Internet Mental Health

Prediction: Chronic For Years

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  • Tobacco use is the leading cause of death in the developed world (due to cancers, cardiovascular diseases, chronic obstructive pulmonary disease); "second hand smoke" causes cancer for those close by (family, coworkers)


Dependence Syndrome Due To Use Of Tobacco F17 - ICD10 Description, World Health Organization
Repeated use of tobacco that typically includes a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and a physical withdrawal state.
Tobacco Use Disorder - 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).

    • 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).

    • Important social, occupational, or recreational activities are given up or reduced because of 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.

    • Specify if:

      • In early remission: After full criteria for tobacco use disorder were previously met, none of the criteria for tobacco use disorder have been met for at least 3 months but for less than 12 months (with the exception that the criterion, "Craving, or a strong desire or urge to use tobacco," may be met).

      • In sustained remission: After full criteria for tobacco use disorder were previously met, none of the criteria for tobacco use disorder have been met at any time during a period of 12 months or longer (with the exception that the criterion, "Craving, or a strong desire or urge to use tobacco," may be met).

    • Specify if:

      • On maintenance therapy: The individual is taking a long-term maintenance medication, such as nicotine replacement medication, and no criteria for tobacco use disorder have been met for that class of medication (except tolerance to, or withdrawal from, the nicotine replacement medication).

      • In a controlled environment: This additional specifier is used if the individual is in an environment where access to tobacco is restricted.

The leading causes of death in USA in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (365 000 deaths; 15.2%), and alcohol consumption (85 000 deaths; 3.5%). Thus cigarette smoking is the most common cause of preventable death and disease. Smoking kills one in every 2 smokers. Smokers die, on average, 10 years younger.

Effective Therapies

Nicotine replacement therapy increases the chances of stopping smoking by 50 to 70%. Adding behavioural support (in person or via telephone for at least four sessions of contact) to nicotine replacement therapy increases the chances of stopping smoking by a further 10 to 25%. Group programs are more effective for helping people to stop smoking than being given self-help materials without face-to-face instruction and group support. Medications such as nicotine replacement and bupropion are ineffective with adolescents. Bupropion and nortriptyline aid long-term smoking cessation in adults, but other antidepressant medications do not. However, adding bupropion or nortriptyline to nicotine replacement therapy does not provide an additional long-term benefit. One experiment with 878 smokers achieved a high and long-lasting smoking cessation rate. Instead of running a typical smoking cessation program; this very successful experiment put all its resources into a program of large cash rewards (up to US$750) for non-smoking.

Ineffective Therapies

Anxiolytic medication, acupuncture, acupressure, laser therapy and electrical stimulation are all ineffective for the treatment of this disorder.

Legalizing Harmful Drugs

Some people argue that illicit drugs should be legalized to decrease the crime associated with these drugs. Historically, tobacco and alcohol were once illegal drugs. Tobacco smoking is now the leading cause of death in America, and alcoholism is the third leading cause of death. Thus legalizing illicit drugs does not make them any less medically and socially harmful. In fact the opposite is true; legalizing illicit drugs increases their use and the harm they cause. The Government of Finland is passing legislation that will gradually ban all tobacco use by 2040.

Top 20 Most Harmful Drugs In Britain In 2008

Professor David Nutt published in the Lancet the following rating of Britain's most dangerous drugs. They are listed in descending order from the most harmful.

1. Heroin

Class A drug. Originally used as a painkiller and derived from the opium poppy. There were 897 deaths recorded from heroin and morphine use in 2008 in England and Wales, according to the Office of National Statistics (ONS). There were around 13,000 seizures, amounting to 1.6m tonnes of heroin.

2. Cocaine

Class A. Stimulant produced from the South American coca leaf. Accounted for 235 deaths -- a sharp rise on the previous year's fatalities. Nearly 25,000 seizures were made, amounting to 2.9 tonnes of the drug.

3. Barbituates

Class B. Synthetic sedatives used for anaesthetic purposes. Blamed for 13 deaths.

4. Street methadone

Class A. A synthetic opioid, commonly used as a substitute for treating heroin patients. Accounted for 378 deaths and there were more than 1,000 seizures of the drug.

5. Alcohol

Subject to increasing concern from the medical profession about its damage to health. According to the ONS, there were 8,724 alcohol deaths in the UK in 2007. Other sources claim the true figure is far higher.

6. Ketamine

Class C. A hallucinogenic dance drug for clubbers. There were 23 ketamine-related deaths in the UK between 1993 and 2006. Last year there were 1,266 seizures.

7. Benzodiazepines

Class C. A hypnotic relaxant used to treat anxiety and insomnia. Includes drugs such as diazepam, temazepam and nitrazepam. Caused 230 deaths and 1.8m doses were confiscated in more than 4,000 seizure operations.

8. Amphetamine

Class B. A psychostimulant that combats fatigue and suppresses hunger. Associated with 99 deaths, although this tally includes some ecstasy deaths. Nearly 8,000 seizures, adding up to almost three tonnes of confiscated amphetamines.

9. Tobacco

A stimulant that is highly addictive due to its nicotine content. More than 100,000 people a year die from smoking and tobacco-related diseases, including cancer, respiratory diseases and heart disease.

10. Buprenorphine

An opiate used for pain control, and sometimes as a substitute to wean addicts off heroin. Said to have caused 43 deaths in the UK between 1980 and 2002.

11. Cannabis

Class B. A psychoactive drug recently appearing in stronger forms such as "skunk". [Since this video was made; there is now conclusive proof that cannabis causes a 6.7 fold increase in the risk of developing schizophrenia.] Caused 19 deaths and there were 186,000 seizures, netting 65 tonnes of the drug and 640,000 cannabis plants.

12. Solvents

Fumes inhaled to produce a sense of intoxication. Usually abused by teenagers. Derived from commonly available products such as glue and aerosol sprays. Causes around 50 deaths a year.

13. 4-MTA

Class A. Originally designed for laboratory research. Releases serotonin in the body. Only four deaths reported in the UK between 1997 and 2004.

14. LSD

Class A. Hallucinogenic drug originally synthesised by a German chemist in 1938. Very few deaths recorded.

15. Methylphenidate

Class B drug. Brand name of Ritalin. A psychostimulant sometimes used in the treatment of attention deficit disorders.

16. Anabolic steroids

Class C. Used to develop muscles, notably in competitive sports. Also alleged to induce aggression. Have been blamed for causing deaths among bodybuilders. More than 800 seizures.

17. GHB

Class C drug. A clear liquid dance drug said to induce euphoria, also described as a date rape drug. Can trigger comas and suppress breathing. Caused 20 deaths and 47 seizures were recorded.

18. Ecstasy

Class A. Psychoactive dance drug. Caused 44 deaths, with around 5,000 seizures made.

19. Alykl nitrites

Known as "poppers". Inhaled for their role as a muscle relaxant and supposed sexual stimulant. Reduce blood pressure, which can cause fainting and in some cases death.

20. Khat

A psychoactive plant, the leaves of which are chewed in east Africa and Yemen. Also known as qat. Produces mild psychological dependence. Its derivatives, cathinone and cathine, are Class C drugs in the UK.



Rating Scales


  • Smoking cessation - Epocrates Online
  • Nicotine Dependence Treatment Guidelines
  • Treatment of tobacco dependence. (2011) Motivational interviewing by a physician, including a recommendation to stop smoking and counseling on how to do this, can reinforce a smoker's motivation to quit. Behavioral therapeutic approaches support changes in behavior, while medical aids such as nicotine replacement therapy, bupropion, and varenicline help former smokers overcome the initial withdrawal symptoms. Low-threshold measures such as self-help books, telephone counseling, and Internet-based cessation programs complement the evidence-based treatments. With a combination of medications and psychotherapeutic support, abstinence rates of up to approximately 40% can be achieved at the end of one year.
  • Improved patient outcome with smoking cessation: when is it too late? (2011) Smoking is the leading modifiable risk factor for chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), and lung cancer. Smoking cessation is the only proven way of modifying the natural course of COPD. It is also the most effective way of reducing the risk for myocardial infarction and lung cancer. However, the full benefits of tobacco treatment may not be realized until many years of abstinence. All patients with COPD, regardless of severity, appear to benefit from tobacco treatment. Similarly, patients with recent CVD events also benefit from tobacco treatment. The risk of total mortality and rate of recurrence of lung cancer is substantially lower in smokers who manage to quit smoking following the diagnosis of early stage lung cancer or small cell lung cancer. Together, these data suggest that tobacco treatment is effective both as a primary and a secondary intervention in reducing total morbidity and mortality related to COPD, CVD, and lung cancer.
  • Pharmacotherapeutic management of nicotine dependence in pregnancy. (2011) Smoking in pregnancy can cause serious adverse antenatal and postnatal morbidities, and a significant number of women continue to smoke in pregnancy despite these consequences. Early intervention in the form counseling from their physicians, pregnancy-specific self-help materials, counseling sessions with a health educator, and/or continued follow-up can result in better pregnancy outcomes and possibly long-term cessation. If a woman cannot quit despite these measures, pharmacotherapy can be considered. Currently, nicotine replacement therapy (NRT), transdermal patches, and bupropion are used in pregnancy, but data on the safety and efficacy are largely lacking.
  • Pharmacotherapy for smoking cessation: present and future. (2011) Tobacco dependence is a chronic disease that often requires repeated interventions and multiple attempts to quit. To date, three medications are FDA-approved for smoking cessation: nicotine replacement therapy, sustained-release bupropion, and varenicline. These treatments are effective across a broad range of populations, and are recommended for all smokers, including those with psychiatric or addictive comorbidity. Less is known however concerning the benefit-risk profile of these medications in pregnant women and adolescents. With these limitations in mind, clinicians should encourage and offer counseling and a prescription of pharmacotherapy to every patient willing to make a quit attempt. Despite the relative efficacy of first-line medications, many smokers relapse after one given quit attempt, and alternative pharmacotherapies are needed. Clonidine and nortriptyline have been proposed as second-line medications.
  • Effectiveness of over-the-counter nicotine replacement therapy: a qualitative review of nonrandomized trials. (2011) Some lines of evidence appear to confirm the effectiveness of OTC NRT, but others do not.
  • Adverse effects and tolerability of medications for the treatment of tobacco use and dependence. (2010)Tobacco use is the leading cause of preventable death and disability in the world. Although gradually declining in most developed countries, the prevalence of tobacco use has increased among developing countries. Treatment for tobacco use and dependence is effective, although long-term abstinence rates remain disappointingly low. In response, new treatments continue to be developed. In addition, many of the pharmacotherapies that have been available for years have found new applications with the use of medication combinations, higher doses and a longer duration of therapy for approved medications. There are now seven medications (nicotine patch, nicotine gum, nicotine lozenge, nicotine inhaler, nicotine nasal spray, bupropion sustained release and varenicline) approved for tobacco dependence treatment in most countries, and many national and professional society practice guidelines recommend their use. Although each of the medications used for tobacco dependence treatment has been rigorously tested for efficacy and safety, broader experience in clinical trials and in observational population-based studies suggests that adverse events associated with these medications are relatively common. Since 2008, two of the medications (varenicline and bupropion) have come under increasing scrutiny because of reports of unexplained serious adverse events (SAEs), including behaviour change, depression, self-injurious thoughts and suicidal behaviour. To date, this association has not been shown to be caused by these medications, but concerns about medication safety continue. Prescribers require a working knowledge of the common adverse effects for all of these medications as well as a more detailed knowledge of the SAE potential. Nicotine replacement therapy (NRT) has been rigorously tested in clinical trials for over 30 years. A number of adverse effects are commonly associated with NRT use, although SAEs are rare. The adverse effects associated with NRT are due to the pharmacological action of nicotine as well as the mode and site of the NRT application. Bupropion has been tested in over 40 controlled clinical trials and has been associated with higher rates of treatment discontinuation due to adverse events than NRTs. A number of SAEs are associated with bupropion and new warnings were recently added to bupropion prescribing information because of observed neuropsychiatric symptoms including suicidal thoughts and behaviours. Varenicline is the most recently approved medication for tobacco dependence treatment and, although proven safe in clinical testing, new safety concerns have arisen based on post-marketing reports. Warnings have been added to the prescribing information for varenicline because of neuropsychiatric symptoms also including suicidal thoughts and behaviours. Informed decision making regarding the use of pharmacotherapy for the treatment of tobacco dependence requires knowledge about the risks of drug treatment that is weighed against the risks of continued tobacco use and the benefits of treatment. Over half of all long-term smokers will die of a tobacco-related disease and the risk of a serious or life-threatening adverse event with tobacco cessation pharmacotherapy is vanishingly small. Pharmacotherapy for tobacco dependence is also among the most cost-effective preventive health interventions. Given these factors, the benefit?:?risk ratio is strongly in favour of pharmacotherapy for tobacco dependence treatment in virtually all smokers who are motivated to quit.
  • Motivational interviewing for smoking cessation: a meta-analytic review. (2010) Motivational interviewing (MI) is a treatment approach that has been widely examined as an intervention for tobacco dependence and is recommended in clinical practice guidelines. (However research for) MI for smoking cessation noted effects that were modest in magnitude (with only) 2.3% difference in abstinence rates between MI and comparison groups. (Editor's note: thus motivational interviewing for smoking cessation is ineffective.)
  • Does dual use jeopardize the potential role of smokeless tobacco in harm reduction? (2010) Dual use of smokeless tobacco and cigarettes may result in reduction in smoking-related harm as smoking intensity is decreased and smoking cessation increases.
  • A tobacco reconceptualization in psychiatry: toward the development of tobacco-free psychiatric facilities. (2010) Tobacco dependence is the leading cause of death in persons with psychiatric and substance use disorders. The creation of smoke-free psychiatric hospitals was mandated by the Joint Commission for Accreditation of Health Organizations (JCAHO) in 1992. This review article addresses the reasons why tobacco should be excluded from psychiatric and addictions treatment settings, and strategies that can be employed to initiate and maintain tobacco-free psychiatric settings.
  • Comparison of available treatments for tobacco addiction. (2010) Effective behavioral and pharmacologic treatments for smoking cessation are available. Behavioral treatments including brief (< 3 min) counseling by physicians are effective. Seven first-line pharmacologic treatments are currently available: five nicotine replacement therapies, bupropion, and varenicline. In addition, clonidine and nortriptyline are second-line treatments for smoking cessation. These treatments increase the chances of quitting smoking by two- to threefold, supporting their use in smokers who are motivated to quit. However, effective treatments for many subpopulations, including smokers with psychiatric comorbidities as well as adolescent, pregnant, or postpartum smokers, remain to be developed and represent an important challenge.
  • Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. (2010) Nicotine-dependent individuals made up only 12.8% (95% confidence interval, 12.0-13.6) of the population yet consumed 57.5% of all cigarettes smoked in the United States. Nicotine-dependent individuals with a comorbid psychiatric disorder made up 7.1% (95% confidence interval, 6.6-7.6) of the population yet consumed 34.2% of all cigarettes smoked in the United States.


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