Tobacco and Public Health - TCSC Indonesia

JACK E. HENNINGFIELD AND NEAL L. BENOWITZ 139
or short-acting barbiturates; morphine-like opioids can also produce an overtly recognizable
syndrome (O’Brien 1996). Deprivation after extended administration of
cocaine and cannabis can also produce a diagnosable withdrawal syndrome; however,
it is only since the mid 1980s that addiction experts have come to generally concur that
these drugs can produce syndromes of withdrawal that can be distinguished from the
lack of the effects of the drugs themselves; the role of the withdrawal syndromes in
sustaining cocaine and cannabis use remains unclear (Gawin and Kleber 1986; O’Brien
1996). Acute deprivation from extended tobacco use produces a syndrome of
withdrawal signs and symptoms that is intermediate between that of the opioids
and cocaine in that it has been recognized for several decades, and is generally understood
to serve as a barrier to even short-term efforts to achieve tobacco abstinence.
Tobacco withdrawal can be occupationally and socially debilitating, but other than
standing as a barrier to extended cessation, is not life-threatening in its own right
(American Psychiatric Association 1996).
Tolerance. A high degree of tolerance develops to the acute effects of nicotine, and
some degree of tolerance is gained during each day of smoking and lost during the
approximately 8 hours of tobacco deprivation during sleeping hours (Swedberg et al.
1990). Tolerance to nicotine has been systematically explored for more than a century
(e.g. Langley 1905). Its mechanisms are diverse and the time course of gain and loss of
tolerance varies across responses under evaluation (Collins and Marks 1989; Balfour
and Fagerstrom 1996; Royal College of Physicians 2000; Perkins 2002). Comparing
drugs of abuse on measures of tolerance is complicated by the varying potential range
of measures that can be considered, however, the general degree of tolerance that is
produced by repeated nicotine exposure is comparable to that produced by other
addictive drugs that produce high levels of tolerance such as the opioids.
Implications for treatment of tobacco dependence
Although many people are able to quit smoking without formal intervention, this
generally occurs only after many cessation attempts and after sufficient harm has been
done to substantially increase the risks of premature mortality (Royal College of
Physicians 2000; US DHHS 2000). For others, perhaps as a consequence of the
pathological changes in brain structure and function produced by long-term nicotine
exposure, achieving remission from dependence without treatment may be no more
readily achievable than achieving remission from coronary artery disease or oral
cancer without treatment. In fact, following surgery for coronary artery disease and
lung cancer caused by smoking, many smokers resume smoking in face of the extraordinarily
high risks (US DHHS 1988) (Fig. 6.1). The U.S. Clinical Practice Guideline:
Treating Tobacco Use and Dependence (Fiore et al. 2000) and reports from the U.S.
Surgeon General (US DHHS 2000) and Royal College of Physicians (2000) describe
behavioral and pharmacological treatment interventions that approximately double