Smoking remains the number one preventable cause of morbidity and mortality nationally, despite progress in reducing smoking prevalence over the past 40 years.
While 21% of adults in the U.S. are current smokers, prevalence of smoking among clients in community drug abuse treatment programs are 3-4 times higher, and among staff in these programs smoking prevalence is about twice that in the general population.
Smoking cessation intervention with persons in drug treatment is recommended in national clinical care standards; however, smoking cessation services are often not provided, or provided indifferently, in drug abuse treatment programs.
INS addresses integration of smoking cessation into drug abuse treatment at the level of individual treatment, including effective pharmacotherapy approaches.
Nicotine Replacement Therapy (NRT)
A variety of formulations of nicotine replacement therapies now exist, including the transdermal nicotine patch, nicotine spray, nicotine gum, and nicotine lozenges. Because nicotine is the main addictive ingredient in tobacco, the rationale for NRT is that stable low levels of nicotine will prevent withdrawal symptoms - which often drive continued tobacco use - and help keep people motivated to quit.
Bupropion was originally marketed as an antidepressant (Wellbutrin). It has mild stimulant effects through blockade of the reuptake of catecholamines, especially norepinephrine and dopamine. A serendipitous observation among depressed patients was the medication's efficacy in suppressing tobacco craving, promoting cessation without concomitant weight gain. Although bupropion's exact mechanisms of action in facilitating smoking cessation are unclear, it has FDA approval as a smoking cessation treatment.
Varenicline is the most recently FDA-approved medication for smoking cessation. It acts on a subset of nicotinic receptors (alpha-4 beta-2) thought to be involved in the rewarding effects of nicotine. Varenicline acts as a partial agonist/antagonist at these receptors - this means that it mildly stimulates the nicotine receptor, but not sufficiently to allow the release of dopamine, which is important for the rewarding effects of nicotine. As an antagonist, varenicline also blocks the ability of nicotine to activate dopamine, interfering with the reinforcing effects of smoking, thereby reducing craving.