study Source: Preventive Medicine. 20(4):486-496, July 1991. Summary: A study assessed the effects of a decreased cost on the use of nicotine gum. The study had four purposes: (1) To experimentally quantify the effect of decreased cost on the use of nicotine gum; (2) to determine whether decreased cost increases the incidence of behavioral dependence on nicotine gum; (3) to determine whether decreased cost would increase smoking cessation rates; and (4) to determine whether decreased cost would be cost-beneficial, (i.e., what is the relative costbenefit to a Health Maintenance Organization, insurance plan, of full reimbursement versus partial reimbursement versus no reimbursement for nicotine). Researchers recruited 106 smokers from two rural family practices run by the Department of Family Practice, University of Vermont College of Medicine. Following individual informational counseling on smoking cessation from a physician, smokers received a prescription of nicotine gum. Researchers randomly assigned smokers to pay either $20, $6, or $0 per box of nicotine gum and followed them for 6 months. Decreased cost increased the incidence of obtaining gum, the amount of gum used, and the incidence of long-term use. Decreased cost also increased cessation attempts and 1-week cessation and appeared to increase abstinence during the 6-month followup (19 percent versus 6 percent versus 8 percent). Cost-benefit estimates suggest that an insurance plan or HMO would recoup any costs in subsidizing nicotine gum and perhaps incur a net financial gain. 1 figure, 5 tables, 21 references.

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Is Nicotine More Addictive Than Cocaine? Source: British Journal of Addiction. 86(5):565-569, May 1991.

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Summary: In the context of criteria for addiction or dependence presented by the World Health Organization (WHO), the American Psychiatric Association (APA), and the U.S. Surgeon General, researchers consider several lines of evidence for the claim that nicotine is more addictive than cocaine. The lines of evidence include (1) patterns of use, (2) mortality, (3) physical dependence potential, and (4) pharmacologic addiction liability measures. Although any drug can be misused, and although even addicting drugs are not abused under all conditions, terms such as addicting, dependence-producing, or abused are generally reserved for drugs that are psychoactive and engender selfadministration, often with awareness of the potential for damaging effects. Both the WHO definitions and the criteria of the Surgeon General provide systems for differentiating addictive and nonaddictive drugs, but these are less useful for comparing the severity of addictions. The APA relies upon clinical observations and practical means for medical diagnosis. Among the first steps in determining if a chemical has the potential to produce addiction is to determine if it is psychoactive. Nicotine and the other comparison drugs all produce psychoactive effects which are qualitatively, but not quantitatively, distinct. These effects differentiate potentially addictive drugs from others such as aspirin and antibiotics but do not differentiate addictive drugs from psychoactive drugs such as chlorpromazine or atropine. The potential of a drug to produce physical dependence is determined by the onset of a withdrawal syndrome which occurs when drug administration is abruptly discontinued or when an antagonist is administered. Based on the current evidence, nicotine cannot be considered more addicting than cocaine, but both are highly addictive drugs for which patterns of use and the development of dependence are strongly influenced by factors such as availability, price, social pressures, and regulations, as well as certain pharmacologic characteristics. 28 references. ·

Physicians, Cancer Control and the Treatment of Nicotine Dependence: Defining Success Source: Health Education Research. 4(4):479-487, December 1989. Summary: Cigarette smoking and tobacco use are the major impediments to effective cancer control in the U.S. and many other countries. While a wide range of approaches to smoking prevention and cessation have been identified, evidence suggests that physicians can help smokers stop and thus make significant contributions to reducing the incidence of cancer and other smoking-related diseases. Although over 90 percent of physicians believe that helping patients stop smoking is important in promoting patient health, only 60 percent feel prepared to offer such

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help, less than half routinely offer it, and only 3 percent feel that they are successful in helping patients stop smoking. Reasons for expanding physician efforts to help their patients stop smoking include the (1) public health impact, (2) cost effectiveness, (3) breaking of the dependence cycle, (4) opportunity for continuity of care, and (5) development of treatment expertise. In 1983, the National Cancer Institute's Smoking, Tobacco, and Cancer Program began the design of a research plan that culminated in the support of five randomized, controlled intervention trials aimed at the development of brief training and intervention protocols for physicians and dentists to use in reducing patient smoking prevalence. These trials are being conducted across North America in a variety of medical delivery settings. The training protocols developed for physicians are also diverse, ranging in amount of time required form 2 hours to as much as 2 days. Though the protocols were designed for nonresearch environments, the trials were controlled, the subjects were randomized, and the experimental designs accounted for reliability and validity issues. Trial results provide strong encouragement for physicians to incorporate smoking advice and counseling into their practice. 5 tables, 1 figure, 36 references. ·

Nicotine Dependency and Adolescents: Preventing and Treating Source: Primary Care. 25(1):1-19, March 1998. Summary: The authors describe adolescent tobacco use, research on tobacco cessation for youth, and tobacco use prevention and treatment methods. According to results from the Youth Risk Behavior Survey and other sources, more than 3,000 adolescents become regular smokers every day and at least 6 million adolescents are currently smokers, despite comprehensive health education efforts. Cigarettes and smokeless tobacco are equally addictive because they both contain nicotine, which acts on the central nervous system and fulfills the criteria for drug dependence. Adolescents follow a similar nicotine addiction pattern to adults. Nicotine may serve as a precedent to other, more harmful drugs. Research, including focus groups, shows that adolescents do intend to quit using tobacco products. Few studies have been conducted on adolescent smoking cessation, but school-based cessation programs have been developed. Programs designed for adolescents who have already begun to use tobacco are based on five stages of smoking behavior: (1) Preparatory stage, (2) initial trying, (3) experimentation stage, (4) regular smoking, and (5) nicotine addiction. Adolescent tobacco intervention is based on the stages of change theory. An adolescent's current stage of change is based on (1) social influences; psychological factors, such as depression, negative affect, or self-efficacy building; and (3) addiction.

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The motivational interviewing style used in adolescent tobacco cessation programs guides the overall process of interaction between the provider and the adolescent. Five principles underlie motivational interviewing: (1) Express sympathy, (2) develop discrepancy, (3) avoid argumentation, (4) roll with resistance, and (5) support self-efficacy. It is also important to (1) ask open-ended questions, (2) listen reflectively, (3) affirm, (4) summarize, and (5) elicit self-motivational statements. The authors emphasize the need to tailor adolescent tobacco prevention and treatment interventions to the individual based on his or her stage of change and level of use. 44 references. ·

Tobacco Addiction: Implications for Treatment and Cancer Prevention Source: Journal of the National Cancer Institute. 89(24):1852-1867, December 17, 1997. Summary: The authors discuss issues raised at a June 1996 symposium on tobacco addiction sponsored by the American Society of Clinical Oncology and the National Cancer Institute. The goals of the conference were (1) to describe the burden and public health consequences of tobacco addiction, (2) to describe nicotine dependence treatment, and (3) to explore new strategies to increase quit rates and prevent tobacco use. After discussing the epidemic of tobacco use and the benefits of quitting, the authors describe (1) the implications for disease and prevention, (2) the psychobiological aspects of nicotine dependence, (3) implications for treatment, and (4) implications for public policy. Nicotine dependence, through cigarettes and smokeless tobacco, causes users to expose themselves repeatedly to carcinogens. Although cessation is the goal, recent studies suggest that chemoprevention may be a solution to counteract the effects of carcinogen exposure. Nicotine, absorbed through the mucosal membranes of the mouth and nose and through the lungs, is rapidly distributed through the bloodstream, causing changes in brain electrical potential, adrenal and pituitary hormones, heart rate, and muscle tension. Smoking is related to negative mood states. Since selfquitting is usually not effective, other cessation techniques include nicotine replacement and psychotropic medication to improve negative mood states. Other experimental drugs exist. Treatment recommendations include (1) offering cessation treatments, preferably the most intense, to all; (2) determining tobacco use status of every patient; (3) providing brief cessation treatments, since they are effective; (4) offering nicotine replacement therapy, social support, and problemsolving skills; and (5) changing the health care system to provide effective treatment. The Food and Drug Administration, in an attempt to reduce youth smoking, studied (1) nicotine as a drug, (2) marketing

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directed toward youth, and (3) strategies to reduce youth smoking. Other public policy considerations include changing public attitudes, increasing the legal attack on tobacco advertising, and focusing physicians on tobacco use prevention. 3 figures, 3 tables, 160 references. ·

Clinician Perseverance: Helping Patients Overcoming Tobacco Dependence Source: Wisconsin Medical Journal. 100(3):14-15, 2001. Summary: The authors discuss the importance of clinician perseverance in helping patients overcoming tobacco dependence. In 1996, The Smoking Cessation Clinical Practice Guideline (AHCPR) was released. It evaluated the literature on promoting cessation and provided clinicians with strategies for helping patients interested in quitting smoking. These strategies included identification of tobacco users and offering smoking cessation at every office visit and every hospital admission for every smoker. The AHCPR was updated at the University of Wisconsin's Center for Tobacco Research and Intervention and released in 2000 as a Public Health Service Report: Treating Tobacco Use and Dependence. A key point in this report is that tobacco dependence is a chronic disease. It implies that relapse is expected for those who quit smoking. Over 70 percent of smokers have tried to quit in their lifetimes. The average smoker tries to quit four to seven times. Smokers often feel like failures and physicians trying to help them may feel like they have nothing more to offer the patient who has relapsed many times. Physicians should consider treatment of tobacco dependence in the same paradigm as treatment of other chronic conditions. Appropriate management of chronic conditions requires a collaborative effort between patient and physician. The physician must be committed to providing long-term counseling, support, and reinforcement of treatment at each visit. Physicians may also need to be prepared to refer smokers to specialists and to recommend and prescribe medication such as bupropion and nicotine replacement therapy. The author concludes that it is up to each clinician to put the Guideline into practice and persevere with patients.

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Under-use of Tobacco Dependence Treatment Among Wisconsin's Feefor-service Medicaid Recipients Source: Wisconsin Medical Journal. 100(3):54-58, 2001. Summary: Researchers assessed the extent to which fee-for-service (FFS) Medicaid patients take advantage of tobacco dependence treatment coverage and receive pharmacotherapeutic treatment. They analyzed data for adults with at least 1 month of Medicaid eligibility in 1999. Of the 261,435 adults enrolled in the FFS Medicaid program, 1,131 received

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pharmacotherapeutic treatment for tobacco dependence treatment at an average cost per treatment user of $134.55. Assuming a smoking prevalence rate of 24 percent, fewer than 2 percent of Medicaid patients who smoked obtained tobacco dependence treatment; the actual smoking rate for this population is probably higher. Factors that may affect utilization rates include limited patient awareness of tobacco dependence coverage and limited physician awareness of the program benefit. The researchers conclude that tobacco dependence treatment is a costeffective, low-cost treatment that is grossly underused within the FFS Medicaid program. The Wisconsin Medicaid Program plans to (1) undertake an initiative to inform Medicaid patients in both the FFS and managed care programs about the availability of tobacco dependence treatment, and (2) encourage physicians and health plans to intervene with tobacco dependence treatment. 2 figures, 1 table, 20 references. ·

Physician-based Tobacco Dependence Interventions: Review and Clinical Practice Recommendations Source: Journal of the Mississippi State Medical Association. 41(9):722729, September 2000. Summary: The authors summarize the physician-based tobacco intervention literature, provide an overview of the updated tobacco intervention clinical practice guideline, and describe resources and assistance available through Mississippi's ACT Center, A Comprehensive Tobacco Program. Results from a meta-analysis of 39 controlled tobacco cessation trials showed that (1) brief, personal tobacco interventions provided across multiple sessions by multiple healthcare professionals leads to increased patient quit rates at 6 months; and (2) the total number of months over which patient contact occurs that includes a tobacco component predicts 12-month abstinence. Educating physicians on tobacco cessation methods leads to greater professional self-efficacy. Recently, supportive system interventions have been used to help physicians in delivering tobacco cessation services. System interventions include (1) tobacco user identification, (2) patient educational materials, (3) clinician reminder systems, (4) telephone counseling, (5) use of nonphysician interventionists, and (6) identifying a tobacco treatment coordinator. System interventions combined with physician-based treatments significantly increase quit rates. Tobacco users ready to quit should be offered the five A's clinical intervention: (1) Ask, (2) advise, (3) assess, (4) assist, and (5) arrange. Tobacco users not ready to quit should be offered the five R's clinical intervention: (1) Relevance, (2) risks, (3) rewards, (4) roadblocks, and (5) repetition. Pharmacotherapy, such as nicotine replacement therapy, is recommended for all tobacco users. The

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ACT Center is a recently established resource that was designed to develop and coordinate activities focused on understanding and managing tobacco use. The ACT Center's three core components of education and training, clinical services, and research can provide support to health care providers within the context of implementation of the tobacco dependence treatment guideline. The authors conclude that physicians comprise a well-positioned clinical profession for tobacco dependence intervention. 7 tables, 26 references. ·

Profile of Tobacco Smoking Source: Addiction. 89(11):1371-1376, November 1994. Summary: A researcher summarizes data on the prevalence and onset of smoking and on the level of dependence in users and their expressed motivation to quit, focusing on studies from Great Britain and the United States. For years, cigarette smoking has declined in a number of major Western countries. It remains highly prevalent, however, with onequarter to one-third of adults currently smoking in the United States and Great Britain. Only approximately 40 percent of those who have ever smoked cigarettes regularly have quit the habit. Over the last 20 years, a marked socioeconomic gradient has emerged in prevalence rates in both the United States and in Great Britain. Extrapolation of current trends in the United States shows that by the year 2000, about 22 percent of American adults will be smokers. Fewer than 10 percent of college graduates will smoke, whereas at least 30 percent of those whose education has not progressed beyond high school will smoke. In Great Britain in 1990, 16 percent of professional men and women smoked, but 48 percent of men and 36 percent of women in unskilled manual occupations smoked. The onset of smoking typically occurs in the early teenage years. By age 11 in Great Britain, 1 percent of children smoke regularly. By age 15, this figure rises to 20 percent. Males and females have similar smoking onset rates. Factors that have been reliably associated with smoking onset (although weakly) include sibling and parental smoking, poorer academic achievement, having ever been drunk, and having a boyfriend or girlfriend. Among teenagers, smoking does not show much correlation with social class. Many reasons have been suggested as to why individuals continue to smoke, in spite of the negative health effects. While nicotine is unambiguously a stimulant, many smokers paradoxically report that smoking calms them down, and that they want to smoke most when they experience stress. This theory agrees with the demographic pattern of higher smoking prevalence among those groups that experience the highest amount of stress, such as the unemployed, people with a history of mental illness, or those

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currently using tranquilizers, and among those who are divorced or separated. However, the fear of withdrawal symptoms may act as the primary motivation for smokers to continue smoking. Current trends in smoking prevalence and onset show signs of continuing for many years to come. 1 table, 28 references.

Federally-Funded Research on Nicotine Dependence The U.S. Government supports a variety of research studies relating to nicotine dependence and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.22 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to nicotine dependence and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore nicotine dependence and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for nicotine dependence: ·

Project Title: Behavioral Genetics of Nicotine Dependence Principal Investigator & Institution: Heath, Andrew C.; Spencer T. Olin Professor of Psychiatry; University of Michigan at Ann Arbor Ann Arbor, Mi 48109 Timing: Fiscal Year 2000 Summary: This Research Project requests support for a 3 phase study of genetic influences on nicotine dependence, and their relationship to psychiatric cofactors and to genetically determined differences in initial sensitivity to nicotine. We will ascertain from Missouri state records and

22 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

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trace a target sample of 1600 female like-sex and 1600 male like-sex MZ and DZ pairs born 1950-74. One twin from each pair will receive a brief screening interview, to identify pairs where at least one twin has smoked 100 or more cigarettes (phase 1), A diagnostic follow-up interview will be conducted with both twins from pairs who are either concordant for or discordant for lifetime smoking. Assessments will include history of nicotine dependence (DSM-IV nd Fagerstrom), alcohol dependence, major depression, conduct disorder, and attention deficit hyperactivity disorder (phase 2). Genetic analyses of these data are expected to confirm (i) a substantial genetic influence on risk of nicotine dependence among those who become regular smokers and; (ii) significant genetic covariance between nicotine dependence and other psychopathology. In phase 3 we will assess the response to nicotine challenge of twins (both MZ and DZ) who have never smoked regularly from 3 groups: (a) both twins from pairs concordant for never having smoked regularly; (b) non-smoking twins only from pairs discordant for regular smoking where the smoker has a history of nicotine dependence (scored in upper 75%-ile on the Fagerstrom); and (c) non-smoking twins only from smoking discordant pairs where the smoker scored in the lower 75%-ile on the Fagerstrom. At baseline and after placebo or nicotine dose we will assess (a) heart rate, blood pressure, and digit skin temperature; (b) subjective ratings of stimulant and sedative effects; (c) electrocortical measures including the spontaneous EG and event-related potentials in a forewarned reaction time task. Genetic analyses of these data are expected to confirm a strong genetic influence in differences in initial sensitivity to nicotine that is associated with genetic differences in risk of nicotine dependence, with high initial sensitivity to nicotine associated with increased risk of nicotine dependence, with high initial sensitivity to nicotine associated with increased risk of nicotine dependence in regular smokers. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Dependence

Biobehavioral

Aspects

of

Adolescent

Nicotine

Principal Investigator & Institution: Wood, Teresa L.; Adult Health and Illness; Ohio State University 1800 Cannon Dr, Rm 1210 Columbus, Oh 43210 Timing: Fiscal Year 2001; Project Start 5-NOV-2000 Summary: Adolescent smoking prevalence has continued to climb with 1997 estimates being the highest reported since 1979. The relationship between adolescent smoking and subsequent nicotine dependence in adulthood has been well established. While biological effects of smoking have been studied in adults, the biobehavioral aspects have not been

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examined in adolescents. In addition gender differences in smoking that have been reported for adolescents address sociobehavioral factors with limited emphasis on biological data which is essential for understanding adolescent nicotine dependence. The need to identify biomarkers of adolescent nicotine dependence is essential to the health of adolescent smokers. The first aim of this one-factor factorial design study is to characterize the biomarkers of smoke constituent exposure and smoking topography parameters in adolescent smokers. Smoke constituent exposure includes carbon monoxide and plasma nicotine increases postcigarette and baseline cotinine levels. Smoking topography parameters include puff volume and duration, interpuff interval, and inhalation and exhalation duration. In the second aim smoking topography parameters, smoke constituent exposure, and level of nicotine dependence will be compared between adolescent male and female smokers. The third aim will compare smoke constituent exposure, smoking topography parameters and level of nicotine dependence of prepubescent and later teens. The final aim will contrast biological markers of smoke constituent exposure with accepted behavioral measures of nicotine dependence. Characterizing biological and behavioral aspects of smoking in adolescent boys and girls will provide a foundation to address the gap in this important research area. The proposed study represents the first phase of a program of research that includes analyzing differences in smoking behavior of adolescents from multiple ethnic groups, as well as increasing the scientific basis from which to design tailored smoking prevention and cessation interventions by gender and age group. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Brain Reward System, Depression and Nicotine Dependence Principal Investigator & Institution: Busto, Usoa E.; ; Center for Addiction and Mental Health 250 College St Toronto, Timing: Fiscal Year 2001; Project Start 0-SEP-2001; Project End 0-JUN2004 Summary: (provided by applicant) There is a high comorbidity between nicotine dependence and major depressive disorder (MDD). Smokers with comorbid MDD are more likely to become dependent on nicotine, more severely dependent, and experience more serious withdrawal symptoms than smokers without MDD. MDD also has a negative impact on the outcome of smoking cessation treatments. The neurobiological mechanisms of nicotine dependence and comorbid MDD are unknown. We propose to assess the activity of the brain reward system (BRS) as a possible neurobiological link between MDD and nicotine dependence.

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Although many neurotransmitters are involved in the pathophysiology of these two disorders, we propose that: 1) A dysfunctional dopaminergic BRS may be responsible for some mechanisms involved in nicotine dependence and MDD; and 2) Smoking may modulate the activity of the BRS by enhancing dopaminergic activity relieving some depressive symptoms (e.g., anxiety). We propose two human experimental studies. Study I will a) assess the activity of the BRS by measuring the effects of a single oraF dose of d-amphetamine (d-amph) in depressed (DSM IV diagnosed, not on antidepressants, n=20) and non-depressed smokers (n=20); b) determine whether nicotine modifies the response to d-amph; and c) determine whether nicotine withdrawal symptoms are different during smoking and non-smoking conditions. We will measure physiological and rewarding effects of d-amph using valid self-report instruments at baseline and 30, 60, 120, 180, and 240 min post-drug. Plasma levels of damph and homovanillic acid will be measured. Study 2 will use PET to measure dopamine-medialed ['C] Raclopride displacement before and after 30mg of d-amph in 24 control and 24 MDD (12 smokers and 12 non-smokers/group) subjects. It will also determine whether the rewarding effects of d-amph correlate with ['C] Raclopride displacement. Results may provide evidence for neurobiological mechanism (s) explaining the high comorbidity between MDD and nicotine dependence. The BRS could become the target for developing new treatments for nicotine dependence and some symptoms of MDD. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Genetic Epidemiology of Nicotine Dependence Principal Investigator & Institution: Breslau, Naomi%; ; Washington University Lindell and Skinker Blvd St. Louis, Mo 63130 Timing: Fiscal Year 2001; Project Start 8-SEP-2001; Project End 1-AUG2006 Summary: (provided by applicant): The proposed epidemiologic family study will systematically examine the vulnerability to nicotine dependence due to the combined transmission of genes and family/cultural environmental factors (i.e., familial liability). Four areas are addressed in the proposed study: 1.) the familial liability for nicotine dependence associated with different phenotypes or characteristics of nicotine dependence (e.g. also meeting DSM-IV criteria); 2.) the degree of shared familial liability between nicotine dependence and other substance use and mental disorders; 3.) the interaction between familial liability for nicotine dependence and non-familial environmental factors in the etiology of nicotine dependence; 4.) familial liability, non-familial factors, and individual factors that may be partially under genetic control

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(such as nicotine metabolism) that contribute to estimated differences in nicotine dependence between African Americans and Caucasians, both to spotlight factors that contribute to nicotine dependence in a group at high risk of cancer mortality (African Americans) and to identify protective factors by comparing racial groups with substantially different cigarette smoking profiles. This epidemiologic case - control family study is designed to examine the familial transmission of nicotine dependence among adults 25 to 44 years of age and their families. This age range will be used because the period of risk for daily smoking is largely concluded by age 25 and adults between these ages are still likely to have living parents. Cases will be nicotine dependent by a threshold score of 4 or more on the Fagerstrom Test of Nicotine Dependence (FTND). Controls will be smoking exposed (having smoked at least 100 cigarettes) but never nicotine dependent (FTND = 0). For cases one sibling and both parents will be sought. For controls one sibling will be sought. Direct interviews will be conducted with the case and control family members. The information gathered will include their cigarette smoking, psychiatric disorders, and other substance use, as well as demographic and medical history information. All of the interviewed family members will provide family history of cigarette smoking, substance use and psychiatric disorders. Additionally, cases and controls will be asked about the cigarette smoking, alcohol use and behavior problems of their offspring. This study provides a population-based context for genetic and metabolism studies in the Collaborative Study on the Genetics of Nicotine Dependence. Ascertainment, interviewing, and data management will be integrated across studies. Additionally, as part of the unique opportunity presented by the scientific integration of Projects 1, 2, and 3, we will incorporate genetic, metabolic and epidemiologic measures of a broad array for factors in the development of risk factor models for nicotine dependence. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Linkage and Candidate Gene Study of Nicotine Dependence Principal Investigator & Institution: Bierut, Laura J.; Assistant Professor; Washington University Lindell and Skinker Blvd St. Louis, Mo 63130 Timing: Fiscal Year 2001; Project Start 8-SEP-2001; Project End 1-AUG2006 Summary: The goal of The Linkage and Candidate Gene Study of Nicotine Dependence is to detect, identify, and characterize genetic loci that predispose of protect individuals from the onset and persistence of nicotine dependence and that determine tobacco consumption. Heavy

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smoking (1 pack for 6 months or more) nicotine dependence (Fagerstrom Test for Nicotine Dependence greater than or equal to 4) affects about 10% of the population, and siblings of probands have a 40% risk of developing nicotine dependence (lambda2-3-4). 750 to 800 informative families will be recruited from HMO's (Detroit, MI; Minneapolis, N; St. Louis, MO). Roughly half of the families will be taken from the genetic epidemiology study (Project 1). Families with at least one heavy smoking nicotine dependent sibling pair will be interviewed and have their DNA sampled. Parents and other siblings who have smoked but may not be dependent will also be recruited for genetic analyses using family based association and quantitative linkage methods. A case control sample for association studies will be collected. Subjects will undergo a multidomain assessment of cigarette use, nicotine dependence and related phenotypes. Our date set will include approximately 1200 independently counted affected sibling pairs, 800 discordant sibling samples on both parents; the remaining families are expected to have samples on one. Identify-by-state statistics that are robust to ethnic stratification can be used with these data. Candidate gene testing will be done on 950 cases and 650 controls and can be followed in 750 families using family based association tests. Two-stage genotyping using 400 markers spaced approximately 10cM will be conducted. A genomic survey will be conducted for chromosomal regions linked to nicotine dependence and related phenotypes. Sib-pair and variant component methods, quantitative and quantitative linkage analysis will be performed on the appropriate phenotypes. Areas suggestive of linkage will be followed up with additional genotyping. Candidate genes for nicotine dependence and related phenotypes will be examined. Potential candidate genes will be provided by Project 3. Bioinformatics will help guide candidate gene approaches by taking advantages of the publicly available results from human and mouse genome sequencing projects. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Mapping of Susceptibility Loci for Nicotine Dependence Principal Investigator & Institution: Li, Ming D.; Director of Bioinformatics; Pharmacology; University of Tennessee Health Sci Ctr Health Science Center Memphis, Tn 38163 Timing: Fiscal Year 2000; Project Start 0-SEP-1999; Project End 1-AUG2004 Summary: Despite increasing negative attitudes towards smoking and intensified public campaigns and legislation against smoking, virtually no further reduction in smoking has occurred in this country during the 1990's. According to the 1996 National Household Survey on Drug

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Abuse, an estimated 68.8 million Americans used tobacco products. Therefore, tobacco is one of the most widely abused substances. Many years of twin and family studies provide strong evidence for a genetic component to nicotine dependence. The heritabilities for nicotine dependence, estimated from twin, family and adoption studies, are in the range of 0.28 to 0.84, with a mean heritability of 0.53. Nicotine can increase dopamine release in the nucleus accumbens and the ventral tegmental area regions implicated in the rewarding properties of other addictive drugs. Taken together, these studies of heritability and the neurochemical basis for the rewarding properties of nicotine provide strong evidence that certain aspects of smoking are influenced by genetic factors. We hypothesize that a group of susceptibility genes increases vulnerability to nicotine dependence and that these can be detected by using a combination of a two-stage genome-wide screening and candidate gene approaches. In the first stage of genomic screening, approximately 1600 subjects from 400 nuclear families recruited equally from Caucasian and African American populations will be genotyped by 218 microsatellite markers spaced at approx. 20 cM throughout the genome, followed by model-free sib-pair linkage analysis. The potential regions of interest (P greater than 0.03) will be subjected to second stage genomic analyses by genotyping more markers (i.e., 2-5) on both sides of the region and by searching candidate genes within these regions. The same DNA samples will also be used for family-based association studies between the nicotine dependence and 10 plausible candidate genes, that are related to dopamine reward pathways or nicotine metabolism. The TDT or its variants will be used to test the significance. We expect that the completion of the proposed studies in this application will advance our understanding of genetic influences on nicotine dependence and may eventually allow targeting of novel prevention strategies to individuals at risk. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: MAYO Nicotine Dependence Education Program Principal Investigator & Institution: Dale, Lowell C.; ; Mayo Clinic Rochester 200 1St St Sw Rochester, Mn 55905 Timing: Fiscal Year 2001; Project Start 1-JUN-2001; Project End 1-MAY2006 Summary: (provided by Applicant) Tobacco use is associated with more than 400,000 premature deaths each year in the U.S. Thirty percent of all cancer deaths are due to tobacco. Treatment of nicotine dependence has been recognized as an important means of decreasing cancer deaths and effective intervention programs have been supported by the NCI since

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the late 1980s. Now, with more effective treatment offerings, an increasing number of pharmacologic agents, and financial resources from the recent settlements with the tobacco industry, the demand for education in nicotine dependence treatment is growing. The Mayo Nicotine Dependence Center, established in 1988, has a long history of very successful educational programs supported by an equally successful clinical program that has treated over 21,000 patients. However, the demand for our clinical and educational services, plus our desire to meet the needs locally and nationally, now requires additional funding. Building on our experience with a nationally recognized annual seminar on nicotine dependence treatment and program development and our successful internal medicine residency curriculum, we propose to provide a broad-based educational program including one-day workshops to train health care professionals in the USPHS Clinical Practice Guideline - Treating Tobacco Use and Dependence recommended intervention program, intervention training for physicians in training, continuation of our three and one-half day CME seminar, extended CME seminar specialty training for health care professionals who desire additional training, and a three month practicum in Nicotine Dependence for Master's candidates. We will also collaborate with The Mayo Medical School, The Mayo School of Health-Related Sciences, and The Mayo Graduate School to strengthen the nicotine dependence treatment curriculums of health professionals in training. All of the programs will be carefully evaluated for efficacy and quality improvement. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Comorbidity

Nicotine

Dependence

Treatment

in

Psychiatric

Principal Investigator & Institution: Williams, Jill M.; Psychiatry; Univ of Med/Dent Nj-R W Johnson Med Sch Robert Wood Johnson Medical Sch Piscataway, Nj 08854 Timing: Fiscal Year 2001; Project Start 1-JUL-2001; Project End 0-JUN2006 Summary: Nicotine dependence is very common among psychiatric patients and impacts clinical course, medication levels, and physical health of smokers. Unfortunately, there is a paucity of research for this subgroup of smokers and minimal treatment studies. The goals of this NIDA Mentored Patient-Oriented Research Career Development Award (K23) are to become an independent clinical researcher and create a program of research in the area of nicotine dependence and psychiatric comorbidity. This includes further training in Epidemiology and

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Quantitative Methods including research methodology, biostatistics and biocomputing, experiment design, process research and comorbidity issues. The UMDNJ-Robert Wood Johnson Medical School and the Rutgers Center for Alcohol Studies provide an excellent environment for developing research investigators. The primary mentor, Douglas Ziedonis, had extensive research experience, a NIDA Career Award, and is a leading psychiatrist studying nicotine dependence among individuals with schizophrenia. The research plan includes two studies. 1: Pharmacotherapy for Nicotine Dependence Among Psychiatric Patients. During a six-month study, schizophrenic smokers will be recruited into a double blind study comparing multiple doses of nicotine replacement pact .schizophrenics are believed to be more heavily dependent on nicotine, therefore, higher dose strategies and longer duration of treatment may yield greater quit rates. Study 2: Psychosocial Treatment for Nicotine Dependence Among Psychiatric Patients. Using NIDA stage a Behavioral Therapy approach, the specific aims of this study are to develop patient and clinical manuals, create adherence and rating scales and formalize a training program for clinicians and conduct a pilot study. Schizophrenics have unique disabilities in processing information and interpersonal communications that require specific and tailored therapies. Techniques from dual diagnosis treatment can be adapted for treating nicotine dependence and include aspects of social skills training, motivational enhancement therapy and relapse prevention. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Opiate and Nicotine Dependence--Medications and Therapy Principal Investigator & Institution: Sullivan, Maria A.; Psychiatry; Columbia University Health Sciences Ogc New York, Ny 10032 Timing: Fiscal Year 2000; Project Start 1-SEP-1999; Project End 0-JUN2004 Summary: Heroin and nicotine dependence are two addictions for which new combined pharmacotherapy/behavioral therapy interventions are possible. The goal of this mentored clinical scientist award is to promote the developing research skills of Maria A. Sullivan, M.D., Ph.D., by providing two areas of clinical research for testing novel combined medication/therapy strategies for opiate and nicotine dependence. Dr. Sullivan, a Board-Certified Psychiatrist, has completed a successful research fellowship in the Division on Substance Use at Columbia University/New York State Psychiatric Institute (NYSPI). As a fellow, Dr. Sullivan has begun studying patterns of smoking among schizophrenic

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patients and carried out a pilot intervention using bupropion/behavioral therapy to treat nicotine dependence among patients with chronic psychosis. This year Dr. Sullivan has joined the staff in the Division as an Assistant Professor of Clinical Psychiatry. She is currently serving as the Co-Director for the NIDA funded grant, "Opiate Dependence: Combined Naltrexone/Behavior Therapy." In the next several years, Dr. Sullivan plans to carry out clinical treatment trials to explore novel combined pharmacotherapy/psychotherapy approaches to opiate and nicotine dependence. Her proposed research plan will enable her to develop skills in two specific areas of addiction psychiatry: (1)conducting double-blind pharmacotherapeutic trials of agents which target specific mood symptoms in opiate or nicotine dependence or withdrawal; and (2)developing manualized psychotherapies tailored to promote abstinence and relapse prevention for individuals abusing certain classes of drugs. In this way, Dr. Sullivan will be well prepared to achieve her long-term research career goal of developing treatment approaches for comorbid substance use/psychiatric disorders. Under the sponsorship and guidance of Dr. Herbert Kleber, together with the faculty and resources available at Columbia University, Dr. Sullivan's training plan combines formal course work with clinical research experience at several sites of the New York State Psychiatric Institute. She will be working closely with several preceptors to receive training in the following areas: design and methods of clinical treatment studies; controlled medication trials; developing and implementing manual-guided relapse prevention therapies for opiate and nicotine dependence in selected populations; and biostatistics and epidemiology. Her specific research plan includes double-blind placebo-controlled trials of bupropion for nicotine dependence and nefazodone with open-label naltrexone for opiate dependence. For both treatment studies, manual-guided relapse prevention therapies will be developed and implemented. Dr. Sullivan's planned research will provide her with unique training and will afford her the opportunity to develop a clinical research career focused on developing new combined medication/therapy approaches to the treatment of substance abuse disorders. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Prospective Study of the Onset of Nicotine Dependence Principal Investigator & Institution: Difranza, Joseph R.; Associate Professor; Family and Community Medicine; Univ of Massachusetts Med Sch Worcester 55 Lake Ave N Worcester, Ma 01655 Timing: Fiscal Year 2000; Project Start 0-SEP-1997; Project End 1-JUL-2002

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Summary: (Applicant's Description) Little is known about the process by which nicotine dependence develops among adolescent tobacco users. This project will follow a cohort of 650 7th grade students over a period of three and one half years. These subjects will be interviewed every four months during this period about their experiences with tobacco. The tobacco use of these subjects will be monitored in detail with specific attention to the duration of use, the frequency of use and the amount of tobacco consumed. Subjects will be monitored for the development of symptoms of nicotine dependence. The following specific hypotheses will be addressed: 1) Symptoms of nicotine dependence can appear within two months of the first use of tobacco. 2) Symptoms of nicotine dependence can be present when consumption averages less than one cigarette per day. 3) Youths can develop symptoms of nicotine dependence prior to the onset of the daily use of tobacco. 4) The inability to refrain from smoking where it is prohibited will not be an early symptom of dependence. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: the Collaborative Genetic Study of Nicotine Dependence Principal Investigator & Institution: Reich, Theodore; Professor of Psychiatry and Genetics; Psychiatry; Washington University Lindell and Skinker Blvd St. Louis, Mo 63130 Timing: Fiscal Year 2001; Project Start 8-SEP-2001; Project End 1-AUG2006 Summary: This is a resubmission of the Collaborative Genetic study of Nicotine Dependence (COGEND), a new five-year Program Project Grant to detect and evaluate familial and non-familial causes of nicotine dependence. The goals of the program are the identification of biological mechanisms, genes and environmental features that determine nicotine consumption and predispose or protect individuals from the onset and persistence of the disorder. Improved understanding of these factors will suggest novel, powerful strategies for reducing or eliminating nicotine dependence and the massive health burden it places on all societies. Subjects and families will be recruited from comparable HMOs at three sites; The Henry Ford Hospital (Detroit), The University of Minnesota (Minneapolis-St. Paul) and Washington University (St. Louis). There are three interrelated studies: (1) a genetic epidemiology study of the families of nicotine dependent individuals, (2) a genetic linkage and candidate gene study of nicotine of nicotine dependence and related phenotypes and (3) a neuropharmacology study of the relationship between nicotine dependence and related phenotypes and (3) a neuropharmacology study of the relationship between nicotine metabolism and tobacco

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consumption and dependence. Candidate gene studies include casecontrol and family based designs to maximize power and minimize bias due to ethnic stratification. African-Americans will be over-sampled to provide a sufficient sample for statistical consumption, nicotine metabolism and assessment of familial and non-familial variables in multiple domains that are correlated with the disorder. Data management and administrative cores support these studies. Each project contributes thematically to the program. The family epidemiology project elucidates environmental and familial factors from which informative quantitative and qualitative phenotypes are derived. The linkage and candidates gene studies include a genome-wide survey, fine mapping and case-control and family based candidate gene studies to identify genes that determine nicotine consumption, and susceptibility or protection from nicotine dependence. Their effect on the incidence and familial distribution of nicotine dependence and tobacco consumption will be studied in the large of probands, controls and relatives metabolism providing biological insight into disorder and endophenotypes and candidate genes for the genetic study. Metabolic variables will be used as co-variables in the family, population and linkage studies. A team of investigators from three centers will work together to unravel this disorder. Our team includes epidemiologists, geneticists, statisticians, psychiatrists, psychologists, and pharmacologists. We hope to translate these basic biological and environmental studies into strategies to reduce the massive health burden of nicotine dependence. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Adolescent Progression of Nictoine Dependence Principal Investigator & Institution: Niaura, Raymond S.; Associate Professor; Miriam Hospital 164 Summit Ave Providence, Ri 02906 Timing: Fiscal Year 2000 Summary: (Applicant's Description) Little is known about individual differences in susceptibility to nicotine dependence among youth. While most adolescents experiment with tobacco, the majority do not go on to develop a pattern of habitual use and nicotine dependence. While both familial and biobehavioral factors are important in predicting cigarette use, little is known about; 1) the familial aggregation of smoking especially among adolescents and first degree relatives (parents and siblings); 2) the nicotine use and dependence phenotypes which are transmitted from parent to child; and 3) heritable biobehavioral substrates which may predispose toward nicotine dependence. Characteristics related to disruptive behavior disorders (e.g., attention

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deficit hyperactivity disorder, conduct disorder) and mood disorders (e.g. depression) are associated with smoking in both youth and adults. Maternal smoking during pregnancy increases the likelihood of youth smoking and young adult nicotine dependence, and is simultaneously associated with a variety of developmental and neurocognitive deficits (e.g., ADHD; conduct disorder) that may increase the likelihood of developing nicotine dependence by potentiating the reinforcing effects of nicotine. The aims of this proposal are to study associations between: (1) Adolescent comorbid disruptive behavioral disorders, mood disorders, and the progression of nicotine dependence; (2) Corresponding parental and sibling comorbid smoking, nicotine dependence, antisocial, ADHD, and mood disorders in relation to adolescents' progression of nicotine dependence; and (3) Effects of maternal smoking during pregnancy on incidence and trajectory of comorbid disruptive behavioral and mood disorders and nicotine dependence. Accordingly, 644 families (adolescents, siblings and parents) will be studied prospectively over 3 years to determine those factors which predict progression of nicotine dependence. This prospective family study will utilize both existing and new data gathered as part of the National Collaborative Perinatal Project (NCPP), whose New England cohort includes over 16,000 adults who have been followed since birth, whose early neurological, cognitive, and psychological functioning has been documented, and whose children are, on average, 14 years old, and will be 17 years old when the proposed study is complete. We propose to study comorbid disruptive behavioral and mood disorders in these children, their parents and siblings, and use this information to predict progression of nicotine dependence. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Epidemiological/Familial Aspects of Drug Use Principal Investigator & Institution: Kandel, Denise B.; Professor of Public Health in Psychiatry; Psychiatry; Columbia University Health Sciences Ogc New York, Ny 10032 Timing: Fiscal Year 2001; Project Start 5-AUG-1981; Project End 1-JUL2006 Summary: (Provided by Applicant) This is a competing continuation application for renewal (Years #21-#25, 8/l/01-7/31/06) of a K05 Senior Scientist Award (SSA) held since 8/01/81. The overall objective of the research has been to investigate through epidemiological studies three major themes on substance use in adolescence and adulthood: developmental patterns of involvement and cessation in the use of various drugs; risk and protective factors for involvement in drugs; and consequences of using drugs. Stimulated by findings obtained in the

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current period of support, the goal for the next five years is to conduct a multifactorial examination of the development of nicotine dependence. Six specific aims will be pursued: (1) Describe the epidemiology and natural history of nicotine dependence and other aspects of smoking behavior, in particular the transition to daily smoking and nicotine dependence, among adolescents and young adults. (2) Identify psychological, social and biological factors that promote (risk factors) and factors that reduce the risk (protective factors) of daily smoking and the transition to nicotine dependence. (3) Specify the comorbidity of drug use and dependence with psychiatric symptoms among adolescents, in particular the sequencing and reciprocal relationships between nicotine dependence and depression. (4) Examine interpersonal influences on drug behavior, especially nicotine dependence, within and outside the family, and identify: a. the extent of familial similarity on drug behavior, including nicotine dependence, among parents and adolescents, siblings, and spouses; b. the relative contribution of genetic, shared and nonshared environmental factors to smoking onset, daily smoking and nicotine dependence among twins; c. the relative importance of selection and socialization on smoking among adolescent friendship pairs. (5) Identify pathways of progression in smoking, nicotine dependence, and the use of other drugs. (6) Identify gender and ethnic commonalities and differences for #1-#5. An overall goal is to incorporate a biological perspective in epidemiological research. Three interrelated research programs will be pursued to achieve these aims: analyses of a national longitudinal sample of young adults (Add Health), analyses of the National Household Surveys on Drug Abuse, and the implementation of a new longitudinal study of the transition to nicotine dependence in adolescence. The research will provide understanding crucial for the development of effective prevention and treatment interventions. Components of the program represent innovative activities in epidemiological research carried out on general population samples. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Pediatric Pharmacology Research Unit Principal Investigator & Institution: Kearns, Gregory L.; Professor of Pediatrics; Children's Mercy Hosp (Kansas City, Mo) 2401 Gillham Rd Kansas City, Mo 64108 Timing: Fiscal Year 2001; Project Start 1-JAN-1994; Project End 1-DEC2003 Summary: The propose epidemiologic family study will systematically examine the vulnerability to nicotine dependence due to the combined transmission of genes and family/cultural environmental factors (e.g.,

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familial liability). Four areas are addressed in the proposed study: 1) the familial liability for nicotine dependence associated with different phenotypes or characteristics of nicotine dependence (e.g. also meeting DSM-IV criteria); 2) the degree of shared familial liability dependence and non- familial environmental factors in the etiology of nicotine dependence; 4) familial liability, non-familial factors, and individual factors that may be partially under genetic control (such as nicotine metabolism) that contribute to estimated differences in nicotine dependence between African Americans and Caucasians, both to spotlight factors that contribute to nicotine dependence in a group at high risk of cancer mortality (African Americans) and to identify protective factors by comparing racial groups with substantially different cigarette smoking profiles. This epidemiologic case-control family study is designed to examine the familial transmission of nicotine dependence among adults 25 to 44 years of age and their families. This range will be used because the period of risk for daily smoking is largely concluded by age 25 and adults between these ages are still likely to have living parents. Cases will be nicotine dependent by a threshold score of 4 or more on the Fagerstrom Test of Nicotine Dependence (FTND). Controls will be smoking exposed (having smoked at least 100 cigarettes) but never nicotine dependent (FTND=0). For cases on sibling and both parents will be sought. For controls one sibling will be sought. Direct interviews will be conducted with the case and control family members. The information gathered will include their cigarette smoking, psychiatric disorders, and other substance use, as well as demographic and medical history information. All of the interviewed family members will provide family history of cigarette smoking, substance use and psychiatric disorders. Additionally, cases and controls will be asked about the cigarette smoking, alcohol use and behavior problems of their offspring. This study provides a population-based context for genetic and metabolism studies in the Collaborative Study on the Genetics of Nicotine Dependence. Ascertainment, interviewing, and data management will be integrated across studies. Additionally, as part of the unique opportunity presented by the scientific integration of Projects 1, 2, and 3 we will incorporate genetic, metabolic and epidemiologic measures of a broad array for factors in the development of risk factor models for nicotine dependence. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Prenatal, Child, and Family Risks Principal Investigator & Institution: Buka, Stephen L.; Associate Professor; Miriam Hospital 164 Summit Ave Providence, Ri 02906

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Timing: Fiscal Year 2000 Summary: (Applicant's Description) The proposed project addresses: a) the effect of in utero exposure (IUE) to nicotine and other prenatal and childhood conditions on the risk of nicotine dependence in adulthood; and b) the familial aggregation of nicotine dependence and related phenotypes. Building on current research in this area, findings from the proposed study will advance the field of nicotine research in at least two important ways. Firstly, the proposed study will use prenatal and early childhood measures collected prospectively in a large community sample, enabling statistically powerful analyses of multiple and alternative early risks for adult nicotine dependence. Secondly, through a hybrid design we examine hypotheses and anticipate future studies of gene:environment interactions in the etiology of adult nicotine dependence. We focus primarily on a specific environmental risk, in utero exposure (IUE) to nicotine both based on the strength of the existing human and animal study data and for parsimony of effort. We have developed a sampling and measurement strategy intended both to distinguish the role of IUE from other salient characteristics of pregnant women who smoke and from known sequelae of IUE that may explain or mediate any observed link between IUE and later nicotine dependence. In so doing, we are able to simultaneously investigate the predictive utility of a range of hypothesized prenatal, childhood and familial risks for adult nicotine dependence. We propose to accomplish these aims through a, multidisciplinary, multi- method longitudinal investigation. The proposed project integrates: 1) a natural history study of the smoking trajectories and associated behaviors through mid-life of subjects whose mother did and did not smoke during pregnancy; 2) a family study of sibling pairs, discordant for maternal smoking during pregnancy; 3) a sibling study of current or ex-regular smokers to investigate the familial aggregation of nicotine dependence and related phenotypes; and 4) a baseline assessment of current smokers targeted for a randomized smoking cessation trial. The resulting 40-year prospective study will: 1) determine whether nicotine dependence is elevated among adult offspring exposed in utero to nicotine; 2) investigate the mechanisms for this potential association; 3) identify prenatal, child and familial risks f adult nicotine dependence; and 4) examine patterns of familial aggregation to identify potential mechanisms for familial clustering and identify the components of nicotine dependence that may be familial. These data will provide an empirical basis for conducting future studies of susceptibility genes for nicotine dependence. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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E-Journals: PubMed Central23 PubMed Central (PMC) is a digital archive of life sciences journal literature developed and managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).24 Access to this growing archive of e-journals is free and unrestricted.25 To search, go to http://www.pubmedcentral.nih.gov/index.html#search, and type “nicotine dependence” (or synonyms) into the search box. This search gives you access to full-text articles. The following is a sample of items found for nicotine dependence in the PubMed Central database: ·

Effect of nicotine on brain activation during performance of a working memory task by Monique Ernst, John A. Matochik, Stephen J. Heishman, John D. Van Horn, Peter H. Jons, Jack E. Henningfield, and Edythe D. London; 2001 April 10 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=31902

The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.26 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals.

Adapted from the National Library of Medicine: http://www.pubmedcentral.nih.gov/about/intro.html. 24 With PubMed Central, NCBI is taking the lead in preservation and maintenance of open access to electronic literature, just as NLM has done for decades with printed biomedical literature. PubMed Central aims to become a world-class library of the digital age. 25 The value of PubMed Central, in addition to its role as an archive, lies the availability of data from diverse sources stored in a common format in a single repository. Many journals already have online publishing operations, and there is a growing tendency to publish material online only, to the exclusion of print. 26 PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication. 23

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To generate your own bibliography of studies dealing with nicotine dependence, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “nicotine dependence” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “nicotine dependence” (hyperlinks lead to article summaries): ·

Treatment of nicotine dependence. Author(s): Haxby DG. Source: American Journal of Health-System Pharmacy : Ajhp : Official Journal of the American Society of Health-System Pharmacists. 1995 February 1; 52(3): 265-81; Quiz 314-5. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7749954&dopt=Abstract

·

Acupuncture therapy for the treatment of tobacco smoking addiction. Author(s): Steiner RP, Hay DL, Davis AW. Source: Am J Chin Med. 1982; 10(1-4): 107-21. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7183202&dopt=Abstract

Vocabulary Builder Acid: Common street name for LSD. [NIH] Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antidepressants: A group of drugs used in treating depressive disorders. [NIH]

Atropine: A toxic alkaloid, originally from Atropa belladonna, but found in other plants, mainly Solanaceae. [NIH] Chlorpromazine: The prototypical phenothiazine antipsychotic drug. Like the other drugs in this class chlorpromazine's antipsychotic actions are thought to be due to long-term adaptation by the brain to blocking dopamine receptors. Chlorpromazine has several other actions and

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therapeutic uses, including as an antiemetic and in the treatment of intractable hiccup. [NIH] Comorbidity: The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. [NIH] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Epidemiological: Relating to, or involving epidemiology. [EU] Habitual: Of the nature of a habit; according to habit; established by or repeated by force of habit, customary. [EU] Hormones: Chemical substances having a specific regulatory effect on the activity of a certain organ or organs. The term was originally applied to substances secreted by various endocrine glands and transported in the bloodstream to the target organs. It is sometimes extended to include those substances that are not produced by the endocrine glands but that have similar effects. [NIH] Locomotor: Of or pertaining to locomotion; pertaining to or affecting the locomotive apparatus of the body. [EU] Menthol: An alcohol produced from mint oils or prepared synthetically. [NIH]

Neuropharmacology: The branch of pharmacology dealing especially with the action of drugs upon various parts of the nervous system. [NIH] Neurotransmitters: Endogenous signaling molecules that alter the behavior of neurons or effector cells. Neurotransmitter is used here in its most general sense, including not only messengers that act directly to regulate ion channels, but also those that act through second messenger systems, and those that act at a distance from their site of release. Included are neuromodulators, neuroregulators, neuromediators, and neurohumors, whether or not acting at synapses. [NIH] Outpatients: Persons who receive ambulatory care at an outpatient department or clinic without room and board being provided. [NIH] Pharmacists: Those persons legally qualified by education and training to engage in the practice of pharmacy. [NIH] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of yeasts. [NIH]

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Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Proportional: Being in proportion : corresponding in size, degree, or intensity, having the same or a constant ratio; of, relating to, or used in determining proportions. [EU] Psychiatric: Pertaining to or within the purview of psychiatry. [EU] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH] Psychopathology: The study of significant causes and processes in the development of mental illness. [NIH] Psychopharmacology: The study of the effects of drugs on mental and behavioral activity. [NIH] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Psychotropic: Exerting an effect upon the mind; capable of modifying mental activity; usually applied to drugs that effect the mental state. [EU] Reflex: 1; reflected. 2. a reflected action or movement; the sum total of any particular involuntary activity. [EU] Schizophrenia: A severe emotional disorder of psychotic depth characteristically marked by a retreat from reality with delusion formation, hallucinations, emotional disharmony, and regressive behavior. [NIH] Socialization: The training or molding of an individual through various relationships, educational agencies, and social controls, which enables him to become a member of a particular society. [NIH] Substrate: A substance upon which an enzyme acts. [EU] Tranquilizers: Drugs prescribed to promote sleep or reduce anxiety; this National Household Survey on Drug Abuse classification includes benzodiazepines, barbiturates, and other types of CNS depressants. [NIH] Ventral: 1. pertaining to the belly or to any venter. 2. denoting a position more toward the belly surface than some other object of reference; same as anterior in human anatomy. [EU]

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CHAPTER 5. PATENTS ON NICOTINE DEPENDENCE Overview You can learn about innovations relating to nicotine dependence by reading recent patents and patent applications. Patents can be physical innovations (e.g. chemicals, pharmaceuticals, medical equipment) or processes (e.g. treatments or diagnostic procedures). The United States Patent and Trademark Office defines a patent as a grant of a property right to the inventor, issued by the Patent and Trademark Office.27 Patents, therefore, are intellectual property. For the United States, the term of a new patent is 20 years from the date when the patent application was filed. If the inventor wishes to receive economic benefits, it is likely that the invention will become commercially available to patients with nicotine dependence within 20 years of the initial filing. It is important to understand, therefore, that an inventor’s patent does not indicate that a product or service is or will be commercially available to patients with nicotine dependence. The patent implies only that the inventor has “the right to exclude others from making, using, offering for sale, or selling” the invention in the United States. While this relates to U.S. patents, similar rules govern foreign patents. In this chapter, we show you how to locate information on patents and their inventors. If you find a patent that is particularly interesting to you, contact the inventor or the assignee for further information.

27Adapted

from The U. S. Patent and Trademark Office: http://www.uspto.gov/web/offices/pac/doc/general/whatis.htm.

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Patents on Nicotine Dependence By performing a patent search focusing on nicotine dependence, you can obtain information such as the title of the invention, the names of the inventor(s), the assignee(s) or the company that owns or controls the patent, a short abstract that summarizes the patent, and a few excerpts from the description of the patent. The abstract of a patent tends to be more technical in nature, while the description is often written for the public. Full patent descriptions contain much more information than is presented here (e.g. claims, references, figures, diagrams, etc.). We will tell you how to obtain this information later in the chapter. The following is an example of the type of information that you can expect to obtain from a patent search on nicotine dependence: · ·

Method of treating nicotine dependence Inventor(s): Mason; Barbara J. (Coconut Grove, FL), Mason; Barbara J. (Coconut Grove, FL) Assignee(s): The University of Miami (Miami, FL), The University of Miami (Miami, FL) Patent Number: 5,852,032 Date filed: November 20, 1996 Abstract: A method of treating a subject afflicted with nicotine dependence with the opiate antagonist, nalmefene is described. The subjects will not gain significant amounts of weight as a result of smoking reduction or cessation. Excerpt(s): The invention pertains to methods of treating human subjects suffering from nicotine dependence or addiction. ... The invention pertains to methods of treating human subjects suffering from nicotine dependence or addiction. ... Nicotine dependence accounts for more mortality and morbidity in this country than does dependence on any other substance of abuse, including alcohol, cocaine and heroin. Thus, nicotine dependence represents an enormous cost to the American economy, in terms of health services and lost work days due to illness and premature death. Consequently, the development of safe and effective smoking cessation strategies is an important public health priority. ... Nicotine dependence accounts for more mortality and morbidity in this country than does dependence on any other substance of abuse, including alcohol, cocaine and heroin. Thus, nicotine dependence represents an enormous cost to the American economy, in terms of health services and lost work days due to illness and premature

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death. Consequently, the development of safe and effective smoking cessation strategies is an important public health priority. ... Current behavioral and somatic treatments for nicotine dependence, e.g., the nicotine patch, have limited efficacy in interrupting the chronic and relapsing course of the disorder. Moreover, existing treatments are associated with undesirable consequences. For example, the New England Journal of Medicine published a report on Nov. 2, 1995 of a nationwide survey of Americans over the age of 35 that found women who gave up smoking gained an average of 11 pounds and men 10 pounds. Such weight gain is a common reason for women, in particular, to return to cigarette smoking after an initial period of abstinence. ... Current behavioral and somatic treatments for nicotine dependence, e.g., the nicotine patch, have limited efficacy in interrupting the chronic and relapsing course of the disorder. Moreover, existing treatments are associated with undesirable consequences. For example, the New England Journal of Medicine published a report on Nov. 2, 1995 of a nationwide survey of Americans over the age of 35 that found women who gave up smoking gained an average of 11 pounds and men 10 pounds. Such weight gain is a common reason for women, in particular, to return to cigarette smoking after an initial period of abstinence. Web site: http://www.delphion.com/details?pn=US05852032__ ·

Pharmaceutical formulation for the treatment of nicotine dependence Inventor(s): Moormann; Joachim (Werne, DE) Assignee(s): Therapie-System GmbH & Co., KG (Neuwied, DE), Arzneimittelforschung GmbH & Co. KG (Werne, DE) Patent Number: 5,643,905 Date filed: October 30, 1995 Abstract: The present invention relates to the use of galanthamine and the pharmaceutically acceptable acid addition salts thereof for the treatment of nicotine dependence. The active substances are released from pharmaceutical formulations, e.g., orally, transdermally, or otherwise parenterally in a continuous and controlled manner. Excerpt(s): The present invention relates to pharmaceutical formulations for the treatment of nicotine dependence. ... The present invention is particularly directed to pharmaceutical formulations and devices by which galanthamine or one of its pharmaceutically acceptable acid addition salts is released in a controlled, for instance continuous manner to treat nicotine dependence. ... Accordingly, there is a demand for drugs which reliably suppress the symptoms of nicotine dependence; however,

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the therapeutic doses of the active substance may not have a toxicity comparable to that of nicotine. Web site: http://www.delphion.com/details?pn=US05643905__

Keeping Current In order to stay informed about patents and patent applications dealing with nicotine dependence, you can access the U.S. Patent Office archive via the Internet at no cost to you. This archive is available at the following Web address: http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” You will see two broad options: (1) Patent Grants, and (2) Patent Applications. To see a list of granted patents, perform the following steps: Under “Patent Grants,” click “Quick Search.” Then, type “nicotine dependence” (or synonyms) into the “Term 1” box. After clicking on the search button, scroll down to see the various patents which have been granted to date on nicotine dependence. You can also use this procedure to view pending patent applications concerning nicotine dependence. Simply go back to the following Web address: http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” Select “Quick Search” under “Patent Applications.” Then proceed with the steps listed above.

Vocabulary Builder Galanthamine: A cholinesterase inhibitor. It has been used to reverse the muscular effects of gallamine and tubocurarine and has been studied as a treatment for Alzheimer's disease and other central nervous system disorders. [NIH] Somatic: 1. pertaining to or characteristic of the soma or body. 2. pertaining to the body wall in contrast to the viscera. [EU]

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CHAPTER 6. BOOKS ON NICOTINE DEPENDENCE Overview This chapter provides bibliographic book references relating to nicotine dependence. You have many options to locate books on nicotine dependence. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on nicotine dependence include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Federal Agencies The Combined Health Information Database collects various book abstracts from a variety of healthcare institutions and federal agencies. To access these summaries, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. You will need to use the “Detailed Search” option. To find book summaries, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer. For the format option, select “Monograph/Book.” Now type “nicotine dependence” (or synonyms) into the “For these words:” box. You will only receive results on books. You should check back periodically with this database which is updated every 3 months. The following is a typical result when searching for books on nicotine dependence:

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·

Cigars: Health Effects and Trends Source: Bethesda, MD, U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Smoking and Tobacco Control Monograph 9, 232 p., February 1998. Contact: National Cancer Institute, Offices of Cancer Communications, Building 31, Room 10A24, 9000 Rockville Pike, Bethesda, MD 20892. (800) 422-6237. NIH Publication No. 98-4302. Summary: Cigars: Health Effects and Trends is organized into eight chapters devoted to (1) an overview and the current state of the science, (2) trends in cigar consumption and smoking prevalence, (3) chemistry and toxicology, (4) disease consequences, (5) indoor pollution from cigar smoke, (6) pharmacology and abuse potential of cigars, (7) marketing and promotion of cigars, and (8) policies regulating cigars. Consumption of cigars in the United States has increased dramatically since 1993. The premium cigar category has increased 154 percent since 1993. Males are more likely to smoke cigars than females. In a 1996 survey of Massachusetts students in grades 6 through 12, cigar use among males ranged from 3.2 percent in the sixth grade to 30 percent in high school. Cigar smoke contains the same carcinogenic compounds identified in cigarette smoke. The risk associated with cigar use is less than that of cigarette use because of less regular use and less inhalation with cigars. Regular cigar smoking causes cancer of the lung, oral cavity, larynx, esophagus, and probably the pancreas. Heavy cigar smokers are at risk for coronary heart disease, chronic obstructive pulmonary disease, and aortic aneurysm. The risk of oral cancer is similar among cigar smokers and cigarette smokers. Environmental tobacco smoke from cigars is an increasing source of indoor air pollution. Cigars contain varying amounts of nicotine. There is enough nicotine absorption among regular cigar smokers to suspect that nicotine dependence would develop, but studies have not yet confirmed this. Promotional activities and advertising have (1) increased the visibility of cigar consumption, (2) normalized cigar use, and (3) removed barriers to cigar use. The cigar industry has had a voluntary code since 1965 to avoid using sex or celebrity to sell cigars, but these are regular features of cigar marketing. Cigars have less federal and state regulation compared to cigarettes and smokeless tobacco.

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Handbook of Health Behavior Change Source: New York, NY, Springer Publishing Company, 607 p., 1998. Contact: Springer Publishing Company, 536 Broadway, New York, NY 10012.

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Summary: The Handbook of Health Behavior Change presents reviews of studies evaluating theoretical and empirical health behavior change interventions for preventing and treating major diseases. Intended as a resource for practitioners of behavioral medicine, the book consists of 24 chapters organized into seven main sections addressing (1) behavior change and maintenance: theory and measurement; (2) lifestyle interventions and maintenance of behaviors; (3) obstacles to lifestyle change and adherence; (4) lifestyle change and adherence issues within specific populations; (5) lifestyle change and adherence issues among patients with chronic disease; (6) adherence issues in clinical trials; and (7) lifestyle change and adherence: the broader context. The chapters grouped under the section on behavior and maintenance address (1) theoretical models and strategies for improving adherence and disease management, (2) relapse prevention and maintenance of optimal health, (3) the transtheoretical model of behavior change, (4) models for provider-patient interaction and their application to health behavior change, and (5) measuring adherence with medication regimens. The chapters grouped under the section on lifestyle interventions and behavior maintenance address (1) adherence to treatment for nicotine dependence, (2) promoting dietary change, (3) adherence to physical activity, (4) adoption and maintenance of safer sexual practices, and (5) intervention elements promoting adherence to mindfulness-based stress reduction programs. The chapters grouped under obstacles to lifestyle change and adherence address (1) biological obstacles to adoption and maintenance of health promoting behaviors, (2) improving physicians' implementation of clinical practice guidelines in primary care practice, and (3) adolescent tobacco use and the social context. The chapters in the section on lifestyle change and adherence issues within specific populations address (1) lifestyle interventions for the young, (2) problems with adherence in the elderly, and (3) adherence issues among adolescents with chronic disease. The chapters under the section on lifestyle change and adherence issues among patients with chronic disease address (1) comanagement of chronic obstructive pulmonary disease, (2) issues in diabetes self-management, and (3) adherence issues among cancer patients. The chapters grouped under adherence issues in clinical trials address (1) prerandomization compliance screening from a statistician's viewpoint; and (2) predictors of patient adherence: patient characteristics. The chapters grouped under the section on lifestyle change and adherence viewed in a broader context address (1) adherence and the placebo effect, (2) collaboration between professionals and mediating structures in the community, and (3) ethical issues in lifestyle change and adherence.

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Women and Tobacco Source: Geneva, Switzerland, World Health Organization, 128 p., 1990. Contact: World Health Organization, Publications Center USA, 49 Sheridan Avenue, Albany, NY 12221. Summary: Women and Tobacco presents the consolidation of activities undertaken by the World Health Organization (WHO) in recent years to review available evidence on tobacco use by women and to identify the most promising strategies for tobacco control. The book provides information for decision makers; staff of ministries of health, education, labor, and social welfare; legislators; nongovernmental organizations; and community leaders. There are six chapters. Chapter one addresses Women and Tobacco: Issues at Stake. Chapter two, Women and Tobacco Use: Patterns and Trends, addresses (1) a global overview of tobacco use, tobacco-related morbidity and mortality, and worldwide prevalence of tobacco consumption by women; (2) women and smoking in developed countries; (3) evolution of tobacco use among women in developing countries; and (4) monitoring the tobacco use epidemic. Chapter three, Tobacco or Health, discusses (1) the constituents of tobacco, (2) nicotine dependence, (3) mortality and morbidity, (4) cardiovascular diseases, (5) cancer, (6) bronchopulmonary diseases, (7) reproductive health, (8) other effects on well-being, (9) smoking and occupational health, (10) passive smoking, (11) economic consequences, and (12) assessing further the effects of the epidemic. Chapter four, Why Women Start and Continue to Smoke, addresses (1) why and when young girls start smoking, (2) why smokers continue to smoke, (3) which women smoke, (4) women as role models, and (5) documenting the epidemic. Chapter five, Prevention and Cessation of Tobacco Use, discusses (1) preventing the uptake of smoking, (2) cessation of tobacco use, (3) role of health professionals, and (4) halting the epidemic. Chapter six, Women Against Tobacco: A Strategy for Individual, Community, National, and International Action, addresses (1) a worldwide strategy, (2) identifying and strengthening the strategists, (3) improving knowledge, and (4) providing the tools. The appendix provides a survey on tobacco use.

·

Nicotine in Psychiatry: Psychopathology and Emerging Therapeutics Source: Washington, DC, American Psychiatric Press, Inc., 296 p., 2000. Contact: American Psychiatric Press, Inc., 1400 K Street, NW., Washington, DC 20005. Internet/Email: www.appi.org. Summary: Nicotine in Psychiatry: Psychopathology and Emerging Therapeutics examines the importance of nicotine and nicotinic pharmacology in psychiatry and neuroscience. The first section addresses

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the (1) neurobiology and clinical pathophysiology of neuronal nicotine acetylcholine receptors, (2) pharmacokinetics and pharmacodynamics of nicotine, (3) behavioral factors influencing the effects of nicotine, and (4) addictive capacity of nicotine. The second section deals with clinical applications including (1) nicotine and major mental disorders; (2) smoking, nicotine, and mood; (3) nicotinic cholinergic systems in Alzheimer's and Parkinson's diseases; (4) smoking, nicotine, and movement disorders; (5) nicotine effects and attention deficit/hyperactivity disorder; (6) nicotine replacement therapies and beyond; (7) behavioral treatment of cigarette smoking and nicotine dependence; and (8) nicotine and nicotinic systems in psychiatry, past and future. As regards exposure to nicotine during pregnancy, there is evidence that indicates that pregnancy produces large changes in the metabolism of nicotine and cotinine. Increased clearance of cotinine levels explains the observation that cotinine levels, normalized for cigarettes smoked per day, are much lower in pregnant than in nonpregnant women. The implications of rapid metabolism for smoking behavior and smoking cessation treatment during pregnancy remain to be determined. Nicotine may arrest neuronal replication and differentiation in the developing fetus and may be associated with sudden infant death syndrome. While nicotine administration in adults seems to improve attentiveness, prenatal nicotine exposure has been associated with attention impairment. Children of women who smoke during pregnancy are more likely to develop cognitive and learning deficits, including (1) attention deficit/hyperactive disorder, (2) impaired attention and orientation, and (3) poor impulse control. Long-lasting deficits in cognitive function after maternal smoking during pregnancy have been seen in most studies. Recent evidence suggests that smoking during pregnancy increases the risk for attention deficit/hyperactivity disorders and reduced childhood IQ scores. ·

Tobacco Epidemic Source: Basel, Switzerland, Karger, Progress in Respiratory Research, Vol. 28, 265 p., 1997. Contact: S. Karger AG, P.O. Box, CH-4009 Basel, Switzerland. Summary: The Tobacco Epidemic provides a review of tobacco smoking, including the clinical, public health, and policy issues of tobacco smoking. Topics include (1) the history and economics of tobacco; (2) smoking prevalence around the world; (3) smoking-related diseases and health effect of passive smoking; (4) nicotine dependence and the psychology of the smoker; (5) patterns and predictors of smoking cessation; (6) the role of general physicians, nurses, and pharmacists in

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smoking cessation; (7) nicotine replacement therapy; (8) smokeless tobacco; (9) effects of smoke-free environments, advertising bans, and price increases; and (10) regulation of tobacco and nicotine. The volume is intended to appeal to a large readership across many medical and nonmedical specialties.

Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ). The following have been recently listed with online booksellers as relating to nicotine dependence (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): · The Clinical Management of Nicotine Dependence by James A. Cocores (Editor) (1991); ISBN: 0387974644; http://www.amazon.com/exec/obidos/ASIN/0387974644/icongroupint erna · The Clinical Management of Nicotine Dependence (1991); ISBN: 3540974644; http://www.amazon.com/exec/obidos/ASIN/3540974644/icongroupint erna · F. A. C. T. S.: Facts and Activities about Chewing Tobacco and Smoking (1998); ISBN: 1580000487; http://www.amazon.com/exec/obidos/ASIN/1580000487/icongroupint erna

The National Library of Medicine Book Index The National Library of Medicine at the National Institutes of Health has a massive database of books published on healthcare and biomedicine. Go to the following Internet site, http://locatorplus.gov/, and then select “Search LOCATORplus.” Once you are in the search area, simply type “nicotine dependence” (or synonyms) into the search box, and select “books only.”

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From there, results can be sorted by publication date, author, or relevance. The following was recently catalogued by the National Library of Medicine:28 ·

Analytical determination of nicotine and related compounds and their metabolites. Author: edited by John W. Gorrod and Peyton Jacob III; Year: 1999; Amsterdam; New York: Elsevier, 1999; ISBN: 0444500952 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0444500952/icongroupin terna

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Brain imaging of nicotine and tobacco smoking. Author: editor, Edward F. Domino; copy editor, Antoinette F. Domino; Year: 1995; Ann Arbor, Mich.: NPP Books, c1995; ISBN: 091618210X (alk. paper) http://www.amazon.com/exec/obidos/ASIN/091618210X/icongroupi nterna

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Cigarette papers. Author: Stanton A. Glantz ... [et al.]; Year: 1996; Berkeley: University of California Press, 1996; ISBN: 0520205723 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0520205723/icongroupin terna

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Cigarette smoking as a dependence process. Author: editor, Norman A. Krasnegor; Year: 1979; Rockville, Md.: Dept. of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, Division of Research, [1979] Cigarettes, nicotine & health: a biobehavioral approach. Author: Lynn T. Kozlowski, Jack E. Henningfield, Janet Brigham; Year: 2001; Thousand Oaks: Sage, c2001; ISBN: 080395946X (hardback) http://www.amazon.com/exec/obidos/ASIN/080395946X/icongroupi nterna

·

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Clearing the smoke: assessing the science base for tobacco harm reduction. Author: Kathleen Stratton ... [et al.], editors; Year: 2001; Washington, D.C.: National Academy Press, c2001; ISBN: 0309072824 (case) http://www.amazon.com/exec/obidos/ASIN/0309072824/icongroupin terna

In addition to LOCATORPlus, in collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the Web. The books may be accessed in two ways: (1) by searching directly using any search term or phrase (in the same way as the bibliographic database PubMed), or (2) by following the links to PubMed abstracts. Each PubMed abstract has a “Books” button that displays a facsimile of the abstract in which some phrases are hypertext links. These phrases are also found in the books available at NCBI. Click on hyperlinked results in the list of books in which the phrase is found. Currently, the majority of the links are between the books and PubMed. In the future, more links will be created between the books and other types of information, such as gene and protein sequences and macromolecular structures. See http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books.

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Clinical management of nicotine dependence. Author: James A. Cocores, editor; Year: 1991; New York: Springer-Verlag, c1991; ISBN: 0387974644 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0387974644/icongroupin terna

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Effects of nicotine on biological systems II. Author: edited by P.B.S. Clarke ... [et al]; Year: 1995; Basel; Boston: Birkhäuser Verlag, c1995; ISBN: 3764350830 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/3764350830/icongroupin terna

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FTC cigarette test method for determining tar, nicotine, and carbon monoxide yields of U.S. cigarettes. Author: report of the NCI expert committee; Year: 1996; [Bethesda, Md.?]: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, [1996]

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International Symposium on Nicotine: the Effects of Nicotine on Biological Systems II: the abstracts. Author: edited by P.B.S. Clarke ... [et al.]; Year: 1994; Basel; Boston: Birkhäuser Verlag, c1994; ISBN: 3764350873 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/3764350873/icongroupin terna

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Neuronal nicotinic receptors: pharmacology and therapeutic opportunities. Author: edited by Stephen P. Arneric, Jorge D. Brioni; Year: 1999; New York: A. John Wiley & Sons, Inc., c1999; ISBN: 047124743X (alk. paper) http://www.amazon.com/exec/obidos/ASIN/047124743X/icongroupi nterna

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Nicotine addiction among adolescents. Author: Eric F. Wagner, guest editor; Year: 2000; New York: Haworth Press, [c2000]

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Nicotine addiction and smoking cessation. Author: Gary Reed; Year: 1994; [Dallas, Tex.]: University of Texas Southwestern Medical Center, 1994

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Nicotine addiction in Britain: a report of the Tobacco Advisory Group of the Royal College of Physicians. Author: Gori, Gio B; Year: 2000; London: The College, c2000; ISBN: 1860161227 Nicotine and public health. Author: edited by Roberta Ferrence ... [et al.]; Year: 2000; Washington, DC: American Public Health Association, c2000; ISBN: 0875532497 http://www.amazon.com/exec/obidos/ASIN/0875532497/icongroupin terna

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Nicotine as a therapeutic agent. Author: edited by K. Opitz; Year: 1997; Stuttgart: G. Fischer, c1997; ISBN: 3437212362

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Nicotine in cigarettes and smokeless tobacco products is a drug and these products are nicotine delivery devices under the Federal Food, Drug, and Cosmetic Act: appendices. Author: Haughton, Samuel; Year: 1995; [Rockville, Md.]: U.S. Food and Drug Administration, Dept. of Health and Human Services, [1995]

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Nicotine in psychiatry: psychopathology and emerging therapeutics. Author: edited by Melissa Piasecki, Paul A. Newhouse; Year: 2000; Washington, DC: American Psychiatric Press, c2000; ISBN: 0880487976 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0880487976/icongroupin terna

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Nicotine safety and toxicity. Author: edited by Neal L. Benowitz; Year: 1998; New York: Oxford University Press, 1998; ISBN: 0195114965 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0195114965/icongroupin terna

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Nicotine water to heroin. Author: Shibani Roy, S.H.M. Rizvi; Year: 1986; Delhi: B.R. Pub. Corp.; New Delhi, India: D.K. Publishers' Distributors, 1986; ISBN: 8170182772

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Nicotine, caffeine and social drinking: behaviour and brain function. Author: edited by Jan Snel and Monicque M. Lorist; Year: 1998; Amsterdam: Harwood Academic Publishers, c1998; ISBN: 9057022184 http://www.amazon.com/exec/obidos/ASIN/9057022184/icongroupin terna

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Nicotinic receptors in the nervous system. Author: edited by Edward D. Levin; Year: 2002; Boca Raton: CRC Press, c2002; ISBN: 084932386X (alk. paper) http://www.amazon.com/exec/obidos/ASIN/084932386X/icongroupi nterna

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Physiological experiments on strychnine and nicotine. Samuel Haughton ..; Year: 1856; [Dublin?: s.n., 1856?]

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Practice guideline for the treatment of patients with nicotine dependence. ; Year: 1996; Washington. DC: American Psychiatric Association, c1996; ISBN: 0890423083 http://www.amazon.com/exec/obidos/ASIN/0890423083/icongroupin terna

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Question of intent: a great American battle with a deadly industry. Author: David Kessler; Year: 2001; New York: Public Affairs, c2001; ISBN: 1891620800 http://www.amazon.com/exec/obidos/ASIN/1891620800/icongroupin terna

Author: by

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Regulation of cigarettes and smokeless tobacco under the federal Food, Drug, and Cosmetic Act. Author: Douglas, Clifford E; Year: 1996; [Washington, D.C.?]: Dept. of Health and Human Services, U.S. Food and Drug Administration: For sale by the U.S. G.P.O., Supt. of Docs., [1996]; ISBN: 0160487382 http://www.amazon.com/exec/obidos/ASIN/0160487382/icongroupin terna

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Smoking: risk, perception, & policy. Author: Paul Slovic, editor; Year: 2001; Thousand Oaks, Calif.: Sage Publications, c2001; ISBN: 0761923802 (c: alk. paper) http://www.amazon.com/exec/obidos/ASIN/0761923802/icongroupin terna

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Tobacco industry's use of nicotine as a drug: what do the recent revelations mean for tobacco control? Author: by Clifford E. Douglas; Year: 1994; New York, N.Y.: American Council on Science and Health, 1994 Tobacco. Author: Mark S. Gold; Year: 1995; New York: Plenum Medical Book Co., 1995; ISBN: 0306449331 http://www.amazon.com/exec/obidos/ASIN/0306449331/icongroupin terna

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Virtually safe cigarettes: reviving an opportunity once tragically rejected. Author: Gio Batta Gori; Year: 2000; Amsterdam; Washington, DC: IOS Press; Tokyo: Ohmsha, c2000; ISBN: 1586030574 http://www.amazon.com/exec/obidos/ASIN/1586030574/icongroupin terna

Chapters on Nicotine Dependence Frequently, nicotine dependence will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with nicotine dependence, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and nicotine dependence using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “nicotine dependence” (or synonyms) into the “For these words:” box, you will only receive results on chapters in books. The following is a typical result when searching for book chapters on nicotine dependence:

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Tobacco: Health Effects and Control Source: in Maxcy-Rosenau-Last Public Health and Preventive Medicine. Fourteenth Edition. Wallace, R.B.; ed. Stamford, CT, Appleton and Lange, pp. 817-845, 1998. Contact: Appleton and Lange, Four Stamford Plaza, P.O. Box 120041, Stamford, CT 06912-0041. INTERNET/EMAIL: www.appletonlange.com. Summary: Tobacco: Health Effects and Control, a chapter in MaxcyRosenau-Last Public Health and Preventive Medicine, describes the toll of smoking with respect to excess mortality and economic costs, cardiovascular disease, cancer, and other smoking-related diseases. The health risks of environmental tobacco smoke are also discussed as are trends in tobacco use, tobacco interventions, tobacco economics, the international perspective on tobacco, and challenges in tobacco prevention and control. Cardiovascular disease is considered with regard to coronary heart disease, peripheral arterial occlusive disease, cerebrovascular disease, and mechanisms of cardiovascular disease as they relate to smoking. An increased risk of lung cancer, oral, laryngeal, and esophageal cancer, bladder and renal cancer, stomach cancer, and cervical cancer is associated with smoking. Other diseases associated with smoking include chronic obstructive pulmonary disease, gastrointestinal disease, diseases of the mouth, in utero effects, and effects on young people. Health risks of environmental tobacco smoke concern the constituents of tobacco smoke, effects on children's health, sudden infant death syndrome, and development of lung cancer and other diseases. The authors review trends in tobacco use by reporting the prevalence of cigarette consumption among adults and teenagers, changes in cigarettes, cigars and pipes, smokeless tobacco, and other tobacco products. The authors discuss treatments for tobacco use/nicotine dependence, treatment for tobacco use in a managed care setting, community intervention programs, government and private sector measures, advertising and promotion, tobacco use prevention, and smoking and the workplace. Despite considerable progress, smoking is still the leading cause of preventable death in the United States and most industrialized societies. Efforts to prevent tobacco use initiation and to promote cessation need to be intensified and to involve widespread use of effective strategies, with reduction of barriers to the interventions and development of innovative strategies, particularly for targeting youth.

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Adherence to Treatment for Nicotine Dependence Source: in Handbook of Health Behavior Change. Shumaker, S.A.; Schron, E.B.; Ockene, J.K; McBee, W.L.; eds. New York, NY, Springer Publishing Company, pp. 137-165, 1998. Contact: Springer Publishing Company, 536 Broadway, New York, NY 10012. Summary: Adherence to Treatment for Nicotine Dependence, a chapter in The Handbook of Health Behavior Change, discusses techniques derived from the Cognitive Social Learning Theory for promoting adherence of adults in smoking cessation interventions. The chapter (1) presents individual and population perspectives on adherence relevant to smoking prevention; (2) presents a broadened definition of adherence; (3) discusses a proposed stepped-care matching model of adherence that can be used in smoking cessation interventions; (4) describes specific applications of the stepped care-approach for smoking cessation; and (5) discusses issues that cut across the levels of stepped care, including ethnic/minority issues and comorbidity. Surveys have shown that despite a steady decrease in the overall percentage of smokers in the United States population from 1965 to 1990 and the variety of clinical and public health interventions available to help smokers quit, population smoking cessation rates during the 1990's have leveled off. The static smoking cessation rates are due to a number of factors that can be construed as related to adherence issues including (1) many smokers not adequately adhering to treatment components known to be effective; (2) a lack of breakthrough treatments that could be more effective at meeting certain smokers' needs; (3) appropriate interventions not being proactively delivered to the majority of smokers who are not currently motivated to quit; and (4) intervention delivery systems, economic, and other societal factors presenting barriers to access to optimal treatment. These factors are, therefore, regarded as making it less likely that smokers will be motivated to participate long-term in smoking cessation programs. This situation indicates that both individual and population or public health perspectives are relevant to a broader framework for conceptualizing adherence. The definition of adherence is, therefore, broadened to mean the degree to which (1) an interventionist and/or the treatment delivery system adheres to a specific protocol, and/or (2) the extent to which the treatment is proactively delivered to and successfully reaches a specific population, such as an underserved population of smokers who are not motivated to consider cessation. The stepped-care model incorporates this wider definition of adherence. For a smoker who is ready to quit, the model has three broad levels of care related to type, intensity, and cost of the intervention: (1) Minimal, based on self-change

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and/or self-help; (2) moderate, consisting of brief (often tailored) counseling plus followup; and (3) maximal, based on specialized formal clinical treatment with both outpatient and inpatient options. Moderate and maximal intensity level interventions (levels 2 and 3) are considered to be more appropriate for ethnic or minority groups than minimal (level 1) interventions, unless self-help materials are specifically targeted to the groups. ·

Patterns and Predictors of Smoking Cessation in the General Population Source: in Tobacco Epidemic. Bolliger, C.T.; Fagerstrom, K.O.; eds. Basel, Switzerland, Karger, Progress in Respiratory Research, Vol. 28, pp. 151164, 1997. Contact: S. Karger AG, P.O. Box, CH-4009 Basel, Switzerland. Summary: Patterns and Predictors of Smoking Cessation in the General Population, a chapter in The Tobacco Epidemic, considers the natural history of smoking cessation in the general population, focusing on outcomes of all cessation attempts mainly among citizens of the United Kingdom. Data estimated from the 1973 and 1994 General Household Survey (GHS) in Great Britain showed that (1) quit ratios increased with age, and (2) cessation rates for all ages combined increased significantly from 1973 to 1994. There is little evidence supporting a gender difference in cessation rates. The family has a strong effect on smoking behavior. Children with smoking parents are more likely to become smokers, and parents caring for children are more likely to quit smoking than adults without children. Smoking cessation rates among those of highsocioeconomic status have significantly increased, while cessation rates among those of low-socioeconomic status have changed little. Based on data from the British National Child Development Study, strong predictors of smoking cessation are (1) household smoking, (2) marital status, and (3) nicotine dependence. The lack of significant progress in reducing smoking prevalence emphasizes the need for effective treatments to help smokers quit. Despite the value of such treatments, relapse continues to be the most common outcome of a quit attempt. The author concludes that the many factors that influence smoking cessation imply that policies regarding smoking need to address many issues, including social acceptability, price, advertising, and nicotine dependence.

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Counseling to Prevent Tobacco Use Source: in Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. Second Edition. US Preventive Services Task Force. Baltimore, MD, Williams and Wilkins, pp. 597-609, 1996. Contact: Williams and Wilkins, 351 West Camden Street, Baltimore, MD 21201-2436. Summary: Counseling to Prevent Tobacco Use, a book chapter in Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force, describes how physicians can counsel their patients to avoid or stop smoking and using smokeless tobacco. Clinical trials have demonstrated the effectiveness of certain forms of clinician and group counseling in changing the smoking behavior of patients. Elements of effective counseling include providing reinforcement through consistent and repeated advice from a team of providers to stop smoking, setting a specific quit date, and scheduling followup contacts or visits. The use of additional modalities, such as self-help materials, referral to group counseling, advice from more than one clinician, or chart reminders identifying patients who smoke, seems to further enhance effectiveness. Preventing the initiation of tobacco use by children and adolescents is an important role for the physician, since almost all initiation of tobacco use occurs before high school graduation. The most successful school-based programs have involved teaching the skills to resist social pressures to use tobacco. Although the significant health hazards of tobacco use and the benefits of cessation are well established, studies have suggested that many physicians do not counsel persons who smoke to stop. Physicians can provide leadership and support that may enhance both school-based programs and community-based efforts, such as restrictions on tobacco advertising, enforcement of laws preventing the access of minors to tobacco, and tax increases on tobacco products to decrease the demand among children. The elements of clinical intervention include (1) obtain a complete history of tobacco use and an assessment of nicotine dependence from all adolescent and adult patients, (2) provide regular counseling for all patients who use tobacco products, and (3) prescribe nicotine patches or gum as adjuncts to counseling.

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Smoking Cessation Source: in Prevention of Myocardial Infarction. Manson, J.E.; Ridker, P.M.; Gaziano, J.M.; Hennekens, C.H.; eds. New York, NY, Oxford University Press, Inc., pp. 99-129, 1996. Contact: Oxford University Press, Inc., 198 Madison Avenue, New York, NY 10016.

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Summary: Smoking Cessation, a chapter in Prevention of Myocardial Infarction, discusses the evidence for the benefit of smoking cessation on coronary heart disease (CHD) risk and intervention strategies for smoking cessation. Cigarette smoking has been recognized as a risk factor for CHD for 40 years. Although the evidence is convincing, variables such as obesity, dietary habits, and exercise levels confound the link between smoking and CHD. The major mechanisms involved in CHD found in smokers involves the thrombogenic and atherogenic effects of smoking. Since no randomized, controlled trials in humans have confirmed this link, the strongest evidence for the link between smoking and CHD comes from observational data in cohort and case-control studies. These studies have consistently shown that smoking increases the risk for CHD morbidity and mortality. There is evidence that smoking cessation accounted for 24 percent of the overall decline in CHD mortality from 1968 to 1976. Smoking cessation intervention strategies include (1) self-help; (2) physician advice to quit; and (3) pharmacologic therapy, including nicotine replacement therapy and clonidine use to alleviate withdrawal symptoms. A comprehensive nicotine dependence treatment model includes the following elements: (1) Identification of the smoker by the treating physician, (2) advice to stop smoking by the physician and referral for a nicotine dependence consultation, (3) assessment, (4) preparation of a tailored treatment plan, (5) relapse prevention, and (6) intensive treatment for severe nicotine dependence. The authors conclude that (1) smoking is the most important modifiable risk factor for the development of CHD; and (2) smoking cessation lowers CHD risk regardless of sex, age, or presence of established CHD. The authors provide two appendixes: (1) Patient education counseling materials, and (2) patient instructions for using nicotine replacement products and clonidine. ·

Minimal-Contact Quit Smoking Strategies for Medical Settings Source: in Nicotine Addiction: Principles and Management. Orleans, C.T.; Slade, J.; eds. New York, NY, Oxford University Press, pages 181-220, 1993. Contact: Oxford University Press, 200 Madison Avenue, New York, NY 10016. Summary: Minimal-Contact Quit Smoking Strategies for Medical Settings, a book chapter in Nicotine Addiction: Principles and Management, describes minimal-contact quit smoking treatment strategies as efforts to stop smoking with the help of brief instructions or advice on how to quit and/or by using self-help materials and quitting aids. The chapter describes physician-initiated minimal-contact

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strategies, focusing on practical primary care smoking cessation interventions exemplified by the National Cancer Institute (NCI) 4-step intervention model. The chapter also covers minimal-contact hospitalbased treatments and interventions by nonphysician health care providers. In medical settings, minimal-contact treatments generally involve a brief smoking history assessment, personalized medical advice to quit, and a self-quitting guide, sometimes with the prescription of a pharmacologic adjunct. Minimal-contact medical treatments require a practice environment that facilitates and reinforces smoking cessation. In the NCI intervention model, step one involves (1) asking about smoking at every opportunity, (2) using smoking status as a vital sign, and (3) assessing nicotine dependence and smoking history. Step two, advising all smokers to stop, involves (1) praising quit efforts, (2) personalizing the risks and benefits, (3) exploring patient quit motives and attempts, and (4) giving a clear, strong quit message tied to an offer of help. Step three, assisting the patient in stopping, involves (1) innovative team approaches, (2) assisting smokers ready for action, (3) prescribing adjunctive pharmacologic therapy, (4) providing brief quitting counseling, and (5) assisting smokers not ready to quit. Step four, arranging followup, discusses (1) essential content of followup counseling, (2) followup formats and methods, (3) hospital-based treatments, and (4) minimal-contact interventions by nonphysician providers. ·

Nicotine Dependence Among Blacks and Hispanics Source: in Nicotine Addiction: Principles and Management. Orleans, C.T.; Slade, J.; eds. New York, NY, Oxford University Press, pages 350-364, 1993. Contact: Oxford University Press, 200 Madison Avenue, New York, NY 10016. Summary: Nicotine Dependence Among Blacks and Hispanics, a book chapter in Nicotine Addiction: Principles and Management, notes that minority populations are edging ahead of their white counterparts in prevalence of adult tobacco use and risk of tobacco-related disease. Both blacks and Hispanics suffer from long-standing disparities in knowledge of smoking health risks and access to health care as compared to whites. Research shows startling increases in daily level of cigarette consumption by Hispanic adults. A lower rate of cigarette consumption among blacks is offset by a predilection for high tar/nicotine, mentholated cigarettes. Sociodemographic factors related to smoking among blacks are similar to those for the United States population as a whole. Demographic factors related to smoking status are similar for Hispanics and whites, though

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smoking status among Hispanics varies with ethnic subgroup and level of acculturation. Compared with whites, blacks and Hispanics are less likely to (1) have information about cancer prevention, (2) associate tobacco use with cancer risk, and (3) seek physician advice. Extensive tobacco marketing campaigns targeting minorities create major barriers to cessation and prevention. Insidious advertising occurs on the streets of minority neighborhoods in the form of billboards. Teens are especially vulnerable to advertising, and minority youth are less equipped to resist it. Determinants of quitting for minorities much like those within the general population. New studies show a stronger desire to quit among blacks than whites, although blacks are less likely than whites to quit smoking regardless of socioeconomic status or demographic factors. Quitting barriers include (1) low income, (2) employment status, (3) limited access to health care, (4) weaker social support, and (5) stronger environmental influences to relapse. Many smoking cessation programs are available, but few are tailored to the groups at highest risk. Appealing to distinct market segments within minority communities is essential for effective communications. A few smoking control interventions for blacks and Hispanics currently offer culturally appropriate materials.

General Home References In addition to references for nicotine dependence, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Drugs (Health Issues) by Sarah Lennard-Brown; Library Binding - 64 pages (March 2002), Raintree/Steck Vaughn; ISBN: 0739847732; http://www.amazon.com/exec/obidos/ASIN/0739847732/icongroupinterna · The Encyclopedia of Drugs and Alcohol (Reference) by Greg Roza; School & Library Binding - 199 pages (September 2001); Franklin Watts, Incorporated; ISBN: 0531118991; http://www.amazon.com/exec/obidos/ASIN/0531118991/icongroupinterna

Vocabulary Builder Acculturation: Process of cultural change in which one group or members of a group assimilates various cultural patterns from another. [NIH] Acetylcholine: A neurotransmitter. Acetylcholine in vertebrates is the major

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transmitter at neuromuscular junctions, autonomic ganglia, parasympathetic effector junctions, a subset of sympathetic effector junctions, and at many sites in the central nervous system. It is generally not used as an administered drug because it is broken down very rapidly by cholinesterases, but it is useful in some ophthalmological applications. [NIH] Arterial: Pertaining to an artery or to the arteries. [EU] Bronchopulmonary: Pertaining to the lungs and their air passages; both bronchial and pulmonary. [EU] Cervical: Pertaining to the neck, or to the neck of any organ or structure. [EU] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Infarction: 1. the formation of an infarct. 2. an infarct. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Pharmacodynamics: The study of the biochemical and physiological effects of drugs and the mechanisms of their actions, including the correlation of actions and effects of drugs with their chemical structure; also, such effects on the actions of a particular drug or drugs. [EU] Pharmacokinetics: The pattern of absorption, distribution, and excretion of a drug over time. [NIH] Strychnine: An alkaloid found in the seeds of nux vomica. It is a competitive antagonist at glycine receptors and thus a convulsant. It has been used as an analeptic, in the treatment of nonketotic hyperglycinemia and sleep apnea, and as a rat poison. [NIH] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH]

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CHAPTER 7. MULTIMEDIA ON NICOTINE DEPENDENCE Overview Information on nicotine dependence can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on nicotine dependence. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Bibliography: Multimedia on Nicotine Dependence The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in nicotine dependence (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on nicotine dependence. For more information, follow the hyperlink indicated: ·

Animated neuroscience and the actions of nicotine, cocaine, and marijuana in the brain. Source: a presentation of Films for the Humanities & Sciences; a Savantes production; Year: 1998; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c1998

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·

Chemical dependence : releasing the hostage within. Source: Nimco; produced by St. Mary's Medical Center; Year: 1995; Format: Videorecording; Calhoun, KY: Nimco, c1995

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Co-dependence : the joy of recovery. Source: [presented by] Johnson Institute; filmed by Gannett Production Services; Year: 1988; Format: Videorecording; Minneapolis: The Institute, c1988

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Dealing with the demon. Source: the Australian Film Finance Corporation presents an Aspire Films production; Year: 1996; Format: Videorecording; New York: First Run/Icarus Films, c1996

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Medical aspects of tobacco. Source: an FMS production, in association with Max A. Schneider and Armstrong Moving Pictures; Year: 1990; Format: Videorecording; Carpinteria, CA: FMS Productions, c1990

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New aspects of tobacco and cancer : a multidisciplinary seminar. Source: sponsored by the University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, and the U.T. M.D. Anderson Associates; Year: 1987; Format: Videorecording; [Houston, Tex.]: University of Texas M.D. Anderson Cancer Center, [1987]

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Nicotine and caffeine. Source: produced by the Office of Telecourses, Continuing Education, University of Washington and the School of Social Work, University of Washington, in cooperation with the Alcoholism and Drug Abuse Institute; Year: 1976; Format: Videorecording; [Seattle]: Roger A. Roffman, 1976

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Nicotine war. Source: written, produced, and directed by Jon Palfreman; Year: 1994; Format: Videorecording; [Boston, Mass.]: WGBH Educational Foundation, c1994

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Smoke in the eye. Source: a coproduction of the Canadian Broadcasting Corporation and WGBH/Frontline; Year: 1996; Format: Videorecording; [Boston, Mass.]: WGBH Educational Foundation, c1996

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Smokeless tobacco usage : a historical review and discussion of its health implications. Source: American Academy of Otolaryngology-Head and Neck Surgery; Year: 1989; Format: Slide; [Alexandria, Va.]: The Academy, c1989

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Smoking and human physiology. Source: [presented by] AIMS Media; produced by Angel Films for the Commission of the European Communities, Europe Against Cancer Programme; Cancer Prevention Association, Denmark ... [et al.]; Year: 1993; Format: Videorecording; Chatsworth, Calif.: Distributed by AIMS Multimedia, c1993

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Substance dependence. Source: Medcom, Inc; Year: 1985; Format: Filmstrip; Garden Grove, Calif.: Medcom, c1985

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·

Tobacco and the human body. Source: produced by Encyclopaedia Britannica Films in collaboration with C.A. Milis and Klaus R. Unna; Year: 1954; Format: Motion picture; United States: EB Films, c1954

Vocabulary Builder Detoxification: A process of allowing the body to rid itself of a drug while managing the symptoms of withdrawal; often the first step in a drug treatment program. [NIH] Opium: The air-dried exudate from the unripe seed capsule of the opium poppy, Papaver somniferum, or its variant, P. album. It contains a number of alkaloids, but only a few - morphine, codeine, and papaverine - have clinical significance. Opium has been used as an analgesic, antitussive, antidiarrheal, and antispasmodic. [NIH] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH]

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CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES Overview Doctors and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internet-based guidelines created or written for this professional audience.

NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by physicians. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

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National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/

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National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html

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National Institute on Drug Abuse (NIDA); guidelines available at http://www.nida.nih.gov/DrugAbuse.html

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NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.29 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:30 ·

Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html

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HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html

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NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html

·

Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/

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Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html

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Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html

Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 30 See http://www.nlm.nih.gov/databases/databases.html. 29

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·

Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/

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Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html

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Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

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Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html

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MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html

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Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html

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Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html

While all of the above references may be of interest to physicians who study and treat nicotine dependence, the following are particularly noteworthy.

The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and nicotine dependence using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By making these selections and typing “nicotine dependence” (or synonyms) into the “For these words:” box above, you will only receive results on fact sheets dealing with nicotine dependence. The following is a sample result:

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·

Smokeless Tobacco: A Medical Perspective Source: Atlanta, GA: American Cancer Society. 1997. [2 p.]. Contact: Available from American Cancer Society (ACS). 1599 Clifton Road, NE, Atlanta, GA 30329. (800) ACS-2345; http://www.cancer.org. Also available from your local American Cancer Society chapter. Price: Single copy free; bulk orders available at cost. Summary: This brief brochure reminds health care professionals of the problem of smokeless tobacco use. The author stresses that the medical and dental professions must recognize and educate the public about the serious health risks of smokeless tobacco use. The brochure presents basic facts about smokeless tobacco use and its adverse affects, including carcinogenesis, gingival recession, in utero damage, and long-term nicotine dependence. Full-color photographs illustrate some of the oral health problems, notably oral carcinoma, resulting from smokeless tobacco use. 3 figures.

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Stop the Sale, Prevent the Addiction Source: Atlanta, GA, US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 14 p., (n.d.). Contact: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 4770 Buford Highway, NE., Mail Stop K-50, Atlanta, GA 30341-3724. (404) 488-5705; (800) 232-1311. Summary: Stop the Sale, Prevent the Addiction, an information package that consists of a folder that contains factsheets, addresses the topic of adolescents and tobacco and encourages adults to prevent the sale of tobacco to anyone under age 18 years. The left side of the folder presents statistics on adolescent cigarette and smokeless tobacco use and discusses the dangers of tobacco. The right side of the folder lists 15 things adults can do to prevent the sale of tobacco to individuals under age 18 years. Ideas include requiring vendors to check identification before they sell tobacco products, joining local groups or coalitions to prevent tobacco sales to minors, writing to local elected officials, writing an editorial to the local newspaper about the hazards of youth access to tobacco, asking coaches of youth sports programs to discuss with their teams the topic of tobacco use and its effect on athletic ability, and involving the community's youth in tobacco control efforts. Factsheets inside the folder offer detailed information on (1) the health effects of smoking among young people, which include respiratory and nonrespiratory damage,

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addiction to nicotine, and the associated risk of other drug use; (2) nicotine dependency in adolescence, which is the most common form of drug addiction and causes more death and disease than all other addictions combined; (3) smokeless tobacco as a dangerous alternative to smoking cigarettes, because it can cause irreversible gum recession, along with cancer of the mouth, pharynx, esophagus, and pancreas; (4) trends in tobacco use among adolescents, which include the fact that more than 3,000 young people begin to smoke each day, and that 90 percent of new smokers are children and adolescents; (5) tobacco sales to persons under age 18 years, which occurs even though the sale of cigarettes to minors is now illegal in all states; and (6) tobacco industry advertising and promotion, which target concerts and sporting events. Contact organizations are listed on the back of the folder for further information. ·

Restricting access and appeal of tobacco products to children and adolescents: Information resource and referral guide Source: Atlanta, GA: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. 1995. 58 pp. Contact: Available from Rebecca Lee-Pethel, Program Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 4770 Buford Highway, N.E., Mailstop K50, Atlanta, GA 30341-3724. Telephone: (770) 488-5705 or (800) CDC-1311 / fax: (770) 488-5939 / Web site: http://www.cdc.gov/tobacco. Summary: This information package contains material relating to the Clinton Administration effort to set measures to significantly reduce the number of children and adolescents who become addicted to nicotine in cigarettes and smokeless tobacco. The three sections of the package contain: information on the proposed rule of the Food and Drug Administration; supporting data on tobacco use; and the transcript of the Presidential Press Conference (8/10/95). A separate conference participant packet contains many of the same items.

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Growing up tobacco free: Preventing nicotine addiction in children and youths Source: Washington, DC: National Academy Press. 1994. 306 pp., overview (25 pp.). Contact: Available from National Academy Press, 2101 Constitution Avenue, N.W., Lockbox 285, Washington, DC 20002 / Web site: http://www.nap.edu. $24.95 plus $4.00 shipping and handling;

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prepayment required by check, money order, or credit card; purchase orders accepted. Summary: This book examines the use of tobacco products by children and youths; it considers the effects of nicotine and the process of addiction. It considers social norms and the acceptability of tobacco use and the extent of tobacco advertising and promotion. It analyzes youths' access to tobacco products such as cigarettes, chewing and spitting tobacco, and snuff; and considers current trends in regulating, labeling, and packaging. The book also covers recent efforts to limit children's access and discusses controls or bans on tobacco sales. The book suggests ways to coordinate research and policy development and includes detailed recommendations to prevent the availability of tobacco to children. The overview consists of the first chapter of the report, and discusses a youth-centered prevention policy.

The NLM Gateway31 The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM's information resources or databases.32 One target audience for the Gateway is the Internet user who is new to NLM's online resources and does not know what information is available or how best to search for it. This audience may include physicians and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.33 To use the NLM Gateway, simply go to the search site at http://gateway.nlm.nih.gov/gw/Cmd. Type “nicotine dependence” (or synonyms) into the search box and click “Search.” The results will be

Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 33 Other users may find the Gateway useful for an overall search of NLM's information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 31 32

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presented in a tabular form, indicating the number of references in each database category. Results Summary Category Items Found Journal Articles 1073 Books / Periodicals / Audio Visual 13 Consumer Health 10 Meeting Abstracts 3 Other Collections 11 Total 1110

HSTAT34 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.35 HSTAT's audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ's Put Prevention Into Practice.36 Simply search by “nicotine dependence” (or synonyms) at the following Web site: http://text.nlm.nih.gov.

Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. The HSTAT URL is http://hstat.nlm.nih.gov/. 36 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force's Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 34 35

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Coffee Break: Tutorials for Biologists37 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist physicians in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.38 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.39 This site has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·

CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.

·

Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center's MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.

·

Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.

·

MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical

37 Adapted

from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 39 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process.

38

Physician Guidelines and Databases 135

literature, and to explore relevant Web http://www.med.virginia.edu/~wmd4n/medweaver.html. ·

sites;

see

Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see http://www.lexical.com/Metaphrase.html.

The Genome Project and Nicotine Dependence With all the discussion in the press about the Human Genome Project, it is only natural that physicians, researchers, and patients want to know about how human genes relate to nicotine dependence. In the following section, we will discuss databases and references used by physicians and scientists who work in this area.

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).40 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI's Entrez database of MEDLINE articles and sequence information. Go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html to search the database. Type “nicotine dependence” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for nicotine dependence: Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

40

136 Nicotine Dependence

·

Tobacco Addiction Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?188890

Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·

Metabolism: Food and energy. Examples: Adreno-leukodystrophy, Atherosclerosis, Best disease, Gaucher disease, Glucose galactose malabsorption, Gyrate atrophy, Juvenile onset diabetes, Obesity, Paroxysmal nocturnal hemoglobinuria, Phenylketonuria, Refsum disease, Tangier disease, Tay-Sachs disease. Web site: http://www.ncbi.nlm.nih.gov/disease/Metabolism.html

·

Nervous System: Mind and body. Examples: Alzheimer disease, Amyotrophic lateral sclerosis, Angelman syndrome, Charcot-Marie-Tooth disease, epilepsy, essential tremor, Fragile X syndrome, Friedreich's ataxia, Huntington disease, NiemannPick disease, Parkinson disease, Prader-Willi syndrome, Rett syndrome, Spinocerebellar atrophy, Williams syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Brain.html

·

Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html

·

Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic kidney disease, sickle cell anemia, Wilson's disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html

Physician Guidelines and Databases 137

Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·

PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

·

Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide

·

Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein

·

Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure

·

Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome

·

PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset

·

OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM

·

Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy

·

Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books

·

ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

NCBI's Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/

To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez/, and then select the database that you would like to search. The databases available are listed in

138 Nicotine Dependence

the drop box next to “Search.” In the box next to “for,” enter “nicotine dependence” (or synonyms) and click “Go.”

Jablonski's Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database41 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html you can also search across syndromes using an alphabetical index. You can also search at http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database42 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB's mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “nicotine dependence” (or synonyms) into the search box, and review the Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 42 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 41

Physician Guidelines and Databases 139

results. If more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to nonprofessionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in nicotine dependence (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): · American Psychiatric Press Textbook of Substance Abuse Treatment by Marc Galanter (Editor), Herbert D. Kleber (Editor); Hardcover - 595 pages, 2nd edition (May 15, 1999), American Psychiatric Press; ISBN: 0880488204; http://www.amazon.com/exec/obidos/ASIN/0880488204/icongroupinterna · Combining Medication and Psychosocial Treatments for Addictions: The BRENDA Approach by Joseph Volpicelli (Editor), et al; Hardcover 208 pages, 1st edition (February 15, 2001), Guilford Press; ISBN: 1572306181; http://www.amazon.com/exec/obidos/ASIN/1572306181/icongroupinterna · Drink, Drugs and Dependence: From Science to Clinical Practice by Woody Caan (Editor); Paperback - 272 pages (June 1, 2002), Routledge; ISBN: 0415279011; http://www.amazon.com/exec/obidos/ASIN/0415279011/icongroupinterna · Neurobiology of Addictions: Implications for Clinical Practice by Richard T. Spence (Editor), et al; Hardcover (February 2002); ISBN: 0789016664; http://www.amazon.com/exec/obidos/ASIN/0789016664/icongroupinterna · Solutions for the 'Treatment-Resistant' Addicted Client : Therapeutic Techniques for Engaging Challenging Clients by Nicholas A. Roes; Textbook Binding (January 2002), Haworth Press; ISBN: 0789011204; http://www.amazon.com/exec/obidos/ASIN/0789011204/icongroupinterna · Substance Abuse: A Guide for Health Professionals by American Academy of Pediatrics, et al; Paperback - 379 pages, 2nd edition (November 15, 2001), American Nurses Association; ISBN: 1581100728; http://www.amazon.com/exec/obidos/ASIN/1581100728/icongroupinterna

140 Nicotine Dependence

Vocabulary Builder Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU]

Dissertations 141

CHAPTER 9. DISSERTATIONS ON NICOTINE DEPENDENCE Overview University researchers are active in studying almost all known diseases. The result of research is often published in the form of Doctoral or Master's dissertations. You should understand, therefore, that applied diagnostic procedures and/or therapies can take many years to develop after the thesis that proposed the new technique or approach was written. In this chapter, we will give you a bibliography on recent dissertations relating to nicotine dependence. You can read about these in more detail using the Internet or your local medical library. We will also provide you with information on how to use the Internet to stay current on dissertations.

Dissertations on Nicotine Dependence ProQuest Digital Dissertations is the largest archive of academic dissertations available. From this archive, we have compiled the following list covering dissertations devoted to nicotine dependence. You will see that the information provided includes the dissertation’s title, its author, and the author’s institution. To read more about the following, simply use the Internet address indicated. The following covers recent dissertations dealing with nicotine dependence: ·

Biobehavioral Aspects of Adolescent Nicotine Dependence by Wood, Teresa Lynne; Phd from The Ohio State University, 2001, 101 pages http://wwwlib.umi.com/dissertations/fullcit/3031289

142 Nicotine Dependence

·

Biopsychosocial Treatment of Nicotine Dependency: Partner Participation Versus No Partner Group Treatment by Martinez, Rey Caytano, Phd from The Florida State University, 1994, 133 pages http://wwwlib.umi.com/dissertations/fullcit/9529606

·

Effect of Counselor and Client Education in Nicotine Addiction on Substance Abusers' Readiness to Begin Smoking Cessation Treatment by Perine, Jessica Lee, Phd from Hofstra University, 1997, 123 pages http://wwwlib.umi.com/dissertations/fullcit/9804829

·

Evaluation of the Ending Nicotine Dependence Program by Librett, John James; Phd from The University of Utah, 2001, 166 pages http://wwwlib.umi.com/dissertations/fullcit/3027432

·

Stress and Smoking: Effects of Daily Events, Nicotine Dependence, and Gender on Smoking Behavior by Todd, Michael Wayne; Phd from Arizona State University, 2001, 134 pages http://wwwlib.umi.com/dissertations/fullcit/3001297

·

The Combined Effect of Passive Immunization and Mecamylamine on Induction of Nicotine Dependence by Cole, Michael Jonathan; Ma from University of Houston-clear Lake, 2001, 58 pages http://wwwlib.umi.com/dissertations/fullcit/1407146

Keeping Current As previously mentioned, an effective way to stay current on dissertations dedicated to nicotine dependence is to use the database called ProQuest Digital Dissertations via the Internet, located at the following Web address: http://wwwlib.umi.com/dissertations. The site allows you to freely access the last two years of citations and abstracts. Ask your medical librarian if the library has full and unlimited access to this database. From the library, you should be able to do more complete searches than with the limited 2-year access available to the general public.

Vocabulary Builder Immunization: The induction of immunity. [EU] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU]

143

PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with nicotine dependence and related conditions.

Researching Your Medications 145

APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with nicotine dependence. While a number of hard copy or CD-Rom resources are available to patients and physicians for research purposes, a more flexible method is to use Internetbased databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for nicotine dependence. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of nicotine dependence. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.

Your Medications: The Basics43 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of nicotine dependence. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with nicotine dependence take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid

43

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.

146 Nicotine Dependence

problems later. Here are some points to cover each time a new medicine is prescribed: ·

Ask about all parts of your treatment, including diet changes, exercise, and medicines.

·

Ask about the risks and benefits of each medicine or other treatment you might receive.

·

Ask how often you or your doctor will check for side effects from a given medication.

Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your doctor believes will work the best. Telling your doctor will help him or her select the best treatment for you. Do not be afraid to “bother” your doctor with your concerns and questions about medications for nicotine dependence. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your doctor. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your doctor the following: ·

The name of the medicine and what it is supposed to do.

·

How and when to take the medicine, how much to take, and for how long.

·

What food, drinks, other medicines, or activities you should avoid while taking the medicine.

·

What side effects the medicine may have, and what to do if they occur.

·

If you can get a refill, and how often.

·

About any terms or directions you do not understand.

·

What to do if you miss a dose.

·

If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).

Do not forget to tell your doctor about all the medicines you are currently taking (not just those for nicotine dependence). This includes prescription

Researching Your Medications 147

medicines and the medicines that you buy over the counter. Then your doctor can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your doctor, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·

Name of medicine

·

Reason taken

·

Dosage

·

Time(s) of day

Also include any over-the-counter medicines, such as: ·

Laxatives

·

Diet pills

·

Vitamins

·

Cold medicine

·

Aspirin or other pain, headache, or fever medicine

·

Cough medicine

·

Allergy relief medicine

·

Antacids

·

Sleeping pills

·

Others (include names)

Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your doctor has recommended for nicotine dependence. One such source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting

148 Nicotine Dependence

USP DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration's (FDA) Drug Approvals database.44 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided. Of course, we as editors cannot be certain as to what medications you are taking. Therefore, we have compiled a list of medications associated with the treatment of nicotine dependence. Once again, due to space limitations, we only list a sample of medications and provide hyperlinks to ample documentation (e.g. typical dosage, side effects, drug-interaction risks, etc.). The following drugs have been mentioned in the Pharmacopeia and other sources as being potentially applicable to nicotine dependence: Clonidine ·

Systemic - U.S. Brands: Catapres; Catapres-TTS http://www.nlm.nih.gov/medlineplus/druginfo/clonidinesystem ic202152.html

Nicotine ·

Systemic - U.S. Brands: Habitrol; Nicorette; Nicotrol; Prostep http://www.nlm.nih.gov/medlineplus/druginfo/nicotinesystemi c202407.html

Nitrates Sublingual, Chewable, or Buccal ·

Systemic - U.S. Brands: Isordil; Nitrogard; Nitrostat; Sorbitrate http://www.nlm.nih.gov/medlineplus/druginfo/nitratessublingu alchewableorbu202412.html

Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.

44

Researching Your Medications 149

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to physicians and their institutions. You may be able to access these sources from your local medical library or your doctor's office.

Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters' database as associated with nicotine dependence (including those with contraindications):45 ·

Nicotine http://www.reutershealth.com/atoz/html/Nicotine.htm

Mosby's GenRx Mosby's GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html.

Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.

Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want 45

Adapted from A to Z Drug Facts by Facts and Comparisons.

150 Nicotine Dependence

to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with nicotine dependence--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat nicotine dependence or potentially create deleterious side effects in patients with nicotine dependence. You should ask your physician about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense. Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it's especially important to read the label every time you use a medication. When your doctor prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.

Researching Your Medications 151

A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with nicotine dependence. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with nicotine dependence. The FDA warns patients to watch out for46: ·

Secret formulas (real scientists share what they know)

·

Amazing breakthroughs or miracle cures (real breakthroughs don't happen very often; when they do, real scientists do not call them amazing or miracles)

·

Quick, painless, or guaranteed cures

·

If it sounds too good to be true, it probably isn't true.

If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Complete Guide to Prescription and Nonprescription Drugs 2001 (Complete Guide to Prescription and Nonprescription Drugs, 2001) by H. Winter Griffith, Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/039952634X/icongroupinterna

·

The Essential Guide to Prescription Drugs, 2001 by James J. Rybacki, James W. Long; Paperback - 1274 pages (2001), Harper Resource; ISBN: 0060958162; http://www.amazon.com/exec/obidos/ASIN/0060958162/icongroupinterna

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This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.

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·

Handbook of Commonly Prescribed Drugs by G. John Digregorio, Edward J. Barbieri; Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/0942447417/icongroupinterna

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Johns Hopkins Complete Home Encyclopedia of Drugs 2nd ed. by Simeon Margolis (Ed.), Johns Hopkins; Hardcover - 835 pages (2000), Rebus; ISBN: 0929661583; http://www.amazon.com/exec/obidos/ASIN/0929661583/icongroupinterna

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Medical Pocket Reference: Drugs 2002 by Springhouse Paperback 1st edition (2001), Lippincott Williams & Wilkins Publishers; ISBN: 1582550964; http://www.amazon.com/exec/obidos/ASIN/1582550964/icongroupinterna

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PDR by Medical Economics Staff, Medical Economics Staff Hardcover 3506 pages 55th edition (2000), Medical Economics Company; ISBN: 1563633752; http://www.amazon.com/exec/obidos/ASIN/1563633752/icongroupinterna

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Pharmacy Simplified: A Glossary of Terms by James Grogan; Paperback 432 pages, 1st edition (2001), Delmar Publishers; ISBN: 0766828581; http://www.amazon.com/exec/obidos/ASIN/0766828581/icongroupinterna

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Physician Federal Desk Reference by Christine B. Fraizer; Paperback 2nd edition (2001), Medicode Inc; ISBN: 1563373971; http://www.amazon.com/exec/obidos/ASIN/1563373971/icongroupinterna

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Physician's Desk Reference Supplements Paperback - 300 pages, 53 edition (1999), ISBN: 1563632950; http://www.amazon.com/exec/obidos/ASIN/1563632950/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Sublingual: Located beneath the tongue. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU]

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APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or doctor have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to nicotine dependence. Finally, at the conclusion of this chapter, we will provide a list of readings on nicotine dependence from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine's (NCCAM) overview of complementary and alternative medicine.

What Is CAM?47 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also known as “preventive,” which means that the practitioner educates and 47

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.

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treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?48 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each. Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are

48

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.

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practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India's traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.

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Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body's systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.

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Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient's recovery and that healing is promoted when the body's energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your doctor who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.49

49

Adapted from http://www.4woman.gov/faq/alternative.htm.

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Is It Okay to Want Both Traditional and Alternative Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a physician or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM References on Nicotine Dependence Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for nicotine dependence. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required. National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine's databases to allow patients to search for articles that specifically relate to nicotine dependence and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “nicotine dependence” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to nicotine dependence: ·

A baseline study of tobacco use among the staff of Aligarh Muslim University, Aligarh, India. Author(s): Yunus M, Khan Z.

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Source: J R Soc Health. 1997 December; 117(6): 359-65. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9519673&dopt=Abstract ·

A cluster-analytic classification of smoking relapse episodes. Author(s): Shiffman S. Source: Addictive Behaviors. 1986; 11(3): 295-307. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3739816&dopt=Abstract

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A comparative clinico-pathological study of oral submucous fibrosis in habitual chewers of pan masala and betelquid. Author(s): Babu S, Bhat RV, Kumar PU, Sesikaran B, Rao KV, Aruna P, Reddy PR. Source: Journal of Toxicology. Clinical Toxicology. 1996; 34(3): 317-22. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8667470&dopt=Abstract

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A meta-analysis of acupuncture techniques for smoking cessation. Author(s): White AR, Resch KL, Ernst E. Source: Tobacco Control. 1999 Winter; 8(4): 393-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10629245&dopt=Abstract

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A meta-analysis of studies into the effect of acupuncture on addiction. Author(s): Ter Riet G, Kleijnen J, Knipschild P. Source: Br J Gen Pract. 1990 September; 40(338): 379-82. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2148263&dopt=Abstract

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Acupuncture and addiction treatment. Author(s): Moner SE. Source: J Addict Dis. 1996; 15(3): 79-100. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8842852&dopt=Abstract

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Acupuncture therapy for the treatment of tobacco smoking addiction. Author(s): Steiner RP, Hay DL, Davis AW. Source: Am J Chin Med. 1982; 10(1-4): 107-21. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7183202&dopt=Abstract

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·

Addiction and withdrawal--current views. Author(s): Melichar JK, Daglish MR, Nutt DJ. Source: Current Opinion in Pharmacology. 2001 February; 1(1): 84-90. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11712541&dopt=Abstract

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Alcohol, tobacco and paan use and understanding of oral cancer risk among Asian males in Leicester. Author(s): Vora AR, Yeoman CM, Hayter JP. Source: Br Dent J. 2000 April 22; 188(8): 444-51. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10953402&dopt=Abstract

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Association of upper gastrointestinal lesions with addictions. Author(s): Ahmed W, Qureshi H, Alam SE, Zuberi SJ. Source: J Pak Med Assoc. 1993 September; 43(9): 176-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8283596&dopt=Abstract

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Differential prevalence of cigarette smoking in patients with schizophrenic vs mood disorders. Author(s): Diwan A, Castine M, Pomerleau CS, Meador-Woodruff JH, Dalack GW. Source: Schizophrenia Research. 1998 September 7; 33(1-2): 113-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9783351&dopt=Abstract

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EEG alpha reactivity and self-regulation correlates of smoking and smoking deprivation. Author(s): Szalai JP, Allon R, Doyle J, Zamel N. Source: Psychosomatic Medicine. 1986 January-February; 48(1-2): 67-72. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3945718&dopt=Abstract

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Effect of treatment for nicotine dependence on alcohol and drug treatment outcomes. Author(s): Joseph AM, Nichol KL, Anderson H. Source: Addictive Behaviors. 1993 November-December; 18(6): 635-44. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8178702&dopt=Abstract

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Effectiveness of personalized written feedback through a mail intervention for smoking cessation: a randomized-controlled trial in Spanish smokers. Author(s): Becona E, Vazquez FL. Source: J Consult Clin Psychol. 2001 February; 69(1): 33-40. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11302275&dopt=Abstract

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Effectiveness of smoking cessation interventions integrated into primary care practice. Author(s): Thompson RS, Michnich ME, Friedlander L, Gilson B, Grothaus LC, Storer B. Source: Medical Care. 1988 January; 26(1): 62-76. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3336245&dopt=Abstract

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Effects of acupuncture on smoking cessation or reduction for motivated smokers. Author(s): He D, Berg JE, Hostmark AT. Source: Preventive Medicine. 1997 March-April; 26(2): 208-14. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9085389&dopt=Abstract

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Evaluating two self-help interventions for smokeless tobacco cessation. Author(s): Severson HH, Akers L, Andrews JA, Lichtenstein E, Jerome A. Source: Addictive Behaviors. 2000 May-June; 25(3): 465-70. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10890303&dopt=Abstract

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Facilitating smoking cessation. Author(s): McKool K. Source: The Journal of Cardiovascular Nursing. 1987 August; 1(4): 28-40. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3298557&dopt=Abstract

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Factors determining the success of nicotine withdrawal: 12-year followup of 532 smokers after suggestion therapy (by a faith healer). Author(s): Gmur M, Tschopp A.

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Source: Int J Addict. 1987 December; 22(12): 1189-200. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3436689&dopt=Abstract ·

Factors in smoking cessation among participants in a televised intervention. Author(s): Warnecke RB, Langenberg P, Gruder CL, Flay BR, Jason LA. Source: Preventive Medicine. 1989 November; 18(6): 833-46. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2626416&dopt=Abstract

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Flotation rest as a smoking intervention. Author(s): Forgays DG. Source: Addictive Behaviors. 1987; 12(1): 85-90. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3565119&dopt=Abstract

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Health beliefs as predictors of success of alternate modalities of smoking cessation: results of a controlled trial. Author(s): Kaufert JM, Rabkin SW, Syrotuik J, Boyko E, Shane F. Source: Journal of Behavioral Medicine. 1986 October; 9(5): 475-89. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3795265&dopt=Abstract

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Nicotine dependence and secondary effects of smoking cessation. Author(s): Clavel F, Benhamou S, Flamant R. Source: Journal of Behavioral Medicine. 1987 December; 10(6): 555-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3437446&dopt=Abstract

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Nicotine withdrawal: a behavioral assessment using schedule controlled responding, locomotor activity, and sensorimotor reactivity. Author(s): Helton DR, Modlin DL, Tizzano JP, Rasmussen K. Source: Psychopharmacology. 1993; 113(2): 205-10. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7855182&dopt=Abstract

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Pharmacotherapy of nicotine dependence. Author(s): Haustein KO.

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Source: Int J Clin Pharmacol Ther. 2000 June; 38(6): 273-90. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10890576&dopt=Abstract ·

Smoking withdrawal, nicotine dependence and prepulse inhibition of the acoustic startle reflex. Author(s): Kumari V, Gray JA. Source: Psychopharmacology. 1999 January; 141(1): 11-5. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9952059&dopt=Abstract

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Tobacco addiction as a psychiatric disease. Author(s): Cohen SB. Source: Southern Medical Journal. 1988 September; 81(9): 1083-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3420439&dopt=Abstract

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Treatment of nicotine dependence. Author(s): Haxby DG. Source: American Journal of Health-System Pharmacy : Ajhp : Official Journal of the American Society of Health-System Pharmacists. 1995 February 1; 52(3): 265-81; Quiz 314-5. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7749954&dopt=Abstract

Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·

Alternative Medicine Foundation, Inc.: http://www.herbmed.org/

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AOL: http://search.aol.com/cat.adp?id=169&layer=&from=subcats

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Chinese Medicine: http://www.newcenturynutrition.com/

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drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html

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Family Village: http://www.familyvillage.wisc.edu/med_altn.htm

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Google: http://directory.google.com/Top/Health/Alternative/

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Healthnotes: http://www.thedacare.org/healthnotes/

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Open Directory Project: http://dmoz.org/Health/Alternative/

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·

TPN.com: http://www.tnp.com/

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Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/

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WebMDÒHealth: http://my.webmd.com/drugs_and_herbs

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WellNet: http://www.wellnet.ca/herbsa-c.htm

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WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

The following is a specific Web list relating to nicotine dependence; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: ·

Herbs and Supplements Aesculus Alternative names: Horse Chestnut; Aesculus hippocastanum L. Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Aloe Alternative names: Aloe vera L. Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Equisetum Alternative names: Horsetail; Equisetum arvense L. Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ GINKGO Source: The Canadian Internet Directory for Holistic Help, WellNet, Health and Wellness Network; www.wellnet.ca Hyperlink: http://www.wellnet.ca/herbsg-i.htm Horsetail Source: Prima Communications, Inc. Hyperlink: http://www.personalhealthzone.com/pg000183.html Horsetail Source: WholeHealthMD.com, LLC.; www.wholehealthmd.com

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Hyperlink: http://www.wholehealthmd.com/refshelf/substances_view/0,1525,101 05,00.html Indian Tobacco Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsHerbs/Lobeliach.ht ml Lobelia Alternative names: Lobelia inflata L. Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Lobelia Alternative names: Lobelia inflata Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Herb/Lobelia.htm Lobelia Alternative names: Lobelia inflata, Indian Tobacco Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsHerbs/Lobeliach.html Lobelia inflata Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsHerbs/Lobeliach.html Panax Alternative names: Ginseng; Panax ginseng Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Piper nigrum Alternative names: Black Pepper Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Plantago major Alternative names: Plantain; Plantago major/lanceolata

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Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Taraxacum Alternative names: Dandelion; Taraxacum officinale (Dhudhal) Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Tyrosine Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsSupplements/Tyros inecs.html Uncaria asian Alternative names: Asian species; Uncaria sp. Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ ·

Related Conditions Alzheimer's Disease Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Alzhei mersDiseasecc.html Angina Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Angina.htm Atherosclerosis Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Atherosclerosis.htm Atherosclerosis and Heart Disease Prevention Source: Prima Communications, Inc. Hyperlink: http://www.personalhealthzone.com/pg000263.html Attention Deficit Hyperactivity Disorder Source: Integrative Medicine Communications; www.onemedicine.com

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Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Attenti onDeficitHyperactivityDisordercc.html Blood Pressure, High Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Hypert ensioncc.html Bronchitis Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Bronchitis.htm Cancer, Lung Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Cancer Lungcc.html Female Infertility Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Infertility_Female.htm Heart Attack Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Heart_Attack.htm High Blood Pressure Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Hypert ensioncc.html High Cholesterol Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/High_Cholesterol.htm High Homocysteine

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Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/High_Homocysteine. htm High Triglycerides Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/High_Triglycerides.htm Hypertension Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Hypert ensioncc.html Insomnia Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Insomnia.htm Insomnia Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insomn iacc.html Insulin Resistance Syndrome Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Insulin_Resistance_Sy ndrome.htm Intermittent Claudication Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Intermittent_Claudica tion.htm Leukemia Source: Integrative Medicine Communications; www.onemedicine.com

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Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Leuke miacc.html Lung Cancer Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Cancer Lungcc.html Meniere's Disease Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Menieres_Disease.htm Macular Degeneration Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Macular_Degeneratio n.htm Multiple Sclerosis Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Multiple_Sclerosis.htm Pancreatic Insufficiency Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Pancreatic_Insufficien cy.htm Peripheral Vascular Disease Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Peripheral_Vascular_ Disease.htm Pregnancy and Postpartum Support Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Pregnancy.htm

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Raynaud's Disease Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Raynauds_Disease.htm Raynaud's Phenomenon Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Raynau dsPhenomenoncc.html Sleeplessness Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insomn iacc.html Ulcerative Colitis Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Ulcerative_Colitis.htm

General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Clear Body, Clear Mind : The Effective Purification Program by L. Ron Hubbard; Paperback - 312 pages (June 2002), Bridge Publications; ISBN: 1573182249; http://www.amazon.com/exec/obidos/ASIN/1573182249/icongroupinterna · End Your Addiction Now: The Proven Nutritional Supplement Program That Can Set You Free by Charles Gant, Greg Lewis; Hardcover - 320

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pages (January 2002), Warner Books; ISBN: 0446527238; http://www.amazon.com/exec/obidos/ASIN/0446527238/icongroupinterna · Reaching New Highs: Alternative Therapies for Drug Addicts by H. K. Heggenhougen; Hardcover (June 1997), Jason Aronson; ISBN: 0765700360; http://www.amazon.com/exec/obidos/ASIN/0765700360/icongroupinterna · The Tao of Sobriety : Helping You to Recover from Alcohol and Drug Addiction by David Gregson, et al; Paperback - 176 pages, 1st edition (January 2002), St. Martin's Press; ISBN: 0312242506; http://www.amazon.com/exec/obidos/ASIN/0312242506/icongroupinterna For additional information on complementary and alternative medicine, ask your doctor or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Psychosomatic: Pertaining to the mind-body relationship; having bodily symptoms of psychic, emotional, or mental origin; called also psychophysiologic. [EU]

Researching Nutrition 173

APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, doctors have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, doctors and healthcare providers may recommend particular dietary supplements to patients with nicotine dependence. Any dietary recommendation is based on a patient's age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with nicotine dependence may be given different recommendations. Some recommendations may be directly related to nicotine dependence, while others may be more related to the patient's general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of nicotine dependence. We will then show you how to find studies dedicated specifically to nutrition and nicotine dependence.

Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and (6) minerals. Consuming a combination of these elements is considered to be a healthy diet:

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·

Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.

·

Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.

·

Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.

·

Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.

Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·

Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.

·

Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.

·

Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs.

·

Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains

·

Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.

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·

Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.

·

Vitamin C allows the body's immune system to fight various diseases, strengthens body tissue, and improves the body's use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.

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Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.

·

Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.

·

Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.

·

Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.

It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·

Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.

·

Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.

·

Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.

·

Iodine helps regulate the body's use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.

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·

Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.

·

Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.

·

Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.

·

Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.

·

Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.

The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your doctor may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:50 ·

DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.

·

DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.

·

RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.”

50

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.

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·

RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge.

What Are Dietary Supplements?51 Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”52 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.53 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 52 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 53 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 51

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symposia on scientific topics related to dietary supplements. The ODS often works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Nicotine Dependence The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.54 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.

54

Researching Nutrition 179

Search” option that allows you to retrieve up to 100 fully explained references in a comprehensive format. Type “nicotine dependence” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following is a typical result when searching for recently indexed consumer information on nicotine dependence: ·

The adverse effects of tobacco smoking on reproduction and health: a review from the literature. Source: Tuormaa, T E Nutr-Health. 1995; 10(2): 105-20 0260-1060

The following information is typical of that found when using the “Full IBIDS Database” when searching using “nicotine dependence” (or a synonym): ·

Nicotine dependence in schizophrenia: clinical phenomena and laboratory findings. Author(s): Ann Arbor VA Medical Center, MI 48105, USA. [email protected] Source: Dalack, G W Healy, D J Meador Woodruff, J H Am-J-Psychiatry. 1998 November; 155(11): 1490-501 0002-953X

·

Tobacco dependence and smoke-free psychiatric units. Source: Menninger, J A West-J-Med. 1991 November; 155(5): 519 00930415

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Weight change after smoking cessation using variable doses of transdermal nicotine replacement. Author(s): Nicotine Dependence Center, Mayo Clinic, Mayo Foundation, Rochester, Minn 55905, USA. Source: Dale, L C Schroeder, D R Wolter, T D Croghan, I T Hurt, R D Offord, K P J-Gen-Intern-Med. 1998 January; 13(1): 9-15 0884-8734

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·

healthfinder®, HHS's gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&page=0

·

The United States Department of Agriculture's Web site dedicated to nutrition information: www.nutrition.gov

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·

The Food and Drug Administration's Web site for federal food safety information: www.foodsafety.gov

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The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/

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The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/

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Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/

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Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/

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Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=174&layer=&from=subcats

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Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html

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Google: http://directory.google.com/Top/Health/Nutrition/

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Healthnotes: http://www.thedacare.org/healthnotes/

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Open Directory Project: http://dmoz.org/Health/Nutrition/

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Yahoo.com: http://dir.yahoo.com/Health/Nutrition/

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WebMDÒHealth: http://my.webmd.com/nutrition

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WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

The following is a specific Web list relating to nicotine dependence; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation:

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·

Vitamins Niacin Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsSupplements/Vita minB3Niacincs.html Niacin Alternative names: Vitamin B3 (Niacin) Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/InteractiveMedicine/ConsSupplements/Inter actions/VitaminB3Niacincs.html Vitamin B3 (Niacin) Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsSupplements/Vita minB3Niacincs.html Vitamin B3 (Niacin) Alternative names: Niacin Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/InteractiveMedicine/ConsSupplements/Inter actions/VitaminB3Niacincs.html

·

Minerals Nicotine Alternatives Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Drug/Nicotine_Alternatives.ht m

·

Food and Diet Hypertension Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Hypertension.htm

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Oats Alternative names: Avena sativa Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Herb/Oats.htm

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU]

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Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH]

Finding Medical Libraries 185

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM's interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.55

55

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.

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Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):56 ·

Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/

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Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM

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Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm

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California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html

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California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html

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California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html

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California: Gateway Health Library (Sutter Gould Medical Foundation)

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California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/

56

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.

Finding Medical Libraries 187

·

California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp

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California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html

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California: San José PlaneTree Health Library, http://planetreesanjose.org/

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California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html

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California: University of California, Davis. Health Sciences Libraries

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California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html

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California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/

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Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm

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Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/

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Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/

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Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml

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Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm

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Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html

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Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm

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Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp

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Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/

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·

Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm

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Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html

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Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/

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Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm

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Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/

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Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/

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Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/

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Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm

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Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html

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Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm

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Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/

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Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library

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Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10

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Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html

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Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html

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Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml

Finding Medical Libraries 189

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Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp

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Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/

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Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html

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Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm

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Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp

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Massachusetts: St. Luke's Hospital Health Sciences Library (St. Luke's Hospital), http://www.southcoast.org/library/

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Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html

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Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/

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Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm

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Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/

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Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html

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Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm

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Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html

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Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41

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·

National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html

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National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/

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National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/

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Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm

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New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld/

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New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm

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New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm

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New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/

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New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html

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New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/

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New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html

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New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/

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Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm

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Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp

Finding Medical Libraries 191

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Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/

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Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/

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Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml

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Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html

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Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html

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Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml

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Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp

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Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm

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Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/

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South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm

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Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/

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Texas: Matustik Family Resource Center (Cook Children's Health Care System), http://www.cookchildrens.com/Matustik_Library.html

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Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/

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Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

Principles of Drug Addiction Treatment 193

APPENDIX E. TREATMENT

PRINCIPLES

OF

DRUG

ADDICTION

Overview57 No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. This appendix reproduces information created by the National Institute for Drug Abuse (NIDA) concerning drug abuse treatment entitled “Principles of Drug Addiction Treatment: A Research-Based Guide”.

Principles of Effective Treatment Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible. Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual's drug use and any associated medical, psychological, social, vocational, and legal problems.

Adapted from the National Institute on Drug Abuse: http://165.112.78.61/PODAT/PODATIndex.html.

57

194 Nicotine Dependence

An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that the treatment approach be appropriate to the individual's age, gender, ethnicity, and culture. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs. Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment. Counseling and Other Behavioral Therapies Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drugusing activities with constructive and rewarding non-drug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual's ability to function in the family and community.

Medications Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethadol (LAAM) are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For patients with mental

Principles of Drug Addiction Treatment 195

disorders, both behavioral treatments and medications can be critically important.

Patients with Mental Disorders Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the cooccurrence of the other type of disorder.

Medical Detoxification Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.

Patient Cooperation Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions. Possible drug use during treatment must be monitored continuously. Lapses to drug use can occur during treatment. The objective monitoring of a patient's drug and alcohol use during treatment, such as through urinalysis or other tests, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that the individual's treatment plan can be adjusted. Feedback to patients who test positive for illicit drug use is an important element of monitoring. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior.

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Counseling also can help people who are already infected manage their illness.

Recovery Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence.

What Is Drug Addiction? Drug addiction is a complex illness. It is characterized by compulsive, at times uncontrollable, drug craving, seeking, and use that persist even in the face of extremely negative consequences. For many people, drug addiction becomes chronic, with relapses possible even after long periods of abstinence. The path to drug addiction begins with the act of taking drugs. Over time, a person's ability to choose not to take drugs can be compromised. Drug seeking becomes compulsive, in large part as a result of the effects of prolonged drug use on brain functioning and, thus, on behavior. The compulsion to use drugs can take over the individual's life. Addiction often involves not only compulsive drug taking but also a wide range of dysfunctional behaviors that can interfere with normal functioning in the family, the workplace, and the broader community. Addiction also can place people at increased risk for a wide variety of other illnesses. These illnesses can be brought on by behaviors, such as poor living and health habits, that often accompany life as an addict, or because of toxic effects of the drugs themselves. Because addiction has so many dimensions and disrupts so many aspects of an individual's life, treatment for this illness is never simple. Drug treatment must help the individual stop using drugs and maintain a drug-free lifestyle, while achieving productive functioning in the family, at work, and in society. Effective drug abuse and addiction treatment programs typically

Principles of Drug Addiction Treatment 197

incorporate many components, each directed to a particular aspect of the illness and its consequences. Three decades of scientific research and clinical practice have yielded a variety of effective approaches to drug addiction treatment. Extensive data document that drug addiction treatment is as effective as are treatments for most other similarly chronic medical conditions. In spite of scientific evidence that establishes the effectiveness of drug abuse treatment, many people believe that treatment is ineffective. In part, this is because of unrealistic expectations. Many people equate addiction with simply using drugs and therefore expect that addiction should be cured quickly, and if it is not, treatment is a failure. In reality, because addiction is a chronic disorder, the ultimate goal of long-term abstinence often requires sustained and repeated treatment episodes. Of course, not all drug abuse treatment is equally effective. Research also has revealed a set of overarching principles that characterize the most effective drug abuse and addiction treatments and their implementation. Treatment varies depending on the type of drug and the characteristics of the patient. The best programs provide a combination of therapies and other services.

Frequently Asked Questions What Is Drug Addiction Treatment? ·

There are many addictive drugs, and treatments for specific drugs can differ. Treatment also varies depending on the characteristics of the patient.

·

Problems associated with an individual's drug addiction can vary significantly. People who are addicted to drugs come from all walks of life. Many suffer from mental health, occupational, health, or social problems that make their addictive disorders much more difficult to treat. Even if there are few associated problems, the severity of addiction itself ranges widely among people.

·

A variety of scientifically based approaches to drug addiction treatment exist. Drug addiction treatment can include behavioral therapy (such as counseling, cognitive therapy, or psychotherapy), medications, or their combination. Behavioral therapies offer people strategies for coping with their drug cravings, teach them ways to avoid drugs and prevent relapse,

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and help them deal with relapse if it occurs. When a person's drugrelated behavior places him or her at higher risk for AIDS or other infectious diseases, behavioral therapies can help to reduce the risk of disease transmission. Case management and referral to other medical, psychological, and social services are crucial components of treatment for many patients. The best programs provide a combination of therapies and other services to meet the needs of the individual patient, which are shaped by such issues as age, race, culture, sexual orientation, gender, pregnancy, parenting, housing, and employment, as well as physical and sexual abuse. ·

Treatment medications, such as methadone, LAAM, and naltrexone, are available for individuals addicted to opiates. Nicotine preparations (patches, gum, nasal spray) and bupropion are available for individuals addicted to nicotine.

·

The best treatment programs provide a combination of therapies and other services to meet the needs of the individual patient. CHILD CARE SERVICES FAMILY SERVICES

FINANCIAL SERVICES

VOCATIONAL SERVICES

P ROCESSING / A SSESSEMENT

HOUSING/ TRANSPORTATION SERVICES

INTAKE

B EHAVIORAL T HERAPY AND C OUNSELING

T REATMENT P LAN

S UBSTANCE U SE MONITORING

C LINICAL AND C ASE MANAGEMENT

P HARMACOTHERAPY

S ELF -H ELP /P EER S UPPORT G ROUPS

MENTAL HEALTH SERVICES

MEDI CAL SERVICES

C ONTINUING C ARE LEGAL

EDUCATIONAL SERVICES

SERVICES AIDS/HIV SERVICES

Components of Comprehensive Drug Abuse Treatment ·

Medications, such as antidepressants, mood stabilizers, or neuroleptics, may be critical for treatment success when patients have co-occurring mental disorders, such as depression, anxiety disorder, bipolar disorder, or psychosis.

·

Treatment can occur in a variety of settings, in many different forms, and for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment often is not sufficient. For many, treatment is a long-term process that involves multiple interventions and attempts at abstinence.

Principles of Drug Addiction Treatment 199

Why Can't Drug Addicts Quit on Their Own? Nearly all addicted individuals believe in the beginning that they can stop using drugs on their own, and most try to stop without treatment. However, most of these attempts result in failure to achieve long-term abstinence. Research has shown that long-term drug use results in significant changes in brain function that persist long after the individual stops using drugs. These drug-induced changes in brain function may have many behavioral consequences, including the compulsion to use drugs despite adverse consequences. This is the defining characteristic of addiction. Understanding that addiction has such an important biological component may help explain an individual's difficulty in achieving and maintaining abstinence without treatment. Psychological stress from work or family problems, social cues (such as meeting individuals from one's drug-using past), or the environment (such as encountering streets, objects, or even smells associated with drug use) can interact with biological factors to hinder attainment of sustained abstinence and make relapse more likely. Research studies indicate that even the most severely addicted individuals can participate actively in treatment and that active participation is essential to good outcomes. How Effective Is Drug Addiction Treatment? In addition to stopping drug use, the goal of treatment is to return the individual to productive functioning in the family, workplace, and community. Measures of effectiveness typically include levels of criminal behavior, family functioning, employability, and medical condition. Overall, treatment of addiction is as successful as treatment of other chronic diseases, such as diabetes, hypertension, and asthma. Treatment of addiction is as successful as treatment of other chronic diseases such as diabetes, hypertension, and asthma. According to several studies, drug treatment reduces drug use by 40 to 60 percent and significantly decreases criminal activity during and after treatment. For example, a study of therapeutic community treatment for drug offenders demonstrated that arrests for violent and nonviolent criminal acts were reduced by 40 percent or more. Methadone treatment has been shown to decrease criminal behavior by as much as 50 percent. Research shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV-related illnesses. Treatment can

200 Nicotine Dependence

improve the prospects for employment, with gains of up to 40 percent after treatment. Although these effectiveness rates hold in general, individual treatment outcomes depend on the extent and nature of the patient's presenting problems, the appropriateness of the treatment components and related services used to address those problems, and the degree of active engagement of the patient in the treatment process.

How Long Does Drug Addiction Treatment Usually Last? Individuals progress through drug addiction treatment at various speeds, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate lengths of treatment. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated. For methadone maintenance, 12 months of treatment is the minimum, and some opiate-addicted individuals will continue to benefit from methadone maintenance treatment over a period of years. Good outcomes are contingent on adequate lengths of treatment. Many people who enter treatment drop out before receiving all the benefits that treatment can provide. Successful outcomes may require more than one treatment experience. Many addicted individuals have multiple episodes of treatment, often with a cumulative impact.

What Helps People Stay in Treatment? Since successful outcomes often depend upon retaining the person long enough to gain the full benefits of treatment, strategies for keeping an individual in the program are critical. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Individual factors related to engagement and retention include motivation to change drug-using behavior, degree of support from family and friends, and whether there is pressure to stay in treatment from the criminal justice system, child protection services, employers, or the family. Within the program, successful counselors are able to establish a positive, therapeutic relationship with the patient. The counselor should ensure that a treatment plan is established and followed so that the individual knows what to expect

Principles of Drug Addiction Treatment 201

during treatment. Medical, psychiatric, and social services should be available. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Since some individual problems (such as serious mental illness, severe cocaine or crack use, and criminal involvement) increase the likelihood of a patient dropping out, intensive treatment with a range of components may be required to retain patients who have these problems. The provider then should ensure a transition to continuing care or “aftercare” following the patient's completion of formal treatment. Is the Use of Medications Like Methadone Simply Replacing One Drug Addiction with Another? No. As used in maintenance treatment, methadone and LAAM are not heroin substitutes. They are safe and effective medications for opiate addiction that are administered by mouth in regular, fixed doses. Their pharmacological effects are markedly different from those of heroin. Injected, snorted, or smoked heroin causes an almost immediate “rush” or brief period of euphoria that wears off very quickly, terminating in a “crash.” The individual then experiences an intense craving to use more heroin to stop the crash and reinstate the euphoria. The cycle of euphoria, crash, and craving is repeated several times a day which leads to a cycle of addiction and behavioral disruption. These characteristics of heroin use result from the drug's rapid onset of action and its short duration of action in the brain. An individual who uses heroin multiple times per day subjects his or her brain and body to marked, rapid fluctuations as the opiate effects come and go. These fluctuations can disrupt a number of important bodily functions. Because heroin is illegal, addicted persons often become part of a volatile drug-using street culture characterized by hustling and crimes for profit. Methadone and LAAM have far more gradual onsets of action than heroin, and as a result, patients stabilized on these medications do not experience any rush. In addition, both medications wear off much more slowly than heroin, so there is no sudden crash, and the brain and body are not exposed to the marked fluctuations seen with heroin use. Maintenance treatment with methadone or LAAM markedly reduces the desire for heroin. If an individual maintained on adequate, regular doses of methadone (once a day) or LAAM (several times per week) tries to take heroin, the euphoric effects

202 Nicotine Dependence

of heroin will be significantly blocked. According to research, patients undergoing maintenance treatment do not suffer the medical abnormalities and behavioral destabilization that rapid fluctuations in drug levels cause in heroin addicts.

What Role Can the Criminal Justice System Play in the Treatment of Drug Addiction? Increasingly, research is demonstrating that treatment for drug-addicted offenders during and after incarceration can have a significant beneficial effect upon future drug use, criminal behavior, and social functioning. The case for integrating drug addiction treatment approaches with the criminal justice system is compelling. Combining prison- and community-based treatment for drug-addicted offenders reduces the risk of both recidivism to drug-related criminal behavior and relapse to drug use. For example, a recent study found that prisoners who participated in a therapeutic treatment program in the Delaware State Prison and continued to receive treatment in a work-release program after prison were 70 percent less likely than non-participants to return to drug use and incur rearrest. Individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily. The majority of offenders involved with the criminal justice system are not in prison but are under community supervision. For those with known drug problems, drug addiction treatment may be recommended or mandated as a condition of probation. Research has demonstrated that individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily. The criminal justice system refers drug offenders into treatment through a variety of mechanisms, such as diverting nonviolent offenders to treatment, stipulating treatment as a condition of probation or pretrial release, and convening specialized courts that handle cases for offenses involving drugs. Drug courts, another model, are dedicated to drug offender cases. They mandate and arrange for treatment as an alternative to incarceration, actively monitor progress in treatment, and arrange for other services to drug-involved offenders. The most effective models integrate criminal justice and drug treatment systems and services. Treatment and criminal justice personnel work together on plans and implementation of screening, placement, testing, monitoring, and supervision, as well as on the systematic use of sanctions

Principles of Drug Addiction Treatment 203

and rewards for drug abusers in the criminal justice system. Treatment for incarcerated drug abusers must include continuing care, monitoring, and supervision after release and during parole. How Does Drug Addiction Treatment Help Reduce the Spread of HIV/AIDS and Other Infectious Diseases? Many drug addicts, such as heroin or cocaine addicts and particularly injection drug users, are at increased risk for HIV/AIDS as well as other infectious diseases like hepatitis, tuberculosis, and sexually transmitted infections. For these individuals and the community at large, drug addiction treatment is disease prevention. Drug injectors who do not enter treatment are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment. Drug users who enter and continue in treatment reduce activities that can spread disease, such as sharing injection equipment and engaging in unprotected sexual activity. Participation in treatment also presents opportunities for screening, counseling, and referral for additional services. The best drug abuse treatment programs provide HIV counseling and offer HIV testing to their patients.

Where Do 12-Step or Self-Help Programs Fit into Drug Addiction Treatment? Self-help groups can complement and extend the effects of professional treatment. The most prominent self-help groups are those affiliated with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model, and Smart Recovery®. Most drug addiction treatment programs encourage patients to participate in a self-help group during and after formal treatment.

How Can Families and Friends Make a Difference in the Life of Someone Needing Treatment? Family and friends can play critical roles in motivating individuals with drug problems to enter and stay in treatment. Family therapy is important, especially for adolescents. Involvement of a family member in an individual's treatment program can strengthen and extend the benefits of the program.

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Is Drug Addiction Treatment Worth Its Cost? Drug addiction treatment is cost-effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives, such as not treating addicts or simply incarcerating addicts. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $18,400 per person. According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drugrelated crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.

Drug Addiction Treatment in the United States Drug addiction is a complex disorder that can involve virtually every aspect of an individual's function in the family, at work, and in the community. Because of addiction's complexity and pervasive consequences, drug addiction treatment typically must involve many components. Some of those components focus directly on the individual's drug use. Others, like employment training, focus on restoring the addicted individual to productive membership in the family and society. Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches. In the United States, more than 11,000 specialized drug treatment facilities provide rehabilitation, counseling, behavioral therapy, medication, case management, and other types of services to persons with drug use disorders. Because drug abuse and addiction are major public health problems, a large portion of drug treatment is funded by local, State, and Federal governments. Private and employer-subsidized health plans also may provide coverage for treatment of drug addiction and its medical consequences. Drug abuse and addiction are treated in specialized treatment facilities and mental health clinics by a variety of providers, including certified drug abuse counselors, physicians, psychologists, nurses, and social workers. Treatment

Principles of Drug Addiction Treatment 205

is delivered in outpatient, inpatient, and residential settings. Although specific treatment approaches often are associated with particular treatment settings, a variety of therapeutic interventions or services can be included in any given setting.

General Categories of Treatment Programs Research studies on drug addiction treatment have typically classified treatment programs into several general types or modalities, which are described in the following text. Treatment approaches and individual programs continue to evolve, and many programs in existence today do not fit neatly into traditional drug addiction treatment classifications.

Agonist Maintenance Treatment Agonist maintenance treatment for opiate addicts usually is conducted in outpatient settings, often called methadone treatment programs. These programs use a long-acting synthetic opiate medication, usually methadone or LAAM, administered orally for a sustained period at a dosage sufficient to prevent opiate withdrawal, block the effects of illicit opiate use, and decrease opiate craving. Patients stabilized on adequate, sustained dosages of methadone or LAAM can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. Patients stabilized on opiate agonists can engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation. The best, most effective opiate agonist maintenance programs include individual and/or group counseling, as well as provision of, or referral to, other needed medical, psychological, and social services. Narcotic Antagonist Treatment Using Naltrexone Narcotic antagonist treatment using Naltrexone for opiate addicts usually is conducted in outpatient settings although initiation of the medication often begins after medical detoxification in a residential setting. Naltrexone is a long-acting synthetic opiate antagonist with few side effects that is taken orally either daily or three times a week for a sustained period of time. Individuals must be medically detoxified and opiate-free for several days before Naltrexone can be taken to prevent precipitating an opiate abstinence

206 Nicotine Dependence

syndrome. When used this way, all the effects of self-administered opiates, including euphoria, are completely blocked. The theory behind this treatment is that the repeated lack of the desired opiate effects, as well as the perceived futility of using the opiate, will gradually over time result in breaking the habit of opiate addiction. Naltrexone itself has no subjective effects or potential for abuse and is not addicting. Patient noncompliance is a common problem. Therefore, a favorable treatment outcome requires that there also be a positive therapeutic relationship, effective counseling or therapy, and careful monitoring of medication compliance. Patients stabilized on Naltrexone can hold jobs, avoid crime and violence, and reduce their exposure to HIV. Many experienced clinicians have found Naltrexone most useful for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances, including impaired professionals, parolees, probationers, and prisoners in workrelease status. Patients stabilized on Naltrexone can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping injection drug use and drug-related highrisk sexual behavior.

Outpatient Drug-Free Treatment Outpatient drug-free treatment in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for individuals who are employed or who have extensive social supports. Low-intensity programs may offer little more than drug education and admonition. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient's characteristics and needs. In many outpatient programs, group counseling is emphasized. Some outpatient programs are designed to treat patients who have medical or mental health problems in addition to their drug disorder.

Long-Term Residential Treatment Long-term residential treatment provides care 24 hours per day, generally in non-hospital settings. The best-known residential treatment model is the therapeutic community (TC), but residential treatment may also employ other models, such as cognitive-behavioral therapy.

Principles of Drug Addiction Treatment 207

TCs are residential programs with planned lengths of stay of 6 to 12 months. TCs focus on the “resocialization” of the individual and use the program's entire “community,” including other residents, staff, and the social context, as active components of treatment. Addiction is viewed in the context of an individual's social and psychological deficits, and treatment focuses on developing personal accountability and responsibility and socially productive lives. Treatment is highly structured and can at times be confrontational, with activities designed to help residents examine damaging beliefs, self-concepts, and patterns of behavior and to adopt new, more harmonious and constructive ways to interact with others. Many TCs are quite comprehensive and can include employment training and other support services on site. Compared with patients in other forms of drug treatment, the typical TC resident has more severe problems, with more co-occurring mental health problems and more criminal involvement. Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, those with severe mental disorders, and individuals in the criminal justice system.

Short-Term Residential Programs Short-term residential programs provide intensive but relatively brief residential treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980's, many began to treat illicit drug abuse and addiction. The original residential treatment model consisted of a 3 to 6 week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as Alcoholics Anonymous. Reduced health care coverage for substance abuse treatment has resulted in a diminished number of these programs, and the average length of stay under managed care review is much shorter than in early programs.

Medical Detoxification Medical Detoxification is a process whereby individuals are systematically withdrawn from addicting drugs in an inpatient or outpatient setting, typically under the care of a physician. Detoxification is sometimes called a distinct treatment modality but is more appropriately considered a precursor of treatment, because it is designed to treat the acute physiological effects of

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stopping drug use. Medications are available for detoxification from opiates, nicotine, benzodiazepines, alcohol, barbiturates, and other sedatives. In some cases, particularly for the last three types of drugs, detoxification may be a medical necessity, and untreated withdrawal may be medically dangerous or even fatal. Detoxification is not designed to address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery. Detoxification is most useful when it incorporates formal processes of assessment and referral to subsequent drug addiction treatment.

Treating Criminal Justice-Involved Drug Abusers and Addicts Research has shown that combining criminal justice sanctions with drug treatment can be effective in decreasing drug use and related crime. Individuals under legal coercion tend to stay in treatment for a longer period of time and do as well as or better than others not under legal pressure. Often, drug abusers come into contact with the criminal justice system earlier than other health or social systems, and intervention by the criminal justice system to engage the individual in treatment may help interrupt and shorten a career of drug use. Treatment for the criminal justice-involved drug abuser or drug addict may be delivered prior to, during, after, or in lieu of incarceration. Combining criminal justice sanctions with drug treatment can be effective in decreasing drug use and related crime.

Prison-Based Treatment Programs Offenders with drug disorders may encounter a number of treatment options while incarcerated, including didactic drug education classes, selfhelp programs, and treatment based on therapeutic community or residential milieu therapy models. The TC model has been studied extensively and can be quite effective in reducing drug use and recidivism to criminal behavior. Those in treatment should be segregated from the general prison population, so that the “prison culture” does not overwhelm progress toward recovery. As might be expected, treatment gains can be lost if inmates are returned to the general prison population after treatment. Research shows that relapse to drug use and recidivism to crime are

Principles of Drug Addiction Treatment 209

significantly lower if the drug offender continues treatment after returning to the community.

Community-Based Treatment for Criminal Justice Populations A number of criminal justice alternatives to incarceration have been tried with offenders who have drug disorders, including limited diversion programs, pretrial release conditional on entry into treatment, and conditional probation with sanctions. The drug court is a promising approach. Drug courts mandate and arrange for drug addiction treatment, actively monitor progress in treatment, and arrange for other services to drug-involved offenders. Federal support for planning, implementation, and enhancement of drug courts is provided under the U.S. Department of Justice Drug Courts Program Office. As a well-studied example, the Treatment Accountability and Safer Communities (TASC) program provides an alternative to incarceration by addressing the multiple needs of drug-addicted offenders in a communitybased setting. TASC programs typically include counseling, medical care, parenting instruction, family counseling, school and job training, and legal and employment services. The key features of TASC include: ·

Coordination of criminal justice and drug treatment;

·

Early identification, assessment, and referral of drug-involved offenders;

·

Monitoring offenders through drug testing; and

·

Use of legal sanctions as inducements to remain in treatment.

Scientifically-Based Approaches to Drug Addiction Treatment This section presents several examples of treatment approaches and components that have been developed and tested for efficacy through research supported by the National Institute on Drug Abuse (NIDA). Each approach is designed to address certain aspects of drug addiction and its consequences for the individual, family, and society. The approaches are to be used to supplement or enhance (not replace) existing treatment programs. This section is not a complete list of efficacious, scientifically-based treatment approaches. Additional approaches are under development as part of NIDA's continuing support of treatment research.

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Relapse Prevention Relapse prevention, a cognitive-behavioral therapy, was developed for the treatment of problem drinking and adapted later for cocaine addicts. Cognitive-behavioral strategies are based on the theory that learning processes play a critical role in the development of maladaptive behavioral patterns. Individuals learn to identify and correct problematic behaviors. Relapse prevention encompasses several cognitive-behavioral strategies that facilitate abstinence as well as provide help for people who experience relapse. The relapse prevention approach to the treatment of cocaine addiction consists of a collection of strategies intended to enhance self-control. Specific techniques include exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings early on and to identify high-risk situations for use, and developing strategies for coping with and avoiding high-risk situations and the desire to use. A central element of this treatment is anticipating the problems patients are likely to meet and helping them develop effective coping strategies. Research indicates that the skills individuals learn through relapse prevention therapy remain after the completion of treatment. In one study, most people receiving this cognitive-behavioral approach maintained the gains they made in treatment throughout the year following treatment.

The Matrix Model The Matrix model provides a framework for engaging stimulant abusers in treatment and helping them achieve abstinence. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, become familiar with self-help programs, and are monitored for drug use by urine testing. The program includes education for family members affected by the addiction. The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behavior change. The interaction between the therapist and the patient is realistic and direct but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient's self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is a critical element for patient retention.

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Treatment materials draw heavily on other tested treatment approaches. Thus, this approach includes elements pertaining to the areas of relapse prevention, family and group therapies, drug education, and self-help participation. Detailed treatment manuals contain work sheets for individual sessions; other components include family educational groups, early recovery skills groups, relapse prevention groups, conjoint sessions, urine tests, 12-step programs, relapse analysis, and social support groups. A number of projects have demonstrated that participants treated with the Matrix model demonstrate statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission. These reports, along with evidence suggesting comparable treatment response for methamphetamine users and cocaine users and demonstrated efficacy in enhancing naltrexone treatment of opiate addicts, provide a body of empirical support for the use of the model.

Supportive-Expressive Psychotherapy Supportive-expressive psychotherapy is a time-limited, focused psychotherapy that has been adapted for heroin- and cocaine-addicted individuals. The therapy has two main components: ·

Supportive techniques to help patients feel comfortable in discussing their personal experiences.

·

Expressive techniques to help patients identify and work through interpersonal relationship issues.

Special attention is paid to the role of drugs in relation to problem feelings and behaviors, and how problems may be solved without recourse to drugs. The efficacy of individual supportive-expressive psychotherapy has been tested with patients in methadone maintenance treatment who had psychiatric problems. In a comparison with patients receiving only drug counseling, both groups fared similarly with regard to opiate use, but the supportive-expressive psychotherapy group had lower cocaine use and required less methadone. Also, the patients who received supportiveexpressive psychotherapy maintained many of the gains they had made. In an earlier study, supportive-expressive psychotherapy, when added to drug counseling, improved outcomes for opiate addicts in methadone treatment with moderately severe psychiatric problems.

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Individualized Drug Counseling Individualized drug counseling focuses directly on reducing or stopping the addict's illicit drug use. It also addresses related areas of impaired functioning such as employment status, illegal activity, family/social relations as well as the content and structure of the patient's recovery program. Through its emphasis on short-term behavioral goals, individualized drug counseling helps the patient develop coping strategies and tools for abstaining from drug use and then maintaining abstinence. The addiction counselor encourages 12-step participation and makes referrals for needed supplemental medical, psychiatric, employment, and other services. Individuals are encouraged to attend sessions one or two times per week. In a study that compared opiate addicts receiving only methadone to those receiving methadone coupled with counseling, individuals who received only methadone showed minimal improvement in reducing opiate use. The addition of counseling produced significantly more improvement. The addition of onsite medical/psychiatric, employment, and family services further improved outcomes. In another study with cocaine addicts, individualized drug counseling, together with group drug counseling, was quite effective in reducing cocaine use. Thus, it appears that this approach has great utility with both heroin and cocaine addicts in outpatient treatment.

Motivational Enhancement Therapy Motivational enhancement therapy is a client-centered counseling approach for initiating behavior change by helping clients to resolve ambivalence about engaging in treatment and stopping drug use. This approach employs strategies to evoke rapid and internally motivated change in the client, rather than guiding the client stepwise through the recovery process. This therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. The first treatment session focuses on providing feedback generated from the initial assessment battery to stimulate discussion regarding personal substance use and to elicit self-motivational statements. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the client. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage

Principles of Drug Addiction Treatment 213

commitment to change or sustained abstinence. Clients are sometimes encouraged to bring a significant other to sessions. This approach has been used successfully with alcoholics and with marijuana-dependent individuals.

Behavioral Therapy Behavioral therapy for Adolescents incorporates the principle that unwanted behavior can be changed by clear demonstration of the desired behavior and consistent reward of incremental steps toward achieving it. Therapeutic activities include fulfilling specific assignments, rehearsing desired behaviors, and recording and reviewing progress, with praise and privileges given for meeting assigned goals. Urine samples are collected regularly to monitor drug use. The therapy aims to equip the patient to gain three types of control: ·

Stimulus Control helps patients avoid situations associated with drug use and learn to spend more time in activities incompatible with drug use.

·

Urge Control helps patients recognize and change thoughts, feelings, and plans that lead to drug use.

·

Social Control involves family members and other people important in helping patients avoid drugs. A parent or significant other attends treatment sessions when possible and assists with therapy assignments and reinforcing desired behavior.

According to research studies, this therapy helps adolescents become drug free and increases their ability to remain drug free after treatment ends. Adolescents also show improvement in several other areas such as employment/school attendance, family relationships, depression, institutionalization, and alcohol use. Such favorable results are attributed largely to including family members in therapy and rewarding drug abstinence as verified by urinalysis.

Multidimensional Family Therapy (MDFT) for Adolescents Multidimensional family therapy (MDFT) for adolescents is an outpatient family-based drug abuse treatment for teenagers. MDFT views adolescent drug use in terms of a network of influences (that is, individual, family, peer, community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. Treatment includes individual and family sessions held in the clinic, in the home, or

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with family members at the family court, school, or other community locations. During individual sessions, the therapist and adolescent work on important developmental tasks, such as developing decision-making, negotiation, and problem-solving skills. Teenagers acquire skills in communicating their thoughts and feelings to deal better with life stressors, and vocational skills. Parallel sessions are held with family members. Parents examine their particular parenting style, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their child.

Multisystemic Therapy (MST) Multisystemic therapy (MST) addresses the factors associated with serious antisocial behavior in children and adolescents who abuse drugs. These factors include characteristics of the adolescent (for example, favorable attitudes toward drug use), the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes toward drug use), school (dropout, poor performance), and neighborhood (criminal subculture). By participating in intense treatment in natural environments (homes, schools, and neighborhood settings) most youths and families complete a full course of treatment. MST significantly reduces adolescent drug use during treatment and for at least 6 months after treatment. Reduced numbers of incarcerations and out-of-home placements of juveniles offset the cost of providing this intensive service and maintaining the clinicians' low caseloads.

Combined Behavioral and Nicotine Replacement Therapy for Nicotine Addiction Combined behavioral and nicotine replacement therapy for nicotine addiction consists of two main components: ·

The transdermal nicotine patch or nicotine gum reduces symptoms of withdrawal, producing better initial abstinence.

·

The behavioral component concurrently provides support reinforcement of coping skills, yielding better long-term outcomes.

and

Through behavioral skills training, patients learn to avoid high-risk situations for smoking relapse early on and later to plan strategies to cope with such situations. Patients practice skills in treatment, social, and work

Principles of Drug Addiction Treatment 215

settings. They learn other coping techniques, such as cigarette refusal skills, assertiveness, and time management. The combined treatment is based on the rationale that behavioral and pharmacological treatments operate by different yet complementary mechanisms that produce potentially additive effects.

Community Reinforcement Approach (CRA) Community reinforcement approach (CRA) plus vouchers is an intensive 24week outpatient therapy for treatment of cocaine addiction. The treatment goals are twofold: ·

To achieve cocaine abstinence long enough for patients to learn new life skills that will help sustain abstinence.

·

To reduce alcohol consumption for patients whose drinking is associated with cocaine use.

Patients attend one or two individual counseling sessions per week, where they focus on improving family relations, learning a variety of skills to minimize drug use, receiving vocational counseling, and developing new recreational activities and social networks. Those who also abuse alcohol receive clinic-monitored disulfiram (Antabuse) therapy. Patients submit urine samples two or three times each week and receive vouchers for cocaine-negative samples. The value of the vouchers increases with consecutive clean samples. Patients may exchange vouchers for retail goods that are consistent with a cocaine-free lifestyle. This approach facilitates patients' engagement in treatment and systematically aids them in gaining substantial periods of cocaine abstinence. The approach has been tested in urban and rural areas and used successfully in outpatient detoxification of opiate-addicted adults and with inner-city methadone maintenance patients who have high rates of intravenous cocaine abuse.

Voucher-Based Reinforcement Therapy in Methadone Maintenance Treatment Voucher-based reinforcement therapy in Methadone maintenance treatment helps patients achieve and maintain abstinence from illegal drugs by providing them with a voucher each time they provide a drug-free urine sample. The voucher has monetary value and can be exchanged for goods

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and services consistent with the goals of treatment. Initially, the voucher values are low, but their value increases with the number of consecutive drug-free urine specimens the individual provides. Cocaine- or heroinpositive urine specimens reset the value of the vouchers to the initial low value. The contingency of escalating incentives is designed specifically to reinforce periods of sustained drug abstinence. Studies show that patients receiving vouchers for drug-free urine samples achieved significantly more weeks of abstinence and significantly more weeks of sustained abstinence than patients who were given vouchers independent of urinalysis results. In another study, urinalyses positive for heroin decreased significantly when the voucher program was started and increased significantly when the program was stopped.

Day Treatment with Abstinence Contingencies and Vouchers Day treatment with abstinence contingencies and vouchers was developed to treat homeless crack addicts. For the first 2 months, participants must spend 5.5 hours daily in the program, which provides lunch and transportation to and from shelters. Interventions include individual assessment and goal setting, individual and group counseling, multiple psycho-educational groups (for example, didactic groups on community resources, housing, cocaine, and HIV/AIDS prevention; establishing and reviewing personal rehabilitation goals; relapse prevention; weekend planning), and patientgoverned community meetings during which patients review contract goals and provide support and encouragement to each other. Individual counseling occurs once a week, and group therapy sessions are held three times a week. After 2 months of day treatment and at least 2 weeks of abstinence, participants graduate to a 4-month work component that pays wages that can be used to rent inexpensive, drug-free housing. A voucher system also rewards drug-free related social and recreational activities. This innovative day treatment was compared with treatment consisting of twice-weekly individual counseling and 12-step groups, medical examinations and treatment, and referral to community resources for housing and vocational services. Innovative day treatment followed by work and housing dependent upon drug abstinence had a more positive effect on alcohol use, cocaine use, and days homeless.

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Resources The National Institute on Drug Abuse58 General inquiries: ·

NIDA Public Information Office, Telephone: 301-443-1124.

Inquiries about NIDA's treatment research activities: ·

Division of Treatment Research and Development (301) 443-6173 (for questions regarding behavioral therapies and medications);

·

Division of Epidemiology, Services and Prevention Research (301) 4434060 (for questions regarding access to treatment, organization, management, financing, effectiveness and cost-effectiveness).

Center for Substance Abuse Treatment (CSAT) CSAT, a part of the Substance Abuse and Mental Health Services Administration, is responsible for supporting treatment services through block grants and developing knowledge about effective drug treatment, disseminating the findings to the field, and promoting their adoption. CSAT also operates the National Treatment Referral 24-hour Hotline (1-800-662HELP) which offers information and referral to people seeking treatment programs and other assistance. CSAT publications are available through the National Clearinghouse on Alcohol and Drug Information (1-800-729-6686). Additional information can be found at CSAT’s Web Site: http://www.samhsa.gov/csat.

Selected NIDA Educational Resources on Drug Addiction Treatment The following are available from the National Clearinghouse on Alcohol and Drug Information (NCADI), the National Technical Information Service (NTIS), or the Government Printing Office (GPO). To order, refer to the NCADI (1-800-729-6686), NTIS (1-800-553-6847), or GPO (202-512-1800) number provided with the resource description.

58

The NIDA: http://www.nida.nih.gov.

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Manuals and Clinical Reports ·

Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs (1999). Offers substance abuse treatment program managers tools with which to calculate the costs of their programs and investigate the relationship between those costs and treatment outcomes. NCADI # BKD340. Available online at http://www.nida.nih.gov/IMPCOST/IMPCOSTIndex.html.

·

A Cognitive-Behavioral Approach: Treating Cocaine Addiction (1998). This is the first in NIDA's “Therapy Manuals for Drug Addiction” series. Describes cognitive-behavioral therapy, a short-term focused approach to helping cocaine-addicted individuals become abstinent from cocaine and other drugs. NCADI # BKD254. Available online at http://www.nida.nih.gov/TXManuals/CBT/CBT1.html.

·

A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction (1998). This is the second in NIDA's “Therapy Manuals for Drug Addiction” series. This treatment integrates a community reinforcement approach with an incentive program that uses vouchers. NCADI # BKD255. Available online at http://www.nida.nih.gov/TXManuals/CRA/CRA1.html.

·

An Individual Drug Counseling Approach to Treat Cocaine Addiction: The Collaborative Cocaine Treatment Study Model (1999). This is the third in NIDA's “Therapy Manuals for Drug Addiction” series. Describes specific cognitive-behavioral models that can be implemented in a wide range of differing drug abuse treatment settings. NCADI # BKD337. Available online at http://www.nida.nih.gov/TXManuals/IDCA/IDCA1.html.

·

Mental Health Assessment and Diagnosis of Substance Abusers: Clinical Report Series (1994). Provides detailed descriptions of psychiatric disorders that can occur among drug-abusing clients. NCADI # BKD148.

·

Relapse Prevention: Clinical Report Series (1994). Discusses several major issues to relapse prevention. Provides an overview of factors and experiences that can lead to relapse. Reviews general strategies for preventing relapses, and describes four specific approaches in detail. Outlines administrative issues related to implementing a relapse prevention program. NCADI # BKD147.

·

Addiction Severity Index Package (1993). Provides a structured clinical interview designed to collect information about substance use and functioning in life areas from adult clients seeking drug abuse treatment. Includes a handbook for program administrators, a resource manual, two

Principles of Drug Addiction Treatment 219

videotapes, and a training AVA19615VNB2KUS. $150.

facilitator's

manual.

NTIS

#

·

Program Evaluation Package (1993). A practical resource for treatment program administrators and key staff. Includes an overview and case study manual, a guide for evaluation, a resource guide, and a pamphlet. NTIS # 95-167268/BDL. $86.50.

·

Relapse Prevention Package (1993). Examines two effective relapse prevention models, the Recovery Training and Self-Help (RTSH) program and the Cue Extinction model. NTIS # 95-167250/BDL. $189; GPO # 017-024-01555-5. $57. (Sold by GPO as a set of 7 books)

Research Monographs ·

Beyond the Therapeutic Alliance: Keeping the Drug-Dependent Individual in Treatment (Research Monograph 165) (1997). Reviews current treatment research on the best ways to retain patients in drug abuse treatment. NTIS # 97-181606. $47; GPO # 017-024-01608-0. $17. http://www.nida.nih.gov/pdf/monographs/monograph165/download16 5.html.

·

Treatment of Drug-Exposed Women and Children: Advances in Research Methodology (Research Monograph 166) (1997). Presents experiences, products, and procedures of NIDA-supported Treatment Research Demonstration Program projects. NCADI # M166; NTIS # 96179106. $75; GPO # 017-01592-0. $13. Available online at http://www.nida.nih.gov/pdf/monographs/monograph166/download.ht ml.

·

Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders (Research Monograph 172) (1997). Promotes effective treatment by reporting state-of-the-art treatment research on individuals with comorbid mental and addictive disorders and research on HIVrelated issues among people with comorbid conditions. NCADI # M172; NTIS # 97-181580. $41; GPO # 017-024-01605. $10. Available online at http://www.nida.nih.gov/pdf/monographs/monograph172/download17 2.html

·

Medications Development for the Treatment of Cocaine Dependence: Issues in Clinical Efficacy Trials (Research Monograph 175) (1998). A state-of-the-art handbook for clinical investigators, pharmaceutical scientists, and treatment researchers. NCADI # M175. http://www.nida.nih.gov/pdf/monographs/monograph175/download17 5.html

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Videos ·

Adolescent Treatment Approaches (1991). Emphasizes the importance of pinpointing and addressing individual problem areas, such as sexual abuse, peer pressure, and family involvement in treatment. Running time: 25 min. NCADI # VHS40. $12.50.

·

NIDA Technology Transfer Series: Assessment (1991). Shows how to use a number of diagnostic instruments as well as how to assess the implementation and effectiveness of the plan during various phases of the patient's treatment. Running time: 22 min. NCADI # VHS38. $12.50.

·

Drug Abuse Treatment in Prison: A New Way Out (1995). Portrays two comprehensive drug abuse treatment approaches that have been effective with men and women in State and Federal Prisons. Running time: 23 min. NCADI # VHS72. $12.50.

·

Dual Diagnosis (1993). Focuses on the problem of mental illness in drugabusing and drug-addicted populations, and examines various approaches useful for treating dual-diagnosed clients. Running time: 27 min. NCADI # VHS58. $12.50.

·

LAAM: Another Option for Maintenance Treatment of Opiate Addiction (1995). Shows how LAAM can be used to meet the opiate treatment needs of individual clients from the provider and patient perspectives. Running time: 16 min. NCADI # VHS73. $12.50.

·

Methadone: Where We Are (1993). Examines issues such as the use and effectiveness of methadone as a treatment, biological effects of methadone, the role of the counselor in treatment, and societal attitudes toward methadone treatment and patients. Running time: 24 min. NCADI # VHS59. $12.50.

·

Relapse Prevention (1991). Helps practitioners understand the common phenomenon of relapse to drug use among patients in treatment. Running time: 24 min. NCADI # VHS37. $12.50.

·

Treatment Issues for Women (1991). Assists treatment counselors help female patients to explore relationships with their children, with men, and with other women. Running time: 22 min. NCADI # VHS39. $12.50.

·

Treatment Solutions (1999). Describes the latest developments in treatment research and emphasizes the benefits of drug abuse treatment, not only to the patient, but also to the greater community. Running time: 19 min. NCADI # DD110. $12.50.

·

Program Evaluation Package (1993). A practical resource for treatment program administrators and key staff. Includes an overview and case

Principles of Drug Addiction Treatment 221

study manual, a guide for evaluation, a resource guide, and a pamphlet. NTIS # 95-167268/BDL. $86.50. ·

Relapse Prevention Package (1993). Examines two effective relapse prevention models, the Recovery Training and Self-Help (RTSH) program and the Cue Extinction model. NTIS # 95-167250. $189; GPO # 017-024-01555-5. $57. (Sold by GPO as a set of 7 books)

Other Federal Resources ·

The National Clearinghouse for Alcohol and Drug Information (NCADI). NIDA publications and treatment materials along with publications from other Federal agencies are available from this information source. Staff provide assistance in English and Spanish, and have TDD capability. Phone: 1-800-729-6686. Website: http://www.health.org.

·

The National Institute of Justice (NIJ). As the research agency of the Department of Justice, NIJ supports research, evaluation, and demonstration programs relating to drug abuse in the contexts of crime and the criminal justice system. For information, including a wealth of publications, contact the National Criminal Justice Reference Service by telephone (1-800-851-3420 or 1-301-519-5500) or on the World Wide Web (http://www.ojp.usdoj.gov/nij).

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Barbiturate: A type of central nervous system (CNS) depressant often prescribed to promote sleep. [NIH] Benzodiazepine: A type of CNS depressant prescribed to relieve anxiety; among the most widely prescribed medications, including Valium and Librium. [NIH] Collapse: 1. a state of extreme prostration and depression, with failure of circulation. 2. abnormal falling in of the walls of any part of organ. [EU] Confusion: Disturbed orientation in regard to time, place, or person, sometimes accompanied by disordered consciousness. [EU] Crack: Short term for a smokable form of cocaine. [NIH] Emesis: Vomiting; an act of vomiting. Also used as a word termination, as

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in haematemesis. [EU] Euphoria: An exaggerated feeling of physical and mental well-being, especially when not justified by external reality. Euphoria may be induced by drugs such as opioids, amphetamines, and alcohol and is also a feature of mania. [EU] Hepatitis: Inflammation of the liver. [EU] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Incarceration: Abnormal retention or confinement of a body part; specifically : a constriction of the neck of a hernial sac so that the hernial contents become irreducible. [EU] Institutionalization: The caring for individuals in institutions and their adaptation to routines characteristic of the institutional environment, and/or their loss of adaptation to life outside the institution. [NIH] Intravenous: Within a vein or veins. [EU] Methamphetamine: A central nervous system stimulant and sympathomimetic with actions and uses similar to dextroamphetamine. The smokable form is a drug of abuse and is referred to as crank, crystal, crystal meth, ice, and speed. [NIH] Neuroleptic: A term coined to refer to the effects on cognition and behaviour of antipsychotic drugs, which produce a state of apathy, lack of initiative, and limited range of emotion and in psychotic patients cause a reduction in confusion and agitation and normalization of psychomotor activity. [EU] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH] Urinalysis: Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. [NIH]

Online Glossaries 223

ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·

ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html

·

MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp

·

Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/

·

Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

·

On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/

·

Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm

·

Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html

Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a) and drkoop.com (http://www.drkoop.com/). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to nicotine dependence and keep them on file. The NIH, in particular, suggests that patients with nicotine dependence visit the following Web sites in the ADAM Medical Encyclopedia:

224 Nicotine Dependence

·

Basic Guidelines for Nicotine Dependence Nicotine overdose Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002510.htm Nicotine withdrawal Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000953.htm

·

Signs & Symptoms for Nicotine Dependence Abdominal cramps Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003120.htm Agitation Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003212.htm Collapse Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003092.htm Coma Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003202.htm Confusion Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003205.htm Convulsions Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003200.htm Depression Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003213.htm

Online Glossaries 225

Difficulty breathing Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003075.htm Drooling Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003048.htm EMESIS Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003117.htm Excitement Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003212.htm Headache Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003024.htm Increased salivation Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003048.htm Mouth lesions Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003059.htm No breathing Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003069.htm Pounding heartbeat Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003081.htm Rapid breathing Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003071.htm

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Restlessness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003212.htm Vomiting Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003117.htm Weakness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003174.htm ·

Diagnostics and Tests for Nicotine Dependence Blood pressure Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003398.htm Gastric lavage Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003882.htm Heart rate Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm Muscular twitching Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003924.htm

·

Background Topics for Nicotine Dependence Respiratory Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002290.htm Smoking - tips on how to quit Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001992.htm

Online Glossaries 227

Smoking hazards Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001994.htm

Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·

Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical

·

MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html

·

Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/

·

Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

Glossary 229

NICOTINE DEPENDENCE GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Abortion: 1. the premature expulsion from the uterus of the products of conception - of the embryo, or of a nonviable fetus. The four classic symptoms, usually present in each type of abortion, are uterine contractions, uterine haemorrhage, softening and dilatation of the cervix, and presentation or expulsion of all or part of the products of conception. 2. premature stoppage of a natural or a pathological process. [EU] Acculturation: Process of cultural change in which one group or members of a group assimilates various cultural patterns from another. [NIH] Acetylcholine: A neurotransmitter. Acetylcholine in vertebrates is the major transmitter at neuromuscular junctions, autonomic ganglia, parasympathetic effector junctions, a subset of sympathetic effector junctions, and at many sites in the central nervous system. It is generally not used as an administered drug because it is broken down very rapidly by cholinesterases, but it is useful in some ophthalmological applications. [NIH] Acid: Common street name for LSD. [NIH] Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Amphetamine: A powerful central nervous system stimulant and sympathomimetic. Amphetamine has multiple mechanisms of action including blocking uptake of adrenergics and dopamine, stimulation of release of monamines, and inhibiting monoamine oxidase. Amphetamine is also a drug of abuse and a psychotomimetic. The l- and the d,l-forms are included here. The l-form has less central nervous system activity but stronger cardiovascular effects. The d-form is dextroamphetamine. [NIH] Aneurysm: A sac formed by the dilatation of the wall of an artery, a vein, or the heart. The chief signs of arterial aneurysm are the formation of a pulsating tumour, and often a bruit (aneurysmal bruit) heard over the swelling. Sometimes there are symptoms from pressure on contiguous parts. [EU]

Antibiotic: A chemical substance produced by a microorganism which has

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the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antidepressants: A group of drugs used in treating depressive disorders. [NIH]

Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU] Arterial: Pertaining to an artery or to the arteries. [EU] Atropine: A toxic alkaloid, originally from Atropa belladonna, but found in other plants, mainly Solanaceae. [NIH] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Barbiturate: A type of central nervous system (CNS) depressant often prescribed to promote sleep. [NIH] Benzodiazepine: A type of CNS depressant prescribed to relieve anxiety; among the most widely prescribed medications, including Valium and Librium. [NIH] Bronchial: Pertaining to one or more bronchi. [EU] Bronchitis: Inflammation of one or more bronchi. [EU] Bronchopulmonary: Pertaining to the lungs and their air passages; both bronchial and pulmonary. [EU] Bupropion: A unicyclic, aminoketone antidepressant. The mechanism of its therapeutic actions is not well understood, but it does appear to block dopamine uptake. The hydrochloride is available as an aid to smoking cessation treatment. [NIH] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Carcinogens: Substances that increase the risk of neoplasms in humans or

Glossary 231

animals. Both genotoxic chemicals, which affect DNA directly, and nongenotoxic chemicals, which induce neoplasms by other mechanism, are included. [NIH] Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Cardiac: Pertaining to the heart. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Cerebrovascular: Pertaining to the blood vessels of the cerebrum, or brain. [EU]

Cervical: Pertaining to the neck, or to the neck of any organ or structure. [EU] Chlorpromazine: The prototypical phenothiazine antipsychotic drug. Like the other drugs in this class chlorpromazine's antipsychotic actions are thought to be due to long-term adaptation by the brain to blocking dopamine receptors. Chlorpromazine has several other actions and therapeutic uses, including as an antiemetic and in the treatment of intractable hiccup. [NIH] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Cholinergic: Resembling acetylcholine in pharmacological stimulated by or releasing acetylcholine or a related compound. [EU]

action;

Chromosomal: Pertaining to chromosomes. [EU] Chronic: Persisting over a long period of time. [EU] Cocaine: An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons; the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. [NIH] Collapse: 1. a state of extreme prostration and depression, with failure of circulation. 2. abnormal falling in of the walls of any part of organ. [EU] Comorbidity: The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. [NIH] Confusion: Disturbed orientation in regard to time, place, or person, sometimes accompanied by disordered consciousness. [EU]

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Contraceptive: conception. [EU]

An agent that diminishes the likelihood of or prevents

Convulsion: A violent involuntary contraction or series of contractions of the voluntary muscles. [EU] Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Cortex: The outer layer of an organ or other body structure, as distinguished from the internal substance. [EU] Crack: Short term for a smokable form of cocaine. [NIH] Craving: A powerful, often uncontrollable desire for drugs. [NIH] Cues: Signals for an action; that specific portion of a perceptual field or pattern of stimuli to which a subject has learned to respond. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Deprivation: Loss or absence of parts, organs, powers, or things that are needed. [EU] Detoxification: A process of allowing the body to rid itself of a drug while managing the symptoms of withdrawal; often the first step in a drug treatment program. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Dopamine: A neurotransmitter present in regions of the brain that regulate movement, emotion, motivation, and feeling of pleasure. [NIH] Emesis: Vomiting; an act of vomiting. Also used as a word termination, as in haematemesis. [EU] Emphysema: A lung disease in which tissue deterioration results in increased air retention and reduced exchange of gases. The result is difficult breathing and shortness of breath. It is often caused by smoking. [NIH] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU]

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Epidemiological: Relating to, or involving epidemiology. [EU] Epinephrine: The active sympathomimetic hormone from the adrenal medulla in most species. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. It is used in asthma and cardiac failure and to delay absorption of local anesthetics. [NIH] Euphoria: An exaggerated feeling of physical and mental well-being, especially when not justified by external reality. Euphoria may be induced by drugs such as opioids, amphetamines, and alcohol and is also a feature of mania. [EU] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Galanthamine: A cholinesterase inhibitor. It has been used to reverse the muscular effects of gallamine and tubocurarine and has been studied as a treatment for Alzheimer's disease and other central nervous system disorders. [NIH] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Habitual: Of the nature of a habit; according to habit; established by or repeated by force of habit, customary. [EU] Hepatitis: Inflammation of the liver. [EU] Homicide: The killing of one person by another. [NIH] Hormone: A chemical substance formed in glands in the body and carried in the blood to organs and tissues, where it influences function, structure, and behavior. [NIH] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Immunization: The induction of immunity. [EU]

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Incarceration: Abnormal retention or confinement of a body part; specifically : a constriction of the neck of a hernial sac so that the hernial contents become irreducible. [EU] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU] Infarction: 1. the formation of an infarct. 2. an infarct. [EU] Ingestion: The act of taking food, medicines, etc., into the body, by mouth. [EU]

Inhalation: The drawing of air or other substances into the lungs. [EU] Insecticides: Pesticides designed to control insects that are harmful to man. The insects may be directly harmful, as those acting as disease vectors, or indirectly harmful, as destroyers of crops, food products, or textile fabrics. [NIH]

Institutionalization: The caring for individuals in institutions and their adaptation to routines characteristic of the institutional environment, and/or their loss of adaptation to life outside the institution. [NIH] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Intravenous: Within a vein or veins. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Larynx: An irregularly shaped, musculocartilaginous tubular structure, lined with mucous membrane, located at the top of the trachea and below the root of the tongue and the hyoid bone. It is the essential sphincter guarding the entrance into the trachea and functioning secondarily as the organ of voice. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Locomotor: Of or pertaining to locomotion; pertaining to or affecting the locomotive apparatus of the body. [EU] Mecamylamine: A nicotinic antagonist that is well absorbed from the gastrointestinal tract and crosses the blood-brain barrier. Mecamylamine has

Glossary 235

been used as a ganglionic blocker in treating hypertension, but, like most ganglionic blockers, is more often used now as a research tool. [NIH] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Menopause: Cessation of menstruation in the human female, occurring usually around the age of 50. [EU] Menthol: An alcohol produced from mint oils or prepared synthetically. [NIH]

Metabolite: process. [EU]

Any substance produced by metabolism or by a metabolic

Methamphetamine: A central nervous system stimulant and sympathomimetic with actions and uses similar to dextroamphetamine. The smokable form is a drug of abuse and is referred to as crank, crystal, crystal meth, ice, and speed. [NIH] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Naltrexone: Derivative of noroxymorphone that is the N-cyclopropylmethyl congener of naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. The FDA has approved naltrexone for the treatment of alcohol dependence. [NIH] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neuroleptic: A term coined to refer to the effects on cognition and behaviour of antipsychotic drugs, which produce a state of apathy, lack of initiative, and limited range of emotion and in psychotic patients cause a reduction in confusion and agitation and normalization of psychomotor activity. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Neuropharmacology: The branch of pharmacology dealing especially with the action of drugs upon various parts of the nervous system. [NIH] Neurotransmitter: Chemical compound that acts as a messenger to carry signals or stimuli from one nerve cell to another. [NIH] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nicotine: An alkaloid derived from the tobacco plant that is responsible for smoking's psychoactive and addictive effects; is toxic at high doses but can

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be safe and effective as medicine at lower doses. [NIH] Ondansetron: A competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and it has reported anxiolytic and neuroleptic properties. [NIH] Opiate: A remedy containing or derived from opium; also any drug that induces sleep. [EU] Opium: The air-dried exudate from the unripe seed capsule of the opium poppy, Papaver somniferum, or its variant, P. album. It contains a number of alkaloids, but only a few - morphine, codeine, and papaverine - have clinical significance. Opium has been used as an analgesic, antitussive, antidiarrheal, and antispasmodic. [NIH] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH] Outpatients: Persons who receive ambulatory care at an outpatient department or clinic without room and board being provided. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Pancreas: A mixed exocrine and endocrine gland situated transversely across the posterior abdominal wall in the epigastric and hypochondriac regions. The endocrine portion is comprised of the islets of langerhans, while the exocrine portion is a compound acinar gland that secretes digestive enzymes. [NIH] Paralysis: Loss or impairment of motor function in a part due to lesion of the neural or muscular mechanism; also by analogy, impairment of sensory function (sensory paralysis). In addition to the types named below, paralysis is further distinguished as traumatic, syphilitic, toxic, etc., according to its cause; or as obturator, ulnar, etc., according to the nerve part, or muscle specially affected. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Perinatal: Pertaining to or occurring in the period shortly before and after birth; variously defined as beginning with completion of the twentieth to twenty-eighth week of gestation and ending 7 to 28 days after birth. [EU] Pharmacists: Those persons legally qualified by education and training to engage in the practice of pharmacy. [NIH] Pharmacodynamics: The study of the biochemical and physiological effects of drugs and the mechanisms of their actions, including the correlation of actions and effects of drugs with their chemical structure; also, such effects on the actions of a particular drug or drugs. [EU]

Glossary 237

Pharmacokinetics: The pattern of absorption, distribution, and excretion of a drug over time. [NIH] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of yeasts. [NIH] Placebos: Any dummy medication or treatment. Although placebos originally were medicinal preparations having no specific pharmacological activity against a targeted condition, the concept has been extended to include treatments or procedures, especially those administered to control groups in clinical trials in order to provide baseline measurements for the experimental protocol. [NIH] Placenta: A highly vascular fetal organ through which the fetus absorbs oxygen and other nutrients and excretes carbon dioxide and other wastes. It begins to form about the eighth day of gestation when the blastocyst adheres to the decidua. [NIH] Poisoning: A condition or physical state produced by the ingestion, injection or inhalation of, or exposure to a deleterious agent. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. [NIH] Proportional: Being in proportion : corresponding in size, degree, or intensity, having the same or a constant ratio; of, relating to, or used in determining proportions. [EU] Psychiatric: Pertaining to or within the purview of psychiatry. [EU] Psychiatry: The medical science that deals with the origin, diagnosis, prevention, and treatment of mental disorders. [NIH] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH] Psychomotor: Pertaining to motor effects of cerebral or psychic activity. [EU] Psychopathology:

The study of significant causes and processes in the

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development of mental illness. [NIH] Psychopharmacology: The study of the effects of drugs on mental and behavioral activity. [NIH] Psychosomatic: Pertaining to the mind-body relationship; having bodily symptoms of psychic, emotional, or mental origin; called also psychophysiologic. [EU] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Psychotropic: Exerting an effect upon the mind; capable of modifying mental activity; usually applied to drugs that effect the mental state. [EU] Pulmonary: Pertaining to the lungs. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Reflex: 1; reflected. 2. a reflected action or movement; the sum total of any particular involuntary activity. [EU] Respiratory: Pertaining to respiration. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Schizophrenia: A severe emotional disorder of psychotic depth characteristically marked by a retreat from reality with delusion formation, hallucinations, emotional disharmony, and regressive behavior. [NIH] Sedative: 1. allaying activity and excitement. 2. an agent that allays excitement. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Socialization: The training or molding of an individual through various relationships, educational agencies, and social controls, which enables him to become a member of a particular society. [NIH] Somatic: 1. pertaining to or characteristic of the soma or body. 2. pertaining

Glossary 239

to the body wall in contrast to the viscera. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Stimulant: 1. producing stimulation; especially producing stimulation by causing tension on muscle fibre through the nervous tissue. 2. an agent or remedy that produces stimulation. [EU] Strychnine: An alkaloid found in the seeds of nux vomica. It is a competitive antagonist at glycine receptors and thus a convulsant. It has been used as an analeptic, in the treatment of nonketotic hyperglycinemia and sleep apnea, and as a rat poison. [NIH] Sublingual: Located beneath the tongue. [EU] Substrate: A substance upon which an enzyme acts. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU] Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Tolerance: A condition in which higher doses of a drug are required to produce the same effect as during initial use; often is associated with physical dependence. [NIH] Toxic: Causing temporary or permanent effects that are detrimental to the functioning of a body organ or group of organs. [NIH] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Tranquilizers: Drugs prescribed to promote sleep or reduce anxiety; this National Household Survey on Drug Abuse classification includes benzodiazepines, barbiturates, and other types of CNS depressants. [NIH] Transdermal: Entering through the dermis, or skin, as in administration of a

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drug applied to the skin in ointment or patch form. [EU] Tremor: An involuntary trembling or quivering. [EU] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH] Ureter: One of a pair of thick-walled tubes that transports urine from the kidney pelvis to the bladder. [NIH] Urinalysis: Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. [NIH] Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses, or rickettsiae), administered for the prevention, amelioration or treatment of infectious diseases. [EU] Vascular: Pertaining to blood vessels or indicative of a copious blood supply. [EU] Ventral: 1. pertaining to the belly or to any venter. 2. denoting a position more toward the belly surface than some other object of reference; same as anterior in human anatomy. [EU] Withdrawal: A variety of symptoms that occur after chronic use of some drugs is reduced or stopped. [NIH]

General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna

·

Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna

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A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna

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·

Dorland's Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna

·

Dorland's Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna

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Dorland's Pocket Medical Dictionary (Dorland's Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna

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Melloni's Illustrated Medical Dictionary (Melloni's Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna

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Stedman's Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna

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Stedman's Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna

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Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna

242 Nicotine Dependence

INDEX A Abortion .........................................36, 229 Acculturation........................................121 Acetylcholine .........................37, 109, 231 Acid................83, 103, 175, 177, 183, 239 Adolescence ......39, 92, 97, 131, 229, 236 Adverse ...................20, 34, 130, 179, 199 Amphetamine ........................................83 Aneurysm ........................18, 36, 106, 229 Antidepressants.............................83, 198 Anxiety...... 24, 26, 83, 99, 198, 221, 230, 239 Arterial ...................36, 115, 222, 229, 233 Atropine .................................................74 B Bacteria .........................40, 174, 239, 240 Bronchial................................25, 122, 230 Bronchitis ...............................................18 Bronchopulmonary ..............................108 Bupropion ..................21, 77, 89, 194, 198 C Capsules..............................................177 Carbohydrate.........................38, 176, 233 Carcinogenic........................................106 Carcinogens ....................................20, 76 Carcinoma ...........................................130 Cardiac ....................................19, 38, 233 Cardiovascular...19, 25, 36, 108, 115, 229 Cerebrovascular ............................25, 115 Cervical................................................115 Chlorpromazine .......................74, 97, 231 Cholesterol ..................................174, 176 Cholinergic.....................................26, 109 Chromosomal ........................................85 Chronic .....11, 18, 25, 26, 40, 77, 89, 103, 106, 107, 115, 196, 197, 198, 199, 240 Cocaine ....... 16, 25, 26, 44, 74, 102, 123, 201, 203, 207, 210, 211, 212, 215, 216, 218, 221, 232 Comorbidity .......................82, 87, 93, 116 Confusion ....................................222, 235 Coronary........................18, 106, 115, 119 Cortex ....................................................24 Crack ...........................................201, 216 Craving .....11, 17, 22, 25, 27, 54, 70, 196, 201, 205 Cues ..............................................53, 199 D Degenerative .......................................175 Deprivation ....................................53, 160 Detoxification ...............195, 205, 208, 215

Diarrhea .............................................. 174 Dopamine... 14, 15, 16, 26, 36, 37, 83, 86, 97, 229, 230, 231 E Emphysema .................................... 18, 25 Enzyme ............... 15, 26, 37, 99, 232, 239 Epidemic ............................... 76, 108, 207 Epidemiological..................................... 92 Epinephrine..................................... 16, 24 Euphoria...................................... 201, 206 F Fatigue .................................... 24, 36, 230 G Galanthamine ..................................... 103 Gastrointestinal ...... 38, 63, 115, 122, 160, 233, 234 Glucose..................... 16, 24, 38, 233, 234 H Habitual......................................... 91, 159 Hepatitis ...................................... 195, 203 Homicide ............................................... 16 Hormone ... 24, 37, 38, 175, 182, 233, 234 Hypertension......................... 63, 199, 235 I Incarceration ....................... 202, 208, 209 Induction ..................................... 142, 233 Ingestion ................... 19, 24, 39, 177, 237 Inhalation ............ 13, 14, 39, 82, 106, 237 Insecticides ........................................... 19 Institutionalization ............................... 213 Insulin.............................. 16, 38, 233, 234 Intravenous ......................................... 215 L Larynx ........................................... 18, 106 Lesion ........................................... 39, 236 Lethal .................................................... 19 Locomotor ........................................... 162 M Mecamylamine...................................... 54 Membrane..................................... 38, 234 Menopause ........................................... 25 Menthol ................................................. 70 Metabolite ........................................... 177 Methamphetamine .............................. 211 Molecular 39, 40, 128, 134, 135, 238, 239 N Naltrexone... 53, 55, 63, 89, 198, 211, 235 Nasal....................................... 20, 21, 198 Neural ................................... 39, 175, 236 Neuroleptic.................................... 63, 236 Neuronal ............................................. 109

Index 243

Neuropharmacology ..............................90 Neurotransmitter...... 14, 26, 37, 121, 229, 232 Niacin...................................................174 O Ondansetron..........................................57 Opiate ...88, 102, 194, 200, 201, 205, 211, 212, 215, 220 Opium ....................................39, 125, 236 Outpatients ............................................70 Overdose .....................................175, 224 P Pancreas ...........16, 18, 38, 106, 131, 234 Paralysis ..................................19, 39, 236 Perinatal ................................................16 Pharmacists.........................................109 Pharmacodynamics .............................109 Pharmacokinetics ................................109 Phenotype .....................................98, 237 Placebos ..................................55, 63, 237 Placenta.................................................19 Poisoning...............................................19 Precursor .....................................195, 207 Prenatal .........................................95, 109 Prevalence......15, 22, 75, 78, 79, 81, 106, 108, 109, 115, 117, 120, 160 Proportional ...........................................72 Psychiatric ......80, 84, 87, 89, 93, 94, 163, 179, 201, 211, 212, 218 Psychiatry ................89, 99, 108, 113, 237 Psychology ..........................................109 Psychomotor..........................25, 222, 235 Psychopathology ...........................81, 113 Psychotherapy...............89, 194, 197, 211 Psychotropic ..........................................76 Pulmonary ...........106, 107, 115, 122, 230 R Receptor ..................................26, 63, 236 Reflex ..................................................163 Respiratory ..................19, 25, 32, 71, 130

Riboflavin ............................................ 174 S Saliva .................................................... 70 Schizophrenia ............................... 88, 179 Sedative .................................... 16, 24, 81 Selenium ............................................. 176 Socialization.......................................... 93 Somatic ................................. 97, 103, 229 Species ..... 12, 38, 40, 222, 233, 239, 240 Stimulant ...... 16, 24, 34, 36, 79, 81, 210, 222, 229, 235 Stomach........................ 18, 115, 122, 233 Strychnine ........................................... 113 Suicide .................................................. 16 Systemic ....................................... 38, 233 T Thermoregulation................................ 174 Thyroxine ............................................ 175 Tolerance ........................................ 17, 24 Toxic .. 19, 39, 40, 97, 122, 175, 183, 196, 230, 235, 236, 238, 239 Toxicology................................... 106, 129 Tranquilizers ......................................... 80 Transdermal..... 20, 21, 27, 32, 56, 57, 73, 179, 214 Tremor ................................................ 136 Tuberculosis................................ 195, 203 U Ureter .................................................... 18 Urinalysis ............ 195, 213, 216, 222, 240 V Vaccine ........................................... 27, 28 Vascular .................................. 18, 39, 237 Ventral................................................... 86 W Withdrawal . 14, 17, 20, 21, 23, 25, 26, 27, 53, 56, 57, 70, 74, 80, 82, 89, 119, 125, 160, 161, 162, 163, 195, 205, 208, 214, 224, 232

244 Nicotine Dependence

Index 245

246 Nicotine Dependence