Supplemental Reading

Benowitz NL (ed). Nicotine Safety and Toxicity. New York: Oxford University Press, 1998.

Clementi F, Fornasari D, and Gotti C. (eds). Neuronal Nicotinic Receptors. Berlin: Springer Verlag, 2000.

Elfvin L-G, Lindh B and Hookfelt T. The chemical neuroanatomy of sympathetic ganglia. Annu Rev Neurosci 1993;16:471-507.

Fant RV, Owen CC, and Henningfield JE. Nicotine replacement therapy. Prim. Care 1999;26:633-652.

Lee EW and D'Alonzo GE. Cigarette smoking, nicotine addiction and its pharmacological treatment. Arch Intern Med 1993;153:34-48.

Sargent PB. The diversity of neuronal nicotine acetyl-choline receptors. Annu Rev Neurosci 1993;16:403-443.

^ Case Study Smoking Cessation

A patient who has been a heavy smoker (2 packs of cigarettes per day for 30 years) comes to you for advice to quit smoking. You inform your patient that sudden cessation of smoking will result in withdrawal symptoms that may include restlessness, irritability, anxiety, tension, stress, intolerance, drowsiness, frequent awakenings from sleep, fatigue, depression, impotence, confusion, impaired concentration, gastrointestinal disturbances, decreased heart rate, and impaired reaction times. You advise your patient that successful cessation of tobacco use requires attention to both the positive and negative (withdrawal) reinforcement properties of nicotine and tobacco use. You plan, therefore, to combine both psychological and pharmacological treatment. What are some therapeutic approaches you can suggest?

Answer: Several options are available for the pharmacological approach, including nicotine replacement and antidepressant drugs (e.g., bupropion).

You explain that nicotine replacement can be carried out with chewing gum (nicotine polacrilex), transdermal patches (e.g., Nicoderm, Habitrol), nasal spray (Nicotrol NS), or vapor inhaler (Nicotrol Inhaler). The objective of the nicotine replacement is to obtain a sustained plasma nicotine concentration that is lower than the venous blood concentrations after smoking. It is known that arterial blood concentrations immediately following cigarette smoke inhalation can be as much as 10 times the venous concentration. You decide on a nicotine patch and combine this strategy with counseling and motivational therapy from a professional trained in such methods. It is quite likely that the combination of the patch plus counseling will ultimately result in a successful cessation of smoking in your patient after a couple of relapses. During a second relapse period, you may wish to consider combining the antidepressant drug bupropion with the other forms of treatment.

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