Nicotine dependence: health consequences, smoking cessation therapies, and pharmacotherapy

Nicotine dependence is a significant addiction with many health consequences. Consistent attempts and efforts at addressing this condition, guiding and advising afflicted patients using motivational techniques and the 5-A stepwise strategies, and instituting appropriate therapies will result in better health outcomes and less incidence of diseases. In pharmacotherapy, Nicotine replacement therapy and oral medications can be used alone or in combination with varying degrees of success.     

尼古丁依赖的脑功能MRI研究进展

近年来,随着功能磁共振技术的发展,越来越多的研究者运用这种技术以探讨尼古丁依赖的神经生物学机制。作者主要总结了尼古丁神经药理作用的脑功能成像研究进展,证实了尼古丁依赖与多巴胺奖赏环路、认知、渴求脑环路之间的相关性。这些研究发现将为人类认识尼古丁依赖的大脑功能改变提供了一定的客观证据,深入认识与尼古丁依赖相关的脑功能状态可能有助于从药理学和行为学上改进戒烟的治疗。     

奎硫平对酒精依赖患者稽延性戒断症状及睡眠质量的影响

目的探究奎硫平对酒精依赖患者稽延性戒断症状及睡眠质量的影响。方法选择我院2015年2月至2019年2月收治的82例长期酒精依赖患者,按随机数字表法将其分为试验组(41例,苯二氮卓类药物+维生素B+奎硫平)和对照组(41例,苯二氮卓类药物+维生素B)。比较两组患者干预前、后的焦虑、抑郁情况、渴求情况及睡眠情况。结果干预后,两组的汉密顿焦虑量表(HAMA)及汉密尔顿抑郁量表(HAMD)、宾夕法尼亚酒精渴求量表(PACS)及视觉评估量表(VAS)评分均降低,且试验组均明显低于对照组(P<0.05)。干预后,两组的睡眠潜伏期(SL)均缩短,总睡眠时间(TST)均延长,睡眠效率(SE)均提高,觉醒次数(AN)均减少,且试验组各项睡眠指标均优于对照组(P<0.05)。结论小剂量奎硫平可缓解长期酒精依赖患者戒断时焦虑、抑郁、渴求心理,同时还有助于提高患者的睡眠质量。     

Flupirtine dependence and withdrawal syndrome

This is the case of a 49-year-old woman, who was treated as an inpatient due to long-term flupirtine use and consecutive dependence to flupirtine. Earlier attempts to reduce the substance use by the patient herself had failed because of withdrawal symptoms such as sweating, tremor and mood alterations. There have been case reports suggesting positive reinforcing effects of flupirtine, consecutive dependence and a flupirtine-specific withdrawal syndrome. In the case reported here, flupirtine withdrawal was monitored by psychometric scales over the inpatient treatment including Beck Depression Inventory (BDI) and specific withdrawal scales for benzodiazepine withdrawal such as the Clinical Institute Withdrawal Assessment scale-Benzodiazepines (CIWA-B) and the Benzodiazepine Craving Questionnaire (BCQ).     

Effects of smoking and paroxetine on stress-induced craving and withdrawal symptoms

Background: When smokers relapse, many cite stressful circumstances as the cause. Most smoking cessation medications do not prevent stress-induced increases in craving and withdrawal symptom severity; however, the effect of smoking prior to stress exposure on symptom severity is unclear.

Methods: We examined how smoking a cigarette immediately prior to a stressful task affects craving and withdrawal symptom severity by analyzing data from a double-blind, crossover study assessing paroxetine’s effects on the physiological response to the combination of stress and smoking. Measures were obtained prior to and following smoking/stress exposure and following a subsequent 30-min period at two laboratory sessions (i.e., after 1 month each of paroxetine and placebo).

Results: Among study completers (n = 63), severity of craving decreased from the beginning of the session to immediately following the smoking/stress exposure (p < 0.01) and severity of smoking urges decreased from the beginning to the end of the laboratory session (p < 0.001). Withdrawal symptoms were less severe while taking paroxetine vs. placebo (p < 0.05) but no treatment × time effects were observed.

Conclusions: Additional research is needed to identify interventions that could similarly decrease stress-induced craving in order to determine if smoking cessation rates can be increased.     

Increased pain sensitivity in alcohol withdrawal syndrome

Withdrawal from analgesic and addictive substances such as opioids or ethanol is associated with increased sensitivity to sensory stimulation in animal models. Here, we investigated perception of innocuous and noxious thermal or electric stimuli applied to the left hand or sternum in 30 male patients undergoing withdrawal from alcohol, 30 male abstained alcoholics and matched controls. The alcohol withdrawal scale and the Banger score were obtained to estimate the severity of withdrawal. In addition, the Beck depression inventory was used to estimate the influence of depressive symptoms on pain perception. The data presented provide substantial evidence that subjects undergoing alcohol withdrawal show increased heat pain sensitivity. Interestingly, this effect was observed both on the left hand and sternum. Pain thresholds and tolerances of electric stimuli did not differ between groups. However, in a subgroup analysis, a higher sensitivity for electrical pain thresholds and tolerances was observed in those patients that were identified to require pharmacological treatment for withdrawal according to disease severity. Furthermore, the perceived painful thermal and electrical sensation was substantially influenced by the affective state of patients. No differences were found between patients of the abstained group and control subjects for any pain parameter. In conclusion, we demonstrate withdrawal‐induced hyperalgesia upon thermal stimulation in patients. Since the influence of affective symptoms on pain perception during withdrawal is remarkable, we assume that peripheral and central mechanisms might account for this finding, which should be assessed in detail in future studies.     

The association between active and passive smoking and frequent pain in a general population

Background: It is controversial whether the association between back pain, and other types of chronic pain, and smoking is causal or not. Aim: To examine the relationship between frequent pain and smoking, and between frequent pain and exposure to environmental tobacco smoke (ETS) in smokers and non‐smokers. Methods: A randomised population‐based study, Inter99 (1999–2006), Denmark. Subjects in the intervention groups (N=6784; participation rate=52.5%) completed self‐report questionnaires. Cross‐sectional data from baseline were analysed in adjusted logistic regression analyses to investigate the relationship between active and passive smoking and frequent pain in the back, abdomen, joints and head. Results: Daily smokers reported significantly more frequent pain in every of the six locations, and in several, minimum three, locations (OR=1.98 (95%CI=1.6–2.4)) than never smokers. We found a dose–response relationship between frequent pain and intensity of both active and passive smoking (test‐for‐trend p<0.001). Those exposed to 5h or more of ETS reported significantly more frequent pain than those almost never exposed to ETS (non‐smokers: OR=1.46 (95%CI=1.2–1.8), and smokers: OR=2.04(95%CI=1.4–3.0)). Also, an earlier smoking debut and an increasing number of pack‐years increased the probability of frequent pain in daily smokers (test‐for‐trend p<0.05). Conclusion: We found significant association, dose–response and reversibility between active smoking and frequent pain in all six locations. Furthermore, we found that increasing intensity of ETS increased the probability of frequent pain in non‐smokers, which has not been shown before. In conclusion, several findings in this study indicate a causal link between tobacco smoke and pain, which is supported by recent prospective studies.     

Combined effects of major depression, pain and somatic disorders on general functioning in the general adult population

This study was carried out to assess the prevalence of major depressive disorder (MDD) in persons suffering from pain symptoms in various locations, both with and without comorbid somatic disorders and to analyze the single and combined effects of MDD, pain symptoms and somatic disorders on general functioning in the community. The 12-month prevalence of MDD, somatic disorders and pain symptoms, grouped according to location, were determined among 4181 participants from a community sample. Depression was assessed utilising the Composite International Diagnostic Interview. Pain symptoms were self-reported by participants whereas medical diagnoses were validated by medical examinations. General functioning was evaluated utilising the established MOS-SF-36 scale. The prevalence of MDD was significantly increased for persons with pain in any location. In the absence of a somatic disorder, MDD prevalence was highest in persons with abdominal/chest pain (9.3%) and arm or leg pain (7.9%) and lowest in persons with back pain (6.2%). Mental and physical well-being were lowest for persons with both MDD and a somatic disorder, irrespective of pain locations. Increasing numbers of pain locations impaired mental and physical well-being across all groups, but the effect on mental well-being was most marked in participants with MDD and comorbid somatic disorders. The presence of pain increases risk of associated MDD. The number of pain locations experienced, rather than the specific location of pain, has the greatest impact on general functioning. Not only chronic pain, but pain of any type may be an indicator of MDD and decreased general functioning.     

Nicotine dependence and smoking topography among Black and White women

Nicotine dependence is a complex phenomenon involving behavioral, biological, and pharmacological components that influence smoking cessation rates. The purpose of this study was to characterize the multidimensional aspects of nicotine dependence and cigarette smoking topography behaviors among Black and White women smokers. Thirty-seven women participated in a 2-hr protocol in the General Clinical Research Center. Plasma cotinine to cigarette ratio was significantly associated with three topography variables: total puff duration, total cigarette time, and carbon monoxide (CO) boost. Black women scored higher on plasma cotinine levels, cotinine per cigarette ratio, and CO increase pre- to postcigarette than White women. Implications for clinical practice include assessing nicotine dependence beyond self-reported cigarettes per day to develop more appropriate smoking cessation interventions. © 1997 John Wiley & Sons, Inc. Res Nurs Health 20: 505–514, 1997.     

Duration of sleep contributes to next-day pain report in the general population

Cross-sectional research in clinical samples, as well as experimental studies in healthy adults, suggests that the experiences of pain and sleep are bi-directionally connected. However, whether sleep and pain experiences are prospectively linked to one another on a day-to-day basis in the general population has not previously been reported. This study utilizes data from a naturalistic, micro-longitudinal, telephone study using a representative national sample of 971 adults. Participants underwent daily assessment of hours slept and the reported frequency of pain symptoms over the course of one week. Sleep duration on most nights (78.0%) was between 6 and 9h, and on average, daily pain was reported with mild frequency. Results suggested that hours of reported sleep on the previous night was a highly significant predictor of the current day's pain frequency (Z=-7.9, p<.0001, in the structural equation model); obtaining either less than 6 or more than 9h of sleep was associated with greater next-day pain. In addition, pain prospectively predicted sleep duration, though the magnitude of the association in this direction was somewhat less strong (Z=-3.1, p=.002, in the structural equation model). Collectively, these findings indicate that night-to-night changes in sleep affect pain report, illuminating the importance of considering sleep when assessing and treating pain.     

米氮平治疗海洛因依赖患者稽延性戒断症状的疗效观察

目的探讨米氮平治疗海洛因依赖患者稽延性戒断症状的疗效。方法将120例海洛因依赖患者随机分为米氮平治疗组(研究组)55例,康复欣治疗组(对照组)65例。两组在急性期均选用美沙酮脱毒治疗10d,尿液检查呈阴性患者分别服用米氮平和康复欣治疗。米氮平15～30mg·d-1,康复欣4粒·d-1,疗程均为4w。于治疗前及治疗第1、2、3、4w末采用稽延性戒断症状评定量表评定临床疗效,并进行对比分析。结果稽延性戒断症状量表评定两组治疗第4w末总分及各因子分显著低于治疗前;躯体症状因子分在治疗第1、2、3w末研究组显著高于对照组;情绪因子分在治疗第1、2、3、4w末对照组显著高于研究组;渴求因子分在治疗第1、2、3、4w末研究组显著高于对照组;睡眠因子分在治疗第1、2w末对照组显著高于研究组。结论米氮平对稽延性戒断症状有良好的疗效,特别是对情绪和睡眠障碍有显著改善。     

Escitalopram is associated with reductions in pain severity and pain interference in opioid dependent patients with depressive symptoms

Pain is common among opioid-dependent patients, yet pharmacologic strategies are limited. The aim of this study was to explore whether escitalopram, a selective serotonin reuptake inhibitor, was associated with reductions in pain. The study used longitudinal data from a randomized, controlled trial that evaluated the effects of escitalopram on treatment retention in patients with depressive symptoms who were initiating buprenorphine/naloxone for treatment of opioid dependence. Participants were randomized to receive escitalopram 10 mg or placebo daily. Changes in pain severity, pain interference, and depression were assessed at 1-, 2-, and 3-month visits with the visual analog scale, Brief Pain Inventory, and the Beck Depression Inventory II, respectively. Fixed-effects estimators for panel regression models were used to assess the effects of intervention on changes in outcomes over time. Additional models were estimated to explore whether the intervention effect was mediated by within-person changes in depression. In this sample of 147 adults, we found that participants randomized to escitalopram had significantly larger reductions on both pain severity (b = −14.34, t = −2.66, P < .01) and pain interference (b = −1.20, t = −2.23, P < .05) between baseline and follow-up. After adjusting for within-subject changes in depression, the estimated effects of escitalopram on pain severity and pain interference were virtually identical to the unadjusted effects. This study of opioid-dependent patients with depressive symptoms found that treatment with escitalopram was associated with clinically meaningful reductions in pain severity and pain interference during the first 3 months of therapy.     

Prevalence and characteristics of chronic pain in the general Norwegian population

BACKGROUND: Population-based studies suggest that prevalence of chronic pain is increasing. The purpose of this study was to determine the prevalence of chronic pain in a sample drawn from the general Norwegian population. In addition, the characteristics of chronic pain, as well as differences in demographic characteristics and health-related variables between persons with and without chronic pain were evaluated. METHODS: A total of 4000 Norwegian citizens, were randomly drawn from the National Register, by Statistics Norway and were mailed a questionnaire. RESULTS: The response rate was 48.5%. The majority of the sample was female (51%), married (59%), and working for pay (69%) with a mean age of 45.2 years. The prevalence of chronic pain in the total sample was 24.4%, and 65% of the participants with chronic pain indicated that they had experienced chronic pain for over 5 years. The cause of the pain was not specified by 57% of the participants in chronic pain, and 31% reported no pain treatments. Women, older individuals, persons with less education, and those who were pensioned, reported chronic pain more frequently. The results of a logistic regression analysis indicate that the variables that provide unique contributions to predicting pain group memberships were: gender, education, being frequently ill, or having a chronic illness. CONCLUSIONS: These findings suggest that chronic pain is a significant problem in the general Norwegian population, and that gender, education, being frequently ill, or having a chronic illness are important variables in predicting pain group membership.     

The relationship between nicotine dependence and addiction severity amongst cocaine abusers

The Addiction Severity Index (ASI) and the Fagerström Test of Nicotine Dependence (FTND) are two widely used instruments in their respective domains, but have rarely been used simultaneously with a substance abuse population. It is argued that the complex link between nicotine and substance dependence continues not to be well understood, partially because the measures of smoking in published research with addiction treatment populations have not been standardized. We studied ASI and FTND responses of 102 crack‐cocaine patients in order to examine the potential utility of using both instruments to enhance our understanding of these addictions and their relationship to each other. Total FTND scores were significantly related to ASI drug severity, psychiatric severity and psychiatric composite scores. Controlling for gender variance yielded similar results. We conclude that using the FTND does prove to be more sensitive than a less objective measure of smoking, but the ASI and FTND appear to be psychometrically distinct, making conjoint use for research limited with some clinical applicability.     

Associations between pain and current smoking status among cancer patients

There is growing empirical and clinical interest in purported associations between smoking and the aggravation of cancer symptoms and treatment side effects, such as pain. Both pain and smoking are highly prevalent among persons with cancer, and there is recent evidence to suggest that cancer patients who continue to smoke despite their diagnosis experience greater pain than nonsmokers. Accordingly, the main goal of this cross-sectional study was to examine associations between multiple levels of smoking status and several pain-related outcomes among a sample of 224 cancer patients about to begin chemotherapy. Patients completed self-report measures of pain severity, pain-related distress, and pain-related interference, as well as a demographics questionnaire. Results indicated that persons who continued to smoke despite being diagnosed with cancer reported more severe pain than never smokers, F (2, 215) = 3.47, p < .05. Current smokers also reported greater interference from pain than either former or never smokers, F (2, 215) = 5.61, p < .01. Among former smokers, an inverse relation between pain severity and the number of years since quitting smoking was observed, r (104) = −.26, p < .01. These data suggest that continued smoking despite a cancer diagnosis is associated with greater pain severity and interference from pain; however, future research is warranted to determine the directionality of this relationship.     

Association of neck pain with symptoms of temporomandibular dysfunction in the general adult population

The association of neck pain with symptoms of temporomandibular dysfunction in the general adult population was evaluated in a sample of 483 subjects selected from the population living in the municipality of Segrate, northern Italy. Subjects were interviewed by a standard questionnaire about oral conditions, temporomandibular symptomatology and neck pain. Symptoms related to the Helkimo Anamnestic Index were the indicators of temporomandibular dysfunction, and the evaluation also included history of trauma of the masticatory system. Troublesome neck pain was experienced within the last year in 38.9% of the total series, and the prevalence of complaints was higher in women than in men (41.7 vs 34.4%). Prevalence increased with age (p < 0.005) and was significantly higher in subjects with than without temporomandibular symptomatology (47.4 vs 28.6%, p < 0.0001). At univariate analysis, facial and jaw pain (p < 0.001) and feeling of stiffness or fatigue of the jaws (p < 0.01) were significantly related to neck pain. Age- and sex-adjusted multiple logistic analysis showed that neck pain is associated with the temporomandibular symptomatology as a whole (p < 0.001), and in particular with facial and jaw pain (p < 0.01). These findings confirm that there is a significant association between neck pain and the temporomandibular symptomatology. Moreover, they suggest that the most relevant relationship is with facial and jaw pain, according to recent neurophysiologic studies on pain mechanism. Further clinical and longitudinal studies are desirable in order to give a better clarification of mutual specific roles of craniocervical and temporomandibular disorders in the aetiology of these pathologies.     

The effects of depression and smoking on pain severity and opioid use in patients with chronic pain

Depression and smoking are common comorbid conditions among adults with chronic pain. The aim of this study was to determine the independent effects of depression on clinical pain and opioid use among patients with chronic pain according to smoking status. A retrospective design was used to assess baseline levels of depression, clinical pain, opioid dose (calculated as morphine equivalents), and smoking status in a consecutive series of patients admitted to a 3-week outpatient pain treatment program from September 2003 through February 2007. Depression was assessed using the Centers for Epidemiologic Studies-Depression scale, and clinical pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. The study cohort (n = 1241) included 313 current smokers, 294 former smokers, and 634 never smokers. Baseline depression (P = .001) and clinical pain (P = .001) were greater among current smokers compared to former and never smokers, and the daily morphine equivalent dose was greater among smokers compared to never smokers (P = .005). In multivariate linear regression analyses, baseline pain severity was independently associated with greater levels of depression, but not with smoking status. However, status as a current smoker was independently associated with greater opioid use (by 27 mg/d), independent of depression scores. The relationship between depression, smoking status, opioid use, and chronic pain is complex, and both depression and smoking status may be potentially important considerations in the treatment of patients with chronic pain who utilize opioids.     

Evaluating screening performances of the Fagerstrom tolerance questionnaire, the Fagerstrom test for nicotine dependence and the heavy smoking index among Taiwanese male smokers

Aim. To compare screening performances of the Fagerstrom Tolerance Questionnaire (FTQ), the Fagerstrom test for nicotine dependence (FTND) and the Heavy Smoking Index (HSI) with a view to determining the optimum cutoff scores using biomarkers as standards. Background. Previous studies proposed inconsistent cutoff scores for the FTQ, the FTND as signalling nicotine dependence and these scores were established by applying diverse standards. Method. Receiver operating characteristic (ROC) analyses were used in pursuit of the study's objectives. Two hundred and forty‐five male smokers were recruited in 2005 from among those attending public health stations in southern Taiwan. The three self‐report measures of nicotine dependence were compared with the saliva cotinine and expired carbon monoxide (CO). The expired CO level was tested by means of a Micro Smokerlyzer, while salivary cotinine was analysed using an enzyme‐linked immunosorbent assay. Results. The areas under the ROC curves for the FTQ, the FTND and the HSI were 0·71, 0·76 and 0·76 for the salivary cotinine and 0·71, 0·79 and 0·80 for the exhaled CO respectively. The sensitivity and specificity of the FTND and the HSI were slightly greater than those for the FTQ. The optimum cutoff scores for the FTQ, the FTND and the HSI as screening tools to establish nicotine dependence would be 5+, 4+ and 3+ respectively. Conclusion. The results indicate that the FTND and the HSI may be more efficacious than the FTQ in assessing nicotine dependence. Further research is needed to confirm these findings, especially among female smokers and for nicotine substitution trials. Relevance to clinical practice. To decrease tobacco‐attributable morbidity and mortality, nurses and healthcare professionals need to implement effective smoking cessation interventions. The FTND and the HSI as well as their cutoff scores will be suitably used to assess nicotine dependence in these interventions.