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Chapter 15. Nicotine and Tobacco

Tony P. George, M.D., F.R.C.P.C.; Andrea H. Weinberger, Ph.D.
DOI: 10.1176/appi.books.9781585623440.347930

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Excerpt

Although rates of tobacco use and dependence have been reduced substantially since the 1960s, one in five Americans continues to smoke. The prevalence of smoking appears to be substantially higher in persons with psychiatric and substance use disorders, and these individuals also have less success when they attempt smoking cessation. In this chapter we review the epidemiology of tobacco use and dependence and the pharmacological effects of nicotine and tobacco and discuss the clinical assessment of tobacco users. We then review behavioral and pharmacological treatments, including the U.S. Food and Drug Administration (FDA)–approved pharmacotherapies: nicotine replacement therapies (NRTs), sustained-release bupropion, and varenicline. Finally, we discuss the integration of tobacco dependence treatment into mental health settings with the view that tobacco dependence is a chronic medical disorder and that more effective treatment of this comorbidity in psychiatric disorders may require targeted treatments based on a better understanding of the pathophysiology of individual psychiatric disorders.

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FIGURE 15–1. Mesolimbic dopamine neurons and their regulation by nicotinic, cholinergic, GABAergic, and glutamatergic inputs.ACh = acetylcholine; DA = dopamine; GABA = γ-aminobutyric acid; Glu = glutamate; NAc = nucleus accumbens; nAChR = nicotinic acetylcholine receptor; VTA = ventral tegmental area.
Table Reference Number
TABLE 15–1. Pharmacological and behavioral treatments for tobacco dependence
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Tobacco dependence rates have decreased substantially, but many people who smoke appear to have comorbidities, such as psychiatric and substance use disorders, that reduce their chance of quitting.

Identification of smokers in clinical settings is of critical importance to the treatment of tobacco dependence.

There are effective pharmacological and behavioral therapies for tobacco dependence, which work best when used in combination.

A better understanding of the pathophysiology of mental health and addictive disorders may lead to improved treatment approaches for tobacco dependence in these smoking populations.

Smokers with psychiatric and substance use comorbidity may best be treated in settings that integrate smoking cessation treatments with mental health and addiction treatment.

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Sample questions:
1.
The 42 nicotinic acetylcholine receptor (nAChR) is the site of action of nicotine. Which of the following statements is not correct?
2.
Nicotine withdrawal features several uncomfortable symptoms that may lead to the diagnosis of a dependence state. Which of the following is not characteristic of nicotine withdrawal?
3.
The mnemonic of the "five As" is a helpful scheme to advise clinicians in assisting patients to stop smoking. Which of the following As is not part of this scheme?
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