Interagency Committee on Smoking and Health
Meeting Summary: August 14, 2001
Smoking Cessation: Facing the Challenges of Tobacco
Addiction
The Role of Nicotine Addiction in Tobacco Use and Cessation
Jack Henningfield, Ph.D., Vice President, Pinney Associates, Bethesda, Maryland and
Associate Professor of Behavioral Biology, Johns Hopkins School of Medicine, Baltimore,
Maryland
Dr. Henningfield began his presentation by providing a vision of what could be possible with
the tobacco epidemic if we could follow the example of how quickly the epidemic of HIV and
AIDS had gone from a "death sentence" to a disease for which science-based prevention and
treatment interventions were now available.
In his talk, Dr. Henningfield described the nature of tobacco addiction as a disease based
on the actions of nicotine on the brain, but observed that as is the case with all drug
addictions, the clinical course in individuals and the prevalence in the population is
determined by more than the actions of a chemical at its target receptor. Specifically he
described how the course and prevalence of tobacco addiction is influenced by factors such
as marketing and advertising of tobacco products, the cost and accessibility of tobacco
products, and the presence of counter forces such as treatment and education. Despite public
statements to the contrary, the tobacco industry has long understood the role of nicotine in
addiction and the potential for tobacco product modifications to make the products more
appealing to a broader range of the population. Unfortunately, while tobacco industry
documents and preliminary data from CDC and other laboratories suggest that there are many
ingredients and design features in tobacco products that could contribute to their addictive
potential and toxicity (e.g., ammonia additives, menthol, and smoke particle size
manipulation) the base of independent science is relatively weak in this area and it is
crucial that research on the products themselves be cultivated outside of the industry. This
is important to public health efforts aimed at prevention and cessation and will be critical
if the FDA ultimately regulates tobacco products.
The need for treatment is based on the fact that nicotine changes the structure and function
of the brain, for example by increasing brain nicotine receptors in some parts of the brain
by as much as 400%. These changes create a physiologically based need for nicotine, which
leads the brain to dysfunction when deprived. Dysfunction can be manifested by withdrawal
signs including impaired ability to concentrate and perform cognitive tasks, as well as
powerful cravings. Systematic behavioral and pharmacological treatments can help people
recover and make cessation possible, though rarely easy. One of the important questions
being addressed by ongoing research is the degree of reversibility of the effects from
decades of nicotine exposure and whether there are some individuals who will need extended
if not life-long treatment to remain abstinent from tobacco.
Although the addiction to tobacco delivered nicotine can be as strong as to substances such
as cocaine, heroine and alcohol, it can be treated. However, Dr. Henningfield observed,
treatment of tobacco dependence can be like attempting to treat malaria in a mosquito
infested swamp, because of the ease of access to tobacco products, their heavy marketing,
and the fact that so many other people are themselves tobacco users. This emphasizes the
importance of integrating comprehensive tobacco control activities including treatment,
prevention, and the many factors important in reducing access and appeal of tobacco
products, because these efforts are important to support treatment and cessation. Treatment
and cessation activities, in turn, support tobacco prevention efforts.
Dr. Henningfield concluded his remarks by offering several recommendations:
- Expanded surveillance and tracking of all nicotine use and attitudes is needed to provide
more rapidly disseminated and comprehensive data
- Product design and ingredient research needs to be supported by the NIH to develop the
knowledge base that will be crucial for prevention and treatment, and critical if the
products are regulated as emphasized in the 2001 report from the National Academy of
Sciences
- FDA prioritization of tobacco addiction treatment to encourage more innovative treatment
development approaches
- Expanded access and reduced barriers to treatment
- Reduced toxicity and addictiveness of tobacco products by regulating their design and
ingredients
- Additional research on diversity of smokers (biological and cultural)
Following the presentation, a question was asked concerning what is known about nicotine's
affect on an adolescent brain as differentiated from an adult brain. Dr. Henningfield
responded that researchers are just beginning to explore this issue and the answer is
important to knowing how best to treat adolescent addiction.
To a question about why FDA had not used the "fast track" and rapid review approaches for
tobacco dependence treatment as it had for treatments for HIV and cancer, Dr. Henningfield
acknowledged that the answer is quite complicated and there are differences of opinion on
the definition of whether the condition is life threatening and whether there are already
existing treatments.
A question was asked regarding individuals' varying ability to quit smoking cigarettes and
whether these differences are due more to biology or unequal access to treatment services.
Dr. Henningfield answered that although we need more research in this area, we do know that
there are certain protective factors; such as, sports, religion, and parents that help
determine one's likelihood of both starting to smoke and ability to quit.
To a question about the use of research conducted by the tobacco industry, Dr. Henningfield
answered that it is both a "goldmine" and a "minefield," in that much of the research does
help us understand some of the questions we should be asking. At the same time, we should
remain wary of some of the results until we are able to cultivate an independent base of
knowledge, particularly with respect to tobacco product ingredients and design
considerations.
A final question was asked concerning the potential for a vaccine to protect the brain from
addiction to tobacco. Dr. Henningfield's response was that there is a real possibility that
such a vaccine could be created and NIDA is supporting research to look at this question.
The trickiest issue is how to determine when and how to deliver the vaccine; for example,
there are different considerations in the potential application as a preventive measure for
high-risk youth than there are for application as a means of relapse prevention in adults
who have achieved abstinence.
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