SN2 SHORT NOTE 5M

Write a short note on nicotine dependence and smoking cessation (de-addiction).

General Medicine · Final Professional

Nicotine Dependence

Nicotine binds nicotinic acetylcholine receptors in the ventral tegmental area, releasing dopamine in the nucleus accumbens — the reward pathway shared by all addictive drugs. Reinforcement is rapid because inhaled nicotine reaches the brain within 10–20 seconds. Chronic use causes receptor up-regulation, so abstinence produces withdrawal.

Dependence severity is assessed by the Fagerström Test for Nicotine Dependence; the single most predictive question is time to first cigarette after waking (within 30 minutes indicates high dependence).

Withdrawal Symptoms

Begin within hours, peak at 2–3 days, and largely subside by 3–4 weeks, though craving may persist for months.

Craving — the most persistent symptom
Irritability, anxiety, restlessness, low mood
Poor concentration
Increased appetite and weight gain (average 3–5 kg)
Insomnia, headache, constipation

ASSESSMENT — THE 5 A's

Ask about tobacco use at every visit; Advise every user to quit in a clear personalised way; Assess willingness to make an attempt; Assist with pharmacotherapy and counselling; Arrange follow-up, ideally within the first week when relapse risk is highest.

For those unwilling to quit, use the 5 R's — Relevance, Risks, Rewards, Roadblocks, Repetition — to build motivation.

Pharmacotherapy

Agent	Mechanism	Key Points
Nicotine replacement therapy (patch, gum, lozenge, inhaler, nasal spray)	Replaces nicotine without the tar and carbon monoxide	Combining a patch (background) with gum or lozenge (breakthrough craving) is more effective than either alone
Varenicline	Partial agonist at alpha-4-beta-2 nicotinic receptors — relieves craving while blocking reward from smoking	The most effective single agent; start 1 week before the quit date; nausea and vivid dreams are common
Bupropion	Dopamine–noradrenaline reuptake inhibitor	Useful where weight gain is a concern; contraindicated in epilepsy and eating disorders (lowers seizure threshold)

Combination of pharmacotherapy with behavioural counselling roughly doubles quit rates compared with either alone — this is the key examination point.

Non-pharmacological Measures

Set a definite quit date; remove tobacco and ashtrays from home and workplace; identify and avoid triggers (tea/coffee, alcohol, peer groups); teach coping strategies for craving, which typically lasts only a few minutes; enlist family support; use telephone quit-lines. In India, the National Tobacco Control Programme and the national quit-line (1800-11-2356) provide free support.

Relapse

Most attempts fail — the average smoker requires several attempts before lasting abstinence. Treat relapse as part of the process, not as failure: review what triggered it, and restart. Follow-up should be arranged at 1 week, 1 month and 3 months.

CLINICAL PEARL

Smoking cessation is the single most effective intervention in COPD — it slows the accelerated decline in FEV1 towards the normal age-related rate. It also reduces cardiovascular risk substantially within 1 year, and lung cancer risk progressively over 10–15 years. Benefit occurs at any age and at any stage of disease.

NEEDS VERIFICATION

Varenicline dosing schedule and current availability status in India — confirm before publication, as marketing status has changed in some markets.

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