NICOTINE

RELATED
DISORDERS
PREPARED BY:
AFSANA KHAN
PRIYANKA SHARMA
SHIVANGI TALWAR
 Nicotine preparation

 The leaves of the tobacco plant are cured and

prepared in different ways, depending on the
intended use of the tobacco
 Leaves dried, then grounded
 Cigars, cigarettes, pipe tobacco, chewing
tobacco, moist snuff
 Nicotine plants

Tobacco & Nicotine

 Introduction
 Nicotine is a colorless, toxic alkaloid made up of
carbon, hydrogen and nitrogen.
 The primary reason why nicotine use has turned into
worldwide concern is because of its ability to induce a
state of euphoria in the brain of the smoker thus leading
to addiction.
 When a person smokes and inhales nicotine, the active
substances are absorbed through alveoli into the lungs
which initiate.
 Chemical reactions in the nerve endings which
increases heart rate, memory, alertness and reaction
time.
 Neurotransmitters called dopamine and later
endorphins are released in the brain producing
feelings of pleasure and satisfaction.
 As an addictive drug, nicotine has two very potent
issues, it is a stimulant as well as depressant.
 Routes of administration
ORALLY
 Not readily absorbed from digestive system;
 pH lower than 6, not very lipid soluble
 Significant first pass metabolism (high rate of
liver
metabolism)

SNIFFED/SNUFFED
 Nicotine absorbed through mucous
membranes of nasal cavity
SMOKED
 90 percent of inhaled nicotine absorbed through mucous

membranes of lungs
 Volume of smoke inhaled vs. duration of inhalation

 Fun Factoid:

OTHER DELIVERY SYSTEMS

 Patch
 Nicotine inhaler
 Lozenges

 Gum
 Effects of nicotine on PNS
Neuromuscular Junctions of Striated or Voluntary

Muscles
• Curare blocks junctions, leading to paralysis and
respiratory arrest.

Effects on the Body

• Muscle tremors
• Decrease in partellar reflex (knee jerk)
At doses found in cigarette smoking

• Increased heart rate and blood pressure

• Constriction of blood vessels in the skin; deleterious

effects on aging.
• Inhibits stomach secretions & stimulated activity of
bowel
• Acts as a laxative with low tolerance
 Effects of Nicotine – PNS & CNS Communication
 Adrenal Glands in PNS affect CNS
 Nicotine stimulates release of epinephrine
 Causes CNS arousal and decrease in alpha activity

 Brain Stem Centers

 Reticular Activating System

 Direct stimulation causes arousal

 Widespread cholinergic projections`1`.3

 Substantial nigra, basal forebrain, thalamus, &

cerebellum.
Medullary Respiratory Centers

 Direct and indirect stimulation

 Overdose of nicotine
 Blocking of these centers and neuromuscular

junctions
 Respiratory arrest
 Effects of nicotine on PNS
Area Postrema / Vomit Center
 5HT system from Raphe to cortex
 Site of action for Antidepressant drugs
 Nicotine may enhance an individual’s level of
alertness.
 Tobacco abuse and dependence may stimulate a
frantic, almost manic picture.
 The speech may also be accelerated in line with
the behaviour.
 Tobacco use can contribute to irritability often
soothened by a dose of nicotine.
 STATISTICS
 It is the second leading cause of death in the
world.
 The WHO estimates that there are 1.3 billion
smokers worldwide today and contributes to
approximately 5 million deaths each year.
 With the present smoking trends, tobacco will
kill 10 million people each year by 2020.
 Non smokers exposed to environmental tobacco
smoke have a significantly higher risk of
developing cancers and pulmonary diseases.
 Children exposed to second hand smoke develop
a variety of respiratory disorders
 Symptoms of nicotine addiction

 Tolerance to nicotine with decreased effect and

increasing dose to obtain same effect
 Withdrawal symptoms after cessation
 Smoking more than usual
 Persistent desire to smoke despite efforts to decrease
intake
 Extensive time spent smoking or purchasing tobacco
 Postponing work, social or recreational events in order
to smoke
 Continuing to smoke despite health hazards.
 Diagnostic criteria
AMERICAN PSYCHIATRIC ASSOCIATION
An individual diagnosed with tobacco use disorder
needs to meet all of the following criteria:

◾ A problematic pattern of tobacco use leading to

clinically significant impairment or distress, as
manifested by at least two of the following, occurring
within a 12 month period:
Tobacco is often taken in larger amounts or

over a longer period than was intended.

There is a persistent desire or unsuccessful

efforts to cut down or control tobacco use.

A great deal of time is spent in activities

necessary to obtain or use tobacco.

Craving, or a strong desire or urge to use

tobacco.
Recurrent tobacco use resulting in a failure to

fulfill major role obligations at work, school, or

home (e.g., interference with work) Important
social, occupational, or recreational activities .
Continued tobacco use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of tobacco (e.g., arguments
with others about tobacco use).
Recurrent tobacco use in situations in which it is
physically hazardous (e.g., smoking in bed).
Tobacco use is continued despite knowledge of having a

persistent or recurrent physical or psychological

problem that is likely to have been caused or
exacerbated by tobacco.
Tolerance, as defined by either of the following:
 A need for markedly increased amounts of tobacco to
achieve the desired effect.

 A markedly diminished effect with continued use of

the same amount of tobacco.

Withdrawal, as manifested by either of the

following:

 The characteristic withdrawal syndrome for tobacco:

 Daily use of tobacco for at least several weeks.
Abrupt cessation of tobacco use, or reduction in the
amount of tobacco used, followed within 24 hours by
four (or more) of the following signs and symptoms:

 Irritability, frustration, or anger.

 Anxiety.
 Difficulty concentrating.
 Increased appetite.
 Restlessness.
 Depressed mood.
 Insomnia.

Tobacco (or closely related substance, such as

nicotine) is taken to relieve or avoid withdrawal
symptoms.
 Hazards of smoking
• Death is the primary adverse effect of cigarette
smoking.
• Causes of death include:
Chronic bronchitis.
Emphysema.
Bronchogenic cancer.
Cerebrovascular disease.
Cardiovascular disease.
• In pregnant women, nicotine crosses the
placenta freely and is in the amniotic fluid and
umbilical cord blood of neonates.
• Sustained exposure of the fetus causes:

Slow growth in utero and lower than average

birth weights.
Increased incidences of newborns with
persistent pulmonary hypertension.
 Causes
•CENTRAL NERVOUS SYSTEM EFFECTS
• It is believed that addictive drugs have common neural
substrates and that nicotine’s release of dopamine in the
mesolimbic pathways is central to its function as an
addicting drug.
• Whereas dopamine’s actions on the ventral tegmental
area, the nucleus accumbens, and the prefrontal cortex
have been thought to play a critical role in drug addiction
through motivation and reward, dopamine also acts as
an aid to learning by highlighting and drawing attention
to certain “significant or surprising events”
 GENETIC BASIS FOR NICOTINE
DEPENDENCE
❖Data from family, adoption, and twin studies strongly
support a genetic influence on the initiation and
maintenance of tobacco smoking.

❖Family studies reveal smoking patterns that differ

according to the subtype of depressive disorder, with the

closest association observed between dysthymia and

heavy smoking.
❖In schizophrenia, genetic studies indicate an autosomal
dominant pattern of inheritance linked to chromosome
15q13- 14, which is the site of the nicotinic receptor.
❖There may also be genetic factors common to all types of
substance abuse. Studies in rodents suggest that common
genes partly modulate the actions of both ethanol and
nicotine, and may explain the frequent combined use of
these agents.
 Factors Contributing to the Addictive Potential
of Nicotine in Cigarettes

1) The more rapid the onset of mood alteration or “rush,”

the more addicting the form of drug. Nicotine’s effects
through a cigarette are more rapid,(10–19 sec for
nicotine to reach the brain), than those of nicotine given
intravenously, intranasally, orally, or transdermally.
2) Individuals can self-titrate their nicotine intake The
smoker can manipulate the intake of nicotine from
each cigarette smoked, in order to achieve and
maintain the desired level of nicotine, by changing
puff volume, the number of puffs per cigarette, the
intensity of puffing, and the depth of inhalation and
by blocking ventilation holes in the filter
3) nicotine is reinforcing under a wide range of
conditions.

Nicotine may act in a stimulating fashion when smokers

experience a low level of arousal (e.g., when fatigued)

but act in a tranquilizing fashion when they experience

a high level of arousal (e.g., when anxious). Supporting

this view are research showing that smokers increase

tobacco use under both low- and high-arousal

conditions.
4)short and frequent dosing interval: If each puff is
considered a dose of nicotine, smokers give themselves a
short interdose interval. An average smoker takes 10
puffs from each cigarette. This corresponds to 200 puffs
per day for the 1-pack/day smoker and 400 puffs per day
for the 2-pack/day smoker. No other drug is dosed this
frequently.
5)The cinema and advertising portray sexy, slender women
and handsome, rugged men smoking. These images
integrate into society and are internalized by smokers.
6) pairing to multiple conditioned cues intertwined with daily
life events:

frequent nicotine dosing with its corresponding subtle mood

alteration becomes intertwined with daily activities, for
many years. Events from waking up in the morning, to
talking on the telephone, driving one’s car, finishing a meal,
taking a coffee break, watching television, having sex,
combating fatigue, dealing with worries or concerns, and
relaxing during stressful interactions all become enmeshed
with the need for a cigarette.
❖PsYCHOANALYTIC VIEWS:
1. Regression to oral stage of development.
2. Pleasure seeking behavior.
3. Aggression towards self (self-destruction)
4. Ego deficit in structure and function, and it
represents a maladaptive attempt to compensate
for these deficits, the major areas of deficits are:
1)-Impairment of affect regulation and impulse control
functions
Defective regulation of painful and powerful affects such as
rage, shame, depression as well as any states of distress.
Defective ability to control impulsive acts.

2)-deficits in self care and self protective functions:

Inadequate internalization of caring parental figures, they

suffer impaired judgment and diminished capacity for self
protection (e.g., unable to evaluate and anticipate the dangers
of drug abuse).
IMPAIRED OBJECT RELATION FUNCTION:
Diminished capacity to tolerate and regulate interpersonal
closeness and maintain stable relations with others.
SELF ESTEEM PROBLEMS
1)-low self-esteem i.e. feeling of lack of worth,
incompetence, powerlessness and helplessness.
2)-smoking help them to:
reestablish a sense of power and control.
Relief of distress and painful affects.
Increase capacity to cope and function.
Better ability to manage interpersonal relations..
LEARNING THEORY
1 Positive reinforcement: Nicotine is rewarding, Taking
nicotine enhances an addicted smoker’s mood and
performance. Smoking is an extremely effective way of
rapidly and conveniently delivering concentrated doses
of nicotine to the brain
2 Smoker receives 73,000 distinct drug reinforcements
per year. Nicotine smokers appear able to discriminate
small, rewarding effects from each individual puff and to
titrate nicotine dose from each cigarette. From the
typical 10 puffs per cigarette, a one pack-per-day
3 Negative reinforcement: when nicotine is taken by an
addicted smoker, the negative consequences of prior
nicotine use are diminished. A nicotine withdrawal
syndrome is relieved
4 Tobacco-taking behavior is made more likely to recur,
reinforced by the pharmacologic actions of nicotine,
With each successive cigarette, a beginning smoker,
usually an adolescent, learns to associate certain moods,
situations, and environmental factors (smoking
paraphernalia) with the rewarding effects of nicotine.
 Associations between cues associated with smoking,
anticipated nicotine effects and the resulting urge to use
tobacco (craving) become all important in maintaining
smoking.
 For example, an adolescent smoker, usually within the first
year of smoking, learns that not having a cigarette available is
associated with feelings of irritability and learns that just a
few puffs from a cigarette diminish irritability and other
dysphoric nicotine withdrawal symptoms. After hundreds of
repeated experiences, irritability from any source serves as a
cue for smoking.
Nicotine-Related Disorders
About 22-30 percent of the population develops
nicotine dependence at some point, making it
one of the most prevalent psychiatric disorders.
According to the (DSM-IV- TR), approximately
85 percent of current daily smokers are nicotine
dependent. Nicotine withdrawal occurs in about
50 percent of smokers who try to quit.
 Diagnosis
✓The DSM-IV-TR lists three nicotine-related
disorders:

1 nicotine dependence

2 nicotine withdrawal and

3 nicotine-related disorder not otherwise

specified.
 Nicotine dependence

✓The DSM-IV-TR does have a diagnosis of

nicotine dependence but not nicotine abuse.
✓Dependence on nicotine develops quickly, probably
because nicotine activates the ventral tegmental area
dopaminergic system, the same system affected by
cocaine and amphetamine.
 Nicotine Withdrawal
 The DSM-IV-TR does not have a diagnostic category
for nicotine intoxication, but does have for nicotine
withdrawal. Withdrawal symptoms can develop within
2 hours of smoking the last cigarette; they generally
peak in the first 24 to 48 hours and can last for weeks or
months.
✓Include an intense craving for nicotine, tension,
irritability, difficulty concentrating, drowsiness and
trouble sleeping, decreased heart rate and blood
pressure, increased appetite and weight gain,
decreased motor performance, and increased muscle
tension.
Nicotine-Related Disorder Not Otherwise
Specified
✓Nicotine-related disorder not otherwise specified is a
diagnostic category for nicotine-related disorders that
do not fit into one of the categories discussed above.
Such diagnoses may include nicotine intoxication,
nicotine abuse, and mood disorders and anxiety
disorders associated with nicotine use.
 Treatment
1-Psychosocial Therapies
✓Cognitive Behavioral therapy is the most widely accepted
and well- proved psychological therapy for smoking.
Skills training and relapse prevention identify high-risk
situations and plan and practice behavioral or cognitive
coping skills for those situations in which smoking
occurs. Stimulus control involves eliminating cues for
smoking in the environment.
✓Aversive therapy has smokers smoke repeatedly and
rapidly to the point of nausea that associates smoking
with unpleasant, rather than pleasant, sensations.
Aversive therapy appears to be effective but requires a
good therapeutic alliance and patient compliance.
✓Clients learn about triggers and cravings and how they
are related to substance use. Clients learn to use thought
stopping techniques to disrupt relapse and scheduling to
organize their recovery.
✓Identifying External Triggers

✓Identifying Internal Triggers

✓Clients learn new coping techniques that do not

involve substance use.

✓Clients identify challenging situations and ways to

address them that help maintain abstinence.

 Psychopharmacological Therapies Nicotine
Replacement Therapies

✓All nicotine replacement therapies double cessation

rates, presumably because they reduce nicotine
withdrawal. Replacement therapies use a short period
of maintenance of 6 to 12 weeks often followed by a
gradual reduction period of another 6 to 12 weeks.
 Nicotine gum (Nicorette)
✓Releases nicotine via chewing and buccal absorption. A
2-mg variety for those who smoke fewer than 25
cigarettes a day and a 4-mg variety for those who smoke
more than 25 cigarettes a day are available. Smokers are
to use one to two pieces of gum per hour up to a
maximum of 24 pieces per day after abrupt cessation.
• Helps in quitting smoking
• Smoking cessation aids
• Decreases withdrawal
symptoms and urges to smoke
 Nicotine lozenges
✓deliver nicotine and are also available in 2-mg and 4-
mg forms; they are useful especially for patients who
smoke a cigarette immediately on awakening.
Generally, 9 to 20 lozenges a day are used during the
first 6 weeks with decrease in dosage thereafter.
Lozenges offer the highest level of nicotine of all
nicotine replacement products. Side effects include
insomnia, nausea, heartburn, headache, and hiccups.
Nicotine patches
✓are available in a 16-hour (Nicotrol) and a 24-hour
preparation (Nicoderm CQ). Patches are administered
each morning and produce blood concentrations about
half those of smoking. Compliance is high, and the only
major adverse effects are rashes and, insomnia.
Nicotine patches
Transdermal
patch releasing
nicotine

Provides low
levels of
nicotine

Reduces physical signs

of withdrawal
symptoms
Nicotine nasal spray (Nicotrol)
✓available only by prescription, produces nicotine
concentrations in the blood that are more similar to
those from smoking a cigarette, and it appears to be
especially helpful for heavily dependent smokers.
 The nicotine inhaler, a prescription
product
✓Was designed to deliver nicotine to the lungs, but
the nicotine is actually absorbed in the upper throat.
It delivers 4 mg per cartridge and resultant nicotine
levels are low. The major asset of the inhaler is that
it provides a behavioral substitute for smoking. The
inhaler doubles quit rates.
 Non-nicotine Medications
✓Non-nicotine therapy may help smokers who object
philosophically to the notion of replacement therapy and
smokers who fail replacement therapy. Bupropion is an
antidepressant medication that has both dopaminergic
and adrenergic actions. Daily dosages of 300 mg doubles
quit rates in smokers with and without a history of
depression. In one study, combined bupropion and
nicotine patch had higher quit rates than either alone.
✓Clonidine (Catapres) decreases sympathetic activity from
the locus ceruleus and, thus, is thought to abate
withdrawal symptoms. Whether given as a patch or orally,
0.2 to 0.4 mg a day of clonidine appears to double quit
rates; clonidine can cause drowsiness and hypotension.
✓Some patients benefit from benzodiazepine therapy (10 to
30 mg per day) for the first 2 to 3 weeks of abstinence.
✓A nicotine vaccine that produces nicotine-specific
antibodies in the brain is under investigation at the
National Institute on Drug Abuse (NIDA).
✓Combined Psychosocial and Pharmacological Therapy.
✓Several studies have shown that combining nicotine
replacement and behavior therapy increases quit rates
over either therapy alone.
 E- Cigarettes

• Battery-powered vaporizer
which creates a mist
• Vaporizes e-liquid: Vaping
• May not be as safe as the
manufacturers claim it to be
• Seattle-Sickness due to
Its ban in India
liquid nicotine ingestion
 Nicotine free Cigarettes

Herbal cigarettes
which are not
addictive

Consist of herbs and are

made of rolling paper and
filter
Used in acting
scenes by
performers
Made up of corn silk,
mint, cinnamon,
lemongrass, rose
 Tobacco facts
◾ There are about 4000 chemicals in tobacco, and out of the
100 identified poisons, 63 are known to cause cancer
◾ Nicotine is an addictive drug that takes only 6 seconds to
reach your brain
◾ Smoking kills more people than cocaine, heroin, alcohol,
fire automobile accidents, homicides, suicides, and AIDS
combined.
◾ More than 3 million people under the age of 18 smoke
about a ½ billion cigarettes each year, over half of those
people consider themselves dependent on cigarettes
 Every 8 seconds, someone in the world dies from a tobacco
related illness
 About 430,000 people die needlessly every year from
smoking, which means smoking kills about 1,200 people
every day
 A person who smokes dies an average 7 years earlier than
someone who doesn’t smoke
 Kids who smoke experience changes in the lungs, and
reduced lung growth. They risk not achieving normal lung
function as an adult
 Why people smoke

 Peer Pressure
 They think it’s “cool”
 Their parents smoke
 Because they want to be skinny (fashion)
 Because they find it relaxing
 Rebellion
 Why is it so difficult to quit

• Pleasurable feeling
• Tolerance to the drug
• Weight gain
 Reason to stop smoking
 To live longer
 Better breath
 You’ll save a lot of money
 You’ll be around to see your grand children
 You won’t harm people around you
 You’ll cough less
 You won’t have to hide the habit from family
 You’ll be able to smell and taste food better
 Your teeth will become whiter
 You’ll have a smaller chance of getting emphysema
“GIVING UP SMOKING IS THE EASIEST
THING IN THE WORLD. I KNOW
BECAUSE I’VE DONE IT THOUSANDS
OF TIMES.”
-MARK TWAIN