Addicted to Nicotine
A National Research Forum

Section VI: Treatment of Nicotine Dependence
John Hughes, M.D., Chair

TREATMENT OF SPECIAL POPULATIONS

Dorothy K. Hatsukami, Ph.D.
Department of Psychiatry
University of Minnesota

Introduction

The treatment needs of tobacco users may vary according to gender, age, and route of nicotine administration. Research is beginning to show that gender differences may exist in response to nicotine and tobacco use and that differences exist in the issues that surface when treating adolescents or elderly persons. Research also shows that treatments that are effective for one route of tobacco administration do not generalize to others. It is important to learn more about the specific needs of these different populations of tobacco users in order to develop effective treatments.

What We Know

• Gender. Men are more likely to quit tobacco use than women, and they experience greater confidence in their ability to quit. Women may also have a higher relapse rate than men. The reasons for these differences are not entirely clear. However, some evidence shows that women respond differently to the effects of nicotine and nicotine abstinence compared with men, and therefore, their treatment needs may differ. For example, studies show that women are less sensitive to nicotine and therefore may experience fewer beneficial effects from nicotine replacement therapy (NRT). Some evidence suggests that the sensory aspects of smoking may be more important to women. Women are also more likely than men to smoke to reduce stress, and women experience greater weight concerns, and weight gain, after cessation. Furthermore, the menstrual cycle phase may contribute to differences in the experience of craving for cigarettes.

• Age. The rate of smoking at both ends of the age spectrum tends to be lower than the middle part of the age spectrum. However, treatment of individuals at these ends cannot be neglected. The rate of smoking among adolescents is increasing, and smoking that begins in adolescence is likely to continue into adulthood. Also, negative physical consequences from smoking are experienced even among the young. For elderly persons, quitting is important because the beneficial effects from smoking cessation can still be experienced in spite of many years of smoking. Unfortunately, research in these areas is lacking.

  Research on adolescent smoking cessation is limited, and treatment success rates tend to be low. Treatment issues that need to be addressed with adolescent smokers include physical dependence on tobacco products. The type of withdrawal symptoms experienced by adolescents are reported to be similar to those observed among adults; a substantial percent of adolescents who are daily smokers report experiencing these symptoms. Other issues involve the high occurrence of comorbid disorders, including alcohol and other drug use among adolescents. Many adolescents have concerns regarding peer acceptance, must deal with the role of cigarette smoking as part of their self-image, and experience difficulties in coping with the stresses in their lives. In addition, sustaining the motivation to remain abstinent after quitting is another prominent issue among this population. These findings indicate that adolescents may require medications to treat the physical dependence on nicotine, but more importantly, cessation treatment must have strong motivational and behavioral components.

  Elderly individuals may also require tailored treatments. Many elderly people have smoked for a long time, tend to be highly addicted, and have tried quitting but have been unsuccessful. Few clinical trials have been conducted with this population. Assessment of the nicotine patch use has shown that few experienced side effects, success rates were comparable to those found in younger adult populations, and more advice led to better treatment rates.

• Route of Administration. Much of the treatment focus has been on cigarette smoking. The development of treatment methods is crucial for individuals who self-administer tobacco by methods other than inhalation. There are several reasons why this area needs attention. First, individuals who use tobacco through other routes, such as oral spit tobacco, constitute a significant number of individuals. Second, these individuals experience negative health consequences, including an addiction to nicotine. Third, effective methods observed for cigarette smokers may not generalize to other populations of tobacco users. For example, with spit tobacco users, nicotine replacements have been observed to reduce withdrawal signs and symptoms, but not to enhance tobacco abstinence rates, as observed with cigarette smokers. The interaction between intensity of treatment and the use of NRT may differ among spit tobacco users compared with cigarette smokers. For example, nicotine gum in conjunction with minimal treatment results in poorer treatment outcome compared with placebo gum with minimal treatment. Replacement of sensory aspects of tobacco use may not be as important with smokeless tobacco users as with cigarette smokers.

  In summary, differences observed across gender, age and route of administration indicate that distinct areas need to be emphasized and addressed in treatment, with particular attention paid to differences in response to medications.

What We Need To Know More About

General Issues

• How do gender, age, and different routes of tobacco administration affect the pharmacologic, physical, and psychological response to nicotine? What are the implications of these potential differences with regard to treatment, including the use of nicotine replacement or other medications?

• What are good assessment tools for these different special populations?

• What are the primary and population-specific issues that need to be addressed in treating these special populations, and how can we address them?

• Does the importance of sensory aspects of tobacco use differ across genders, age groups, and routes of tobacco administration?

• Does the interaction of pharmacologic and behavioral treatments differ across genders, age groups, and routes of tobacco use? Do certain populations require different emphasis on these types of treatments?

• Do differences exist in the obstacles toward success, relapse patterns, and relapse situations and factors that facilitate abstinence across genders, age groups, and routes of tobacco use? Are there differences in the recovery process?

Age

• How can we motivate adolescents and elderly individuals to quit or seek treatment, and how can we sustain this motivation? What are the various avenues for intervention?

• What are other important strategies to have in place that incorporate the developmental issues experienced by adolescents to enhance treatment success among them?

• Can we intervene with adolescents at an earlier stage in the progression to nicotine dependence? Would reduction in exposure to nicotine be considered a feasible outcome variable, especially since many adolescents fail at quitting?

Gender

• What are the hormonal effects on nicotine sensitivity? Do hormones affect reactions to stress? Are some phases of the menstrual cycle more likely to lead to relapse compared with others? What is the effect of nicotine among postmenopausal women? What is the impact of pregnancy, as a result of the hormonal changes, on the pharmacology of the drug?

Routes of Administration

• What is the interplay among cigarette, cigar, and oral tobacco use during attempts at abstinence?

• Are there effective methods to reduce tobacco use and toxic exposure to tobacco products that may facilitate abstinence among users who do not want to quit?

Recommended Reading

Benowitz, N.L., and Hatsukami, D. Gender differences in the pharmacology of nicotine addiction. Addiction, in press.

Hatsukami, D., and Boyle, R.G. Prevention and treatment of smokeless tobacco use. Adv Dent Res 11(3):341-350, 1997.

Institute of Medicine. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: National Academy Press, 1994.

Orleans, C.T.; Rimer, B.K.; Cristinzio, S.; Keintz, M.K.; and Fleisher, L. A national survey of older smokers: Treatment needs of a growing population. Health Psychol 10:343-351, 1991.

Pomerleau, C. Issues for women who wish to stop smoking. In: Seidman, D., and Covey, L., eds. Helping Smokers Quit: A Handbook for Helping Professions. New York: Lawrence Erlbaum, in press.

U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report to the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 1994.