ADDICTIONS

Tobacco Addiction and Abuse

The harmful effects of tobacco use are well-documented, but why do some users persist? Tobacco use disorder is extremely prevalent amongst individuals who smoke cigarettes or use other nicotine medication. An individual might experience nausea and dizziness during the beginning of tobacco use. However, as tolerance increases, these symptoms disappear. Over time, prolonged use might lead to withdrawal effects when the consumption of tobacco is ceased. Cravings for tobacco are experienced in as little as a few hours upon cessation of use. Consequences of prolonged or excessive tobacco use are abundant, with it affecting various facets of life (e.g physical, social aspects).

Tobacco Withdrawal

Tobacco withdrawal is the presence of characteristic withdrawal symptoms that develop after cessation of, or reduction in, tobacco consumption. Symptoms typically develop within a few hours or days after prolonged use and cause significant distress or impairment in social, occupational, or other important areas of functioning. The following must be observed:

  1. Daily use of tobacco for at least several weeks

  2. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, causing clinically significant distress or impairment in social, occupational, or other important areas of functioning, followed within 24 hours by four or more of the following signs/symptoms:

    • Irritability, frustration, or anger

    • Anxiety

    • Difficulty concentrating

    • Increased appetite

    • Restlessness

    • Depressed mood

    • Insomnia

Credits: AsapSCIENCE

Tobacco Use Disorder

To be diagnosed with tobacco use disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, a problematic pattern of tobacco use leading to clinically significant impairment or distress must be observed, as manifested by at least two of the following, occurring within a 12-month period:

Alcohol Use Disorder.jpg

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

  2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.

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

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

  5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g interference with work)

  6. Continued tobacco use despite having persistent or recurrent social and interpersonal problems caused or exacerbated by the effects of tobacco (e.g arguments with others about tobacco use)

  7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use.

  8. Recurrent tobacco use in situations in which it is physically hazardous (e.g smoking in bed).

  9. Tobacco use is continued despite knowledge of having a persistent or recurrent physical or physiological problem that is likely to have been caused or exacerbated by tobacco.

  10. Tolerance, as defined as either of the following:

    • A need for markedly increased amounts of tobacco to achieve the desired effect

    • A markedly diminished effect with continued use of the same amount of tobacco

  11. Withdrawal, as manifested by either of the following:

    • The characteristic withdrawal syndrome for tobacco

    • Tobacco (or nicotine) is taken to relieve or avoid withdrawal symptoms.

The severity of tobacco use disorder is classified under the following categories: Mild (2 - 3 symptoms), Moderate (4 - 5 symptoms), and Severe (6 or more symptoms).

Prevalence and Course

Roughly 10% of Singaporeans aged 18-29 smoke cigarettes. Amongst secondary school, ITE, and Polytechnic students, the prevalence of smoking is around 4%, due to the social desirability factor of wanting to be perceived as “cool”.

While 80% of individuals who use tobacco attempt to quit, 60% end up relapsing within a week and only 5% end up abstaining from tobacco use altogether.

Risk Factors

There are several temperamental risk factors that increase the probability of tobacco use, though these factors differ between children and adults. Examples of risk factors for children include attention-deficit hyperactive disorder and conduct disorders. As for adults, depression, bipolar disorder, personality disorders or other substance use disorder might put one at higher risk of experiencing tobacco withdrawal/having tobacco use disorder.

Environmental risk factors include lower incomes and lower educational levels. Genetic factors also contribute to initiating and continuation of tobacco use. Smoking is also more prevalent in developing countries than in developed countries.

Consequences and Comorbidity

Around 50% of smokers who do not cease tobacco use tend to have a shorter life expectancy, with this decrease in life expectancy related to a tobacco-related illness (e.g heart disease and cancer). These illnesses might have resulted from the carbon monoxide, tar, and other chemicals found in cigarettes.

Medical diseases from tobacco use include cardiovascular illnesses, chronic obstructive pulmonary disease (airflow to lungs get obstructed), and cancer. Psychiatric comorbidities like substance use, depression, bipolar disorder, personality disorders, and ADHD range from 22%-32%. Individuals that depend on nicotine are also 3 – 8 times more likely to have these disorders as compared to a non-smoker.

Therapy

Nicotine replacement therapy is one of the most popular forms of pharmacotherapy for tobacco use disorder where nicotine replacements are prescribed to satisfy some of the cravings from withdrawal. However, research indicates that a combination of medication with behavioral management procedures improve the rates of quitting.

Behavioral managements include Cognitive Behavioral Therapy (CBT), Motivational Interviewing, and Mindfulness. During CBT, clients are taught to identify triggers and coping strategies to manage during stressful situations, when cravings are the largest. In Motivational Interviewing, clients explore the pros and cons of tobacco use and their motivation is enhanced to quit. The discrepancies between current behavior and ideal behavior are pointed out in order to motivate the clients. Mindfulness-based therapy often requires clients to practice being aware and detaching from their cravings. The expectations of withdrawal symptoms are reframed as expected and tolerable.

How can you support someone with Tobacco Use Disorder?

1.      Don’t nag, scold, or take a negative tone. This will place the person in a defensive stance and information will not be well-received. Instead, try to offer non-judgmental support.

2.      If someone has just begun their journey to quit, be supportive as withdrawal symptoms might cause them to be irritable. Offer to bring them to the doctor if they require any medication to suppress these symptoms.

3.      Remove triggers from their environment – go to areas that do not encourage smoking, such as a swimming pool or a shopping center. If there are tobacco-related products at home, help to throw them away.  

4.      Most importantly, know that relapses might occur because the withdrawal symptoms are extremely uncomfortable. Even so, it is important to be supportive and encouraging when relapses happen.