Nicotine and nicotine dependence

Mental and behavioral disorders caused by tobacco use (synonyms: tobacco smoking, tobacco addiction, nicotine addiction, nicotinism) are traditionally considered in domestic narcology as tobacco smoking (episodic or systematic) and tobacco addiction.

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Causes nicotine addiction

At the beginning of the 21st century, smoking remains a fairly common phenomenon among the population of all countries of the world. Currently, there are 1.1 billion smokers in the world, which is 1/3 of the planet's population over 15 years old. According to WHO forecasts, by 2020, the nicotine addiction epidemic will move to developing countries, which are characterized by a lack of funds to finance anti-smoking programs. In Russia, 8 million women and 44 million men smoke, which is 2 times more than in developed countries of Western Europe and the United States of America.

It is known that most people start smoking in childhood and adolescence. In countries with a high prevalence of smoking, 50-70% of children try smoking. In Russia, the problem of children's smoking is one of the most acute. Children start smoking in grades 5 and 6. The consequences of early smoking have a negative impact on life expectancy: if you start smoking at age 15, your life expectancy is reduced by 8 years.

Among social factors, irregular sports activities, positive or indifferent attitude towards smoking in the family, lack of information about its harm, frequent conflicts in the family have a reliable influence on the prevalence of nicotine addiction among schoolchildren. The following educational factors play an important role in the development of nicotine addiction among students: frequent conflicts at the place of study, difficulties in adapting to studies in senior grades, the presence of complaints about deterioration of health due to the academic workload, the number of unloved subjects (more than 7). The most significant biological risk factors for the development of nicotine addiction among schoolchildren are: passive smoking, a symptom of psychosomatic dissociation after the second try of smoking, frequent alcohol consumption, and the absence of the stage of episodic smoking. If a combination of biological, educational and social factors takes part in the development of nicotine addiction, then in the development of smoking in adolescents, the most significant role belongs mainly to social factors.

There are three critical periods in the development and establishment of smoking and nicotine addiction among schoolchildren. The first period is at the age of 11, when the number of people with their first experience of smoking increases by 2.5 times. The second period corresponds to the age of 13, when the prevalence of occasional smoking increases significantly (by 2 times). The third period is at the age of 15-16, when the prevalence of systematic smoking exceeds the prevalence of occasional smoking, and the number of people with nicotine addiction increases by 2 times. Factors that contribute to smoking in childhood and adolescence include female gender, single-parent family, lack of intention to continue education after school, feeling alienated from school and its values, frequent alcohol consumption, ignorance or lack of understanding of health risks, having at least one smoking parent, parents' permission to smoke, amount of pocket money, and going to discos.

The development and formation of nicotine addiction occurs against the background of two main factors - social and biological. The social factor is traced in the form of tobacco smoking traditions, and the biological factor is reflected in the initially existing individual reactivity of the body to the inhalation of tobacco smoke. The interaction of the "external" and "internal" factors ultimately forms the development of addiction to tobacco smoking. Risk factors of three ranks are distinguished. The leading factor of rank I is a hereditary predisposition to tobacco smoking. In this case, the family nature of smoking, passive smoking, indifferent or positive attitude to the smell of tobacco smoke are detected. Risk factors of rank II include a symptom of psychosomatic dissociation, manifested at the stage of the first attempts at smoking tobacco. Premorbid soil is attributed to factors of rank III. Tobacco addiction includes all three risk factors for the development of tobacco smoking against the background of a microsocial environment with tobacco smoking traditions.

The motivation for smoking in most teenagers is formed in the following way: curiosity, the example of adults and friends, getting pleasure, fear of being out of date, the desire to keep up with peers, to assert oneself, to support the company, “out of boredom” or “just like that”.

The harm of smoking

Numerous studies have proven that smoking causes irreparable damage to public health. The medical consequences of tobacco use include cardiovascular and respiratory diseases, gastrointestinal tract diseases, and malignant neoplasms of various localizations. Cigarette smoking remains one of the leading causes of death. Up to 300,000 people die prematurely in Russia every year from smoking-related causes. The cardiovascular health consequences of cigarette smoking include damage to the coronary arteries (angina, myocardial infarction), aorta (aortic aneurysm), cerebral vessels, and peripheral vessels. Nicotine causes systemic vasospasm and increases blood clotting due to platelet activation. Chronic bronchitis is the most common respiratory disease among tobacco smokers, and acute and chronic forms of pneumonia and pulmonary emphysema are also common. Gastrointestinal diseases considered as consequences of tobacco use are represented by acute gastritis, gastric ulcer and duodenal ulcer, occurring with frequent relapses. Nicotine acts as an atherogenic factor, leading to the development of malignant neoplasms. According to various researchers, in 70-90% of cases, lung cancer develops as a result of tobacco smoking. The proportion of fatal outcomes from malignant neoplasms caused by smoking is quite high. It is noteworthy that the mortality rate in women from lung cancer due to tobacco smoking is higher than the development of breast cancer. Among tobacco smokers, a significant proportion of malignant neoplasms of the oral cavity, pharynx, esophagus, trachea and larynx is recorded. Damage to the kidneys, ureters, bladder, cervix is possible. About 25% of cases of stomach and pancreatic cancer are associated with tobacco use. A serious medical consequence of tobacco use is passive smoking. Non-smoking family members of smokers are at high risk of developing lung cancer, cardiovascular diseases, children under 2 years of age are predisposed to respiratory diseases. Data on the harm of passive smoking, which increases the risk of diseases in healthy people, became the reason for banning smoking in public places.

Smoking products have a significant impact on the female body. Smoking women experience infertility, vaginal bleeding, circulatory disorders in the placenta area, and ectopic pregnancy more often. The number of spontaneous abortions increases by 5 times compared to non-smoking women. There is a higher risk of premature birth (premature babies), delayed labor, or placental abruption (stillbirth). The consequences of exposure to the fetus include slower fetal growth (reduced height and weight at birth); increased risk of congenital anomalies, the possibility of sudden death of the newborn increases by 2.5 times; consequences affecting the further development of the child are possible (mental retardation, behavioral deviations).

Pathogenesis

One cigarette contains on average 0.5 mg of nicotine (the active substance of tobacco). Nicotine is a surfactant (psychoactive substance) with a stimulating effect. Having narcotic properties, it causes addiction, passion and dependence. The physiological effects of nicotine include narrowing of peripheral vessels, increased heart rate and blood pressure, increased intestinal motility, tremor, increased release of catecholamines (norepinephrine and epinephrine). general decrease in metabolism. Nicotine stimulates the hypothalamic pleasure center, which is associated with the emergence of addiction to tobacco. The euphoric effect is somewhat similar to the effect of cocaine. Following brain stimulation, a significant decline occurs, up to depression, which causes a desire to increase the dose of nicotine. A similar two-phase mechanism is characteristic of all narcotic stimulants, first stimulating, then depressing.

Nicotine is easily absorbed through the skin, mucous membranes and the surface of the lungs. With the pulmonary route of administration, the effect on the part of the central nervous system manifests itself after 7 seconds. Each puff has a separate reinforcing effect. Thus, if with 10 puffs on one cigarette and with smoking one pack of cigarettes per day, the habit of smoking receives approximately 200 reinforcements per day. A certain time, situation, ritual of preparation for smoking, when repeated, are conditioned reflexively associated with the effect of nicotine.

Over time, signs of tolerance develop, which are expressed in a weakening of subjective sensations with repeated use of nicotine. Smokers usually report that the first morning cigarette after an overnight abstinence has the most pronounced refreshing effect on them. When a person starts smoking again after a period of abstinence, the sensitivity to the effects of nicotine is restored, and he may even experience nausea if he immediately returns to the previous dose. Nausea may develop in those who have started smoking for the first time even with a low concentration of nicotine in the blood, while long-term smokers experience nausea when the concentration of nicotine exceeds their usual level.

Negative reinforcement refers to the relief an individual experiences when an unpleasant sensation is eliminated. In some cases of nicotine dependence, smoking is done to avoid withdrawal symptoms, since the urge to smoke may occur when blood nicotine levels fall. Some smokers even wake up in the middle of the night to smoke a cigarette, perhaps to relieve withdrawal symptoms that occur when blood nicotine levels are low and interrupt sleep. When blood nicotine levels are artificially maintained by slow intravenous infusion, the number of cigarettes smoked and the number of puffs taken decrease. Thus, people may smoke to maintain the reinforcing effects of nicotine or to avoid the painful sensations associated with nicotine withdrawal, or, more likely, for a combination of both reasons.

A combination of depressed mood (due to dysthymia or another affective disorder) and nicotine dependence is often observed, but it remains unknown whether depression predisposes to the onset of smoking or whether it occurs as a consequence of nicotine dependence. According to some data, adolescents with depressive symptoms are more likely to become dependent on nicotine. Depression increases significantly during the period of abstinence from smoking - this is considered one of the reasons for relapse. The connection between smoking and depression is indicated by the discovery of the ability of the non-nicotine component of tobacco smoke to inhibit the activity of monoamine oxidase (MAO-B). The degree of inhibition of enzymatic activity is less than that of antidepressants - MAO inhibitors, but it can be sufficient to cause an antidepressant (and possibly antiparkinsonian) effect. Thus, smokers with a tendency to depression may feel better when smoking, which makes it difficult to quit.

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Symptoms nicotine addiction

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F17. Acute nicotine intoxication

Symptoms that occur with nicotine poisoning include: nausea, vomiting, excessive salivation, and abdominal pain; tachycardia and hypertension (early symptoms); bradycardia and hypotension (late symptoms), tachypnea (early symptoms) or respiratory depression (late symptoms); miosis; confusion and agitation (late symptoms); mydriasis; convulsions and coma (late symptoms).

In the process of systematic tobacco smoking, a disease gradually develops - tobacco addiction, which has its own clinical features, development dynamics, stages and complications.

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(F 17.2) Clinical picture of nicotine dependence

It is represented by syndromes of altered reactivity of the body to the action of nicotine (change in tolerance, disappearance of protective reactions observed during the first tobacco tests, change in the form of consumption), pathological craving for smoking tobacco, withdrawal syndrome, and personality change syndrome.

During the first attempts at smoking, the toxic effect of tobacco smoke on the body as a whole is normally manifested - a psychosomatic reaction develops: a drop in blood pressure, fainting, tachycardia, a feeling of nausea, severe dizziness, excruciating muscle weakness, vomiting, a feeling of insufficient inhalation, melancholy, anxiety, fear of death (the body's protective reaction). People who have experienced this form of reaction, as a rule, do not smoke anymore. In others, the body's reaction to tobacco smoke is of a split nature (a symptom of psychosomatic dissociation). They experience slight dizziness, calmness, a feeling of mental comfort, simultaneously combined with muscle weakness, nausea and vomiting. The symptom of psychosomatic dissociation, together with the traditions of the microsocial environment, contributes to smoking tobacco in such people.

When using tobacco, tolerance increases in the dynamics of the disease and changes during the day. After smoking during the day for 6-8 hours, the resistance to the effects of tobacco disappears the next morning. That is why many smokers describe the strong effect of the first cigarette. With each subsequent cigarette smoked, tolerance increases.

The core disorder that characterizes tobacco addiction is a pathological attraction to smoking tobacco, while abstinence from smoking causes a complex of psychosomatic disorders. In most people, the syndrome of pathological attraction occurs several years after the beginning of systematic smoking. In other cases, tobacco addiction does not occur in systematic smokers, but a habit of smoking is formed. The syndrome of pathological attraction to smoking tobacco is a psychopathological symptom complex that includes ideational, vegetative-vascular and mental components.

The ideational component is characterized by the presence of a mental, figurative or mental-figurative memory, representation, desire to smoke tobacco, which is realized by patients. Thoughts about smoking become painfully persistent, stimulating the search for tobacco products.

The vegetative-vascular component manifests itself in the form of individual transient symptoms: cough, thirst, dry mouth, pain of various localizations, dizziness, tremors of the fingers of outstretched hands, hyperhidrosis, instability of blood pressure, gastrointestinal dyskinesias.

The mental component is expressed by asthenic and affective disorders. When abstaining from smoking, psychogenic asthenic reactions occur with transient fatigue, exhaustion, restlessness, irritable weakness, sleep and appetite disorders, decreased performance, and deterioration of well-being. Affective disorders are characterized by asthenic or anxious subdepression. Patients complain of depression, weakness, tearfulness, irritability, anxiety, and restlessness. Pronounced manifestations of the syndrome of pathological attraction to tobacco smoking can be represented by illusory and hallucinatory disorders in the form of a sensation of taste and smell of tobacco smoke.

The development of the syndrome of pathological attraction to tobacco smoking goes through several stages (initial, formation, final). At the initial stage, lasting up to 1 month, a symptom of psychosomatic dissociation is observed. It is formed during the first attempts at smoking tobacco and is expressed in the multidirectionality of the mental and somatic forms of reaction to the toxic effect of tobacco smoke. The formation stage lasts up to 2-3 years, characterized by the formation of the syndrome of pathological attraction to tobacco smoking with the simultaneous deactualization of the symptom of psychosomatic dissociation. At the final stage, the dominance of the syndrome of pathological attraction to tobacco smoking in the clinical manifestations of the disease determines the behavior of the individual aimed at finding a tobacco product and smoking it (occurs in the 3-4th year of systematic smoking).

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(P17.3) Nicotine Cessation

Causes the development of withdrawal syndrome (AS, deprivation syndrome), its manifestations reach their peak 24-28 hours after the last smoking. These include: anxiety, sleep disturbance, irritability, intolerance, irresistible desire to smoke, impaired concentration, drowsiness, increased appetite and headache. The intensity of symptoms decreases after 2 weeks. Some symptoms (increased appetite, difficulty concentrating) may persist for several months.

There are two types of nicotine addiction: periodic and constant. The periodic type is characterized by bright periods of time during the day, when patients forget about smoking for 30-40 minutes. The intensity of tobacco smoking in the periodic type is smoking from 15 to 30 pieces of tobacco products. The constant type is characterized by the presence of a constant craving for smoking tobacco, despite current activity. With this type, patients smoke from 30 to 60 pieces of tobacco products during the day.

The clinical picture of the syndrome of pathological attraction to tobacco smoking, the types of the course of the disease determine the main forms of nicotine addiction described in the literature: ideational, psychosomatic and dissociated.

The ideational form is characterized by a combination of the ideational and vegetative-vascular components in the structure of the syndrome of pathological craving for tobacco smoking in individuals with schizoid features in the premorbid period. The ideational form is characterized by: an early age of the first attempt at smoking tobacco (10-12 years), the absence of the stage of episodic smoking, a rapidly occurring need for systematic smoking, a gradual excess of the initial tolerance by 8-10 times, late onset of smoking tobacco during the day (1-4 hours after waking up), early awareness of the craving for smoking, a periodic type of the disease course, the ability to quit smoking on one's own for a period of 2-3 months to 1 year.

In the psychosomatic form of nicotine addiction, a combination of ideational, vegetative-vascular and mental components is noted in the structure of the syndrome of pathological attraction to tobacco smoking in people with epileptoid features and premorbidity. This form is characterized by a relatively late age of the first smoking attempt (13-18 years), the absence of the stage of episodic smoking, a late age of the onset of systematic smoking, a rapid increase in tolerance with an excess of the initial one by 15-25 times, early morning smoking (immediately after waking up, on an empty stomach), late awareness of the craving for smoking, a constant type of the disease course, unsuccessful attempts to quit smoking on your own.

The dissociated form of nicotine addiction is distinguished by the presence in the structure of the syndrome of pathological attraction, not realized at the ideational level of desire to smoke tobacco. Its manifestation is internal poorly differentiated painful vital sensations that appear during long breaks in smoking. They are localized in different areas of the body: in the pancreas, tongue, throat, trachea, lungs, back, shoulder blade, etc. The dissociated form is characterized by early onset of smoking (the first try at 8-9 years), periodic type of the disease course, a short stage of episodic smoking, smoking on an empty stomach. A feature of this form should be considered "flickering" tolerance. The patient can smoke 2-3 cigarettes in one day, without feeling the need for more, but on other days he smokes 18-20 cigarettes. Compared with other forms of nicotine addiction, the latest awareness of the craving for tobacco is revealed, appearing in the structure of the withdrawal syndrome. In the process of independent tobacco smoking cessation, remissions can last from 5 days to 2-3 months. The dissociated form is characterized by the presence of a delayed withdrawal syndrome (can be classified as an actualization of the pathological craving for tobacco).

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Combined dependence

Smoking is very common among people addicted to alcohol, cocaine, or heroin. Because nicotine is a legal substance, many addiction treatment programs in the past ignored nicotine addiction and focused primarily on alcohol or illegal drugs. In recent years, inpatient treatment has begun to combat smoking by encouraging hospitalized patients to quit smoking with nicotine patches. This measure can be an excellent opportunity to begin treatment for nicotine addiction, even though it requires treating other forms of addiction at the same time. The same principles can be applied to patients undergoing outpatient treatment for substance abuse. Nicotine addiction, which has devastating effects, should not be ignored. Treatment can begin by correcting the most acute problems, but attention must also be paid to nicotine addiction, correcting it with the above combination of treatments.

Nasal toxicomania

In recent years, among children and teenagers living in Central Asia, Kazakhstan, and some regions of Russia, the use of nas, a mixture of crushed tobacco leaves, lime, and ash in water or vegetable oil, has become widespread. Depending on the technology of preparation, there are three types of nas: in water from tobacco and ash; in water from tobacco, ash, and lime; in oil from tobacco, ash, and lime. Nas is placed in the oral cavity under the tongue or behind the lower lip.

Research conducted in recent years by various specialists indicates the toxic effect of nas on many human organs and systems. In an animal experiment, it was found that nas causes damage to the stomach and liver, precancerous changes. People who consume nas have a much higher risk of getting cancer than those who do not consume it. If among 1000 examined people who consume nas, precancerous processes of the oral mucosa were found in 30.2 cases, then among those who do not consume nas, this figure was 7.6.

The most pronounced pathological changes in people who consume us are observed in the oral cavity, mainly in places where we are placed. If we are placed under the tongue, tongue cancer is more common; in residents of Kazakhstan, where we are placed behind the lower lip, the lower gum is most often affected.

In children and adolescents, addiction to the use of nas as an intoxicating substance usually begins with curiosity, imitation, and the desire to keep up with their peers. The particular harm of its use by children and adolescents is that they, putting us under their tongues secretly from adults, are often forced to swallow it under unforeseen circumstances, which aggravates the pathological effects of nas due to its direct effect on the esophagus, stomach, and intestines.

The first time you put nas in your mouth, it causes a distinct tingling and prickling sensation under your tongue, and increased salivation. Mixing with nas, it accumulates in large quantities, causing the need to spit it out after 2-3 minutes. Some of the nas is involuntarily swallowed with saliva. The state of acute intoxication is characterized by mild dizziness with increasing intensity, palpitations, and sudden muscle relaxation. In children and adolescents, when trying to stand up, surrounding objects begin to spin, "the ground goes out from under your feet." Against the background of increasing dizziness, nausea occurs, then vomiting, which does not bring relief, for about 2 hours the state of health remains poor: general weakness, dizziness, nausea bother you, this causes the need to stay in a horizontal position. Unpleasant memories of this persist for 6-7 days.

Some children and teenagers who experience the most pronounced symptoms of intoxication when using nas for the first time do not use it again. Others, having information from others that they do not experience any painful sensations when using nas for the first time, but rather feel pleasant, continue using it. In such cases, the clinical picture of intoxication changes after 2-3 doses. The body's protective reaction of nausea, vomiting, and increased salivation typically disappear. Mild euphoria, relaxation, a feeling of comfort, cheerfulness, and a surge of energy appear. Intoxicated people become talkative and sociable. The described condition lasts for 30 minutes. Over the next 2-3 months, the frequency of taking nas increases from 2-3 times a week to 7-10 times a day. At this stage, the amount of nas used at one time increases, and there is a need to hold it in the mouth for a longer time (15-20 minutes) to prolong the state of intoxication.

Systematic use of nas contributes to the formation of a syndrome of pathological attraction, manifested by a decrease in mood, irritability, irascibility, deterioration in performance. Thoughts about nas interfere with concentration, make it difficult to perform usual work. 2-3 days after stopping the use of nas (for various reasons), signs of withdrawal syndrome appear: headache, dizziness, a feeling of weakness, sweating, palpitations, loss of appetite, irritability, anger, decreased mood, insomnia. The described condition is accompanied by a pronounced desire to take nas and lasts up to 2-3 days. At this stage, the systematic use of nas is due not only to the desire to induce a state of intoxication, but also to the need to relieve the withdrawal symptoms described above. The formation of an abstinence state is accompanied by a further increase in a single and daily dose. In people who have been using nas for a long time, a decrease in tolerance to it can be observed.

Mental disorders are most noticeable when using nas in children and adolescents who show signs of brain failure (head injuries, residual effects of neuroinfection, personality anomalies). They manifest themselves in a sharp aggravation of their previously characteristic lack of restraint, irritability, conflict, and aggressiveness. They note a progressive decrease in memory, weakening of concentration, intelligence - the reasons for a decrease in academic performance, discipline, and incompatibility in the school community.

The appearance of people who show signs of nasal toxicomania is quite characteristic: their skin is flabby with an earthy tint, they look older than their years. They often have chronic diseases of the digestive organs.

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Stages

1. (F17.2.1) Initial stage - smoking is systematic, the number of cigarettes consumed is constantly increasing (change in tolerance). Smokers feel increased performance, improved well-being, a state of comfort (signs of pathological attraction). At this stage of the disease, manifestations of psychosomatic dissociation disappear, signs of somatic and mental changes are absent. The duration of the stage varies within 3-5 years.
2. (F17.2.2) Chronic stage - tolerance at first continues to grow (up to 30-40 cigarettes per day), then becomes stable. The desire to smoke arises with any change in the external situation, after minor physical or intellectual exertion, with the appearance of a new interlocutor, a change in the topic of conversation, etc. Manifestations of the syndrome of pathological attraction to tobacco smoking are aggravated, symptoms of withdrawal syndrome are formed. The patient is bothered by morning cough, unpleasant sensations in the heart area, fluctuations in blood pressure, heartburn, nausea, a feeling of general discomfort, low mood, sleep disorders, increased irritability, decreased performance, a constant and stable desire to continue smoking, including at night. The duration of this stage of nicotine addiction is individual, on average from 6 to 15 years or more.
3. (F17.2.3) Late stage - smoking becomes automatic, non-stop, disorderly and without reason. The type and brand of cigarettes does not play any role for the smoker. There is no feeling of comfort when smoking. Constant heaviness in the head, headache, decreased and lost appetite, deterioration of memory and performance are noted. At this stage, smokers become lethargic, apathetic, at the same time easily irritated, "lose their temper". The phenomena of somatic and neurological ill-being increase and intensify. Pathology of the respiratory organs, gastrointestinal tract, cardiovascular system, and central nervous system is clearly expressed. The skin and visible mucous membranes of the smoker acquire a specific yellowish tint.

The stages of nicotine addiction develop strictly individually and depend on many factors - the time of the onset of tobacco use, its type and variety, age, gender, health status, resistance to nicotine intoxication.

Every smoker tries to quit smoking on their own. The duration of clear periods and spontaneous remissions can be completely different, depending on many factors. Breakdowns usually occur as a result of various external influences, situational circumstances, mood swings.

Only a small part of patients with nicotine addiction is able to stop smoking on their own, the rest need medical help. Short remissions, frequent relapses, characteristic of this disease, make it difficult to solve the problem of tobacco smoking among the population.

(F17.7) A comparative study of clinical manifestations of therapeutic and spontaneous remissions in patients with nicotine addiction showed that the occurrence of remissions goes through three stages - formation, development and stabilization. Each stage has clinical features and a time interval of existence. The main types of remission are asymptomatic, residual with neurosis-like symptoms and hyperthymic without symptoms of craving for smoking tobacco.

Asymptomatic type of remission - there are no residual symptoms of nicotine addiction. This type is typical for spontaneous remissions, as well as the ideational form of nicotine addiction during therapeutic remission. This type is most resistant to relapses, which are absent when smoking is stopped on its own, and during therapeutic remissions observed in patients with the ideational form of nicotine addiction, it is rarely encountered against the background of psychogenic disorders.

The residual type of remission is characterized by complete abstinence from tobacco smoking, there are residual symptoms of pathological craving for tobacco smoking in the form of spontaneously or by association arising mental and figurative memories and ideas about smoking tobacco during the day or at night, during sleep, dreams. The residual type among therapeutic remissions is characteristic of the dissociated and psychosomatic forms of nicotine addiction. In the dissociated form of nicotine addiction, neurosis-like symptoms in remission are manifested by mentalism, absent-mindedness, distractibility, fatigue, mood swings during the day. In residual remission with neurosis-like symptoms, its instability is noted. The emergence of a sensitive coloring of experiences is accompanied by an exacerbation of the symptoms of pathological craving for tobacco smoking. Stressful situations, alcohol intoxication also lead to an exacerbation of the symptoms of nicotine addiction. Relapses of smoking resumption during residual type of remission occur quite often.

Hyperthymic type of remission - characterized by elevated mood in the absence of craving for nicotine. The phase nature of affective disorders is noted. This type is characteristic only of the dissociated form of nicotine addiction during therapeutic remissions.

As can be seen, the types of remission are determined by the clinical form of nicotine addiction and premorbid personality traits. The clinical picture of the types of remission is a prognostic criterion for its duration. The most prognostically favorable (the longest duration and the least number of relapses) is the asymptomatic type. Less favorable is the residual type with neurosis-like symptoms, and unfavorable is the hyperthymic type of remission.

In the structure of mental disorders in patients with nicotine addiction, the main place is occupied by general neurotic (asthenic) disorders, expressed more strongly than in non-smokers. Smoking tobacco already at the early stages of nicotine addiction is accompanied by affective disorders, which act as factors contributing to the maintenance and aggravation of nicotine addiction.

Recently, due to the increased interest of researchers in the problem of comorbid conditions in psychiatry and narcology, the mutual influence of cynical diseases, smoking and nicotine addiction has been studied. The main characteristics of smoking and nicotine addiction are the duration of smoking, the age of the first try and the beginning of systematic smoking, incentives, the degree of dependence on nicotine, clinical manifestations of tobacco addiction (they differ in patients with mental disorders of different registers depending on the phenomenology of their disorders). Affective disorders comorbid with nicotine addiction have some clinical features: non-psychotic level of manifestations, insignificant intensity, flickering nature of the course, low progression. Affective disorders are diagnosed for the first time only when seeking medical help to quit smoking. These disorders are not considered to be a consequence of nicotine addiction or its cause; they occur against the background of already formed nicotine addiction and in the presence of unfavorable premorbid soil. Psychogenic factors usually trigger the development of affective disorders, which become the determining factor in the motive for stopping smoking. Among patients with neurotic pathology, the ideational form of nicotine addiction with an average degree of dependence on nicotine predominates, and for patients with schizophrenia, the psychosomatic form with a high degree of dependence is characteristic. The type of accentuation (excitable, cyclothymic, emotive, exalted and demonstrative) is attributed to the factors of increased risk of tobacco smoking and the formation of nicotine addiction in patients with neurotic disorders. Elimination of nicotine addiction improves the course of neurotic disorder, but aggravates the manifestations of schizophrenia.

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Diagnostics nicotine addiction

Below are the diagnostic features of acute intoxication due to tobacco use (acute nicotine intoxication) (F17.0). It must meet the general criteria for acute intoxication (F1*.0). The clinical picture necessarily records dysfunctional behavior or disturbances of perception. This is evidenced by at least one of the following signs: insomnia; bizarre dreams; mood instability; derealization; impaired personal functioning. In addition, at least one of the following signs is revealed: nausea or vomiting, sweating, tachycardia, cardiac arrhythmia.

The diagnosis of withdrawal syndrome (F17.3) is made on the basis of the following signs:

• compliance of the condition with the general criteria for withdrawal syndrome (F1*.3);
• The clinical picture includes any two of the following: a strong desire to use tobacco (or other nicotine-containing products); a feeling of malaise or weakness; anxiety; dysphoric mood; irritability or restlessness; insomnia; increased appetite; severe cough; ulceration of the oral mucosa; decreased concentration and attention.

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Treatment nicotine addiction

The problem of treating nicotine addiction has not lost its relevance to this day. More than 120 methods of treating nicotine addiction are known, of which about 40 are widely used. The main methods of treating typical nicotine addiction include various types of reflexology, suggestive forms of psychotherapy, autogenic training, behavioral therapy, replacement therapy using nicotine (intranasal spray, inhaler, transdermal patch, chewing gum), etc.

There are no radical methods of curing nicotine addiction to date. All methods of treating nicotine addiction that exist in the arsenal of a narcologist are grouped as follows: behavioral therapy; substitution therapy; drug therapy; non-drug therapy.

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Behavioural therapy for nicotine addiction

Behavioural therapy includes activities carried out in some countries to develop behavioural strategies aimed at maintaining a healthy lifestyle (physical exercise and sports, balanced nutrition, optimal alternation of work and rest, elimination of bad habits). Popularisation of a healthy lifestyle implies, first of all, stopping smoking, which is becoming a vital human need; other work should be carried out in educational institutions, healthcare institutions, and in print and electronic media. There are many approaches to behavioural therapy. Those wishing to quit smoking should use certain rules.) reduce daily cigarette consumption according to a certain scheme; increase the interval between cigarettes smoked; start smoking a brand of cigarettes that they do not like.

Clinical manifestations of nicotine addiction allow us to suggest some behavioral therapy techniques. It is known that actions usually accompanied by smoking cause a strong desire to smoke. That is why it is necessary to avoid actions associated with smoking, develop replacement habits (chewing gum, lollipops, drinking mineral water, juices, etc.). Smoking after meals, as a rule, increases pleasure. In this regard, it is advisable to choose alternative options for obtaining pleasure (watching favorite films, listening to music, reading fiction). Quite often, smoking relapses occur in an elevated mood. A smoker needs to tune himself and think over his behavior in situations that cause positive emotions (pleasant excitement, anticipation of a meeting, expectation), in which the risk of resuming smoking is increased for him (an evening with friends, colleagues, visiting a cafe, restaurant, fishing trips, hunting, etc.). A strong desire to smoke can appear in a state of psychoemotional stress. Apparently, relapses occur when smokers experience sadness, sorrow, despondency, are restless and irritated. In such cases, they should take psychotropic drugs (tranquilizers, antidepressants), and also use behavioral methods to overcome negative emotions (self-hypnosis in a state of relaxation, seeking support from specialists). The increase in body weight observed when abstaining from tobacco use is one of the main reasons for relapse. An important role here is given to the organization of proper nutrition, physical exercise, and sports.

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Hypnosuggestive express method

Among non-drug approaches to treating nicotine addiction, the hypnosuggestive express method is used. In a hypnotic trance, suggestions with therapeutic settings are made. They suggest the inevitability of severe health consequences with further smoking; the possibility of premature death; the disappearance of the consequences of smoking, strengthening health when quitting smoking. With the help of suggestion, the pathological craving for smoking is removed, indifference, apathy and disgust for tobacco are developed. A stereotype of the patient's behavior in society is formed with quitting smoking in any situation, even under the influence of psychotraumatic factors that provoke craving. The patient's own attitude to quit smoking is strengthened.

Among the methods of psychotherapy for smoking, stress psychotherapy according to A.R. Dovzhenko occupies a certain place. When influencing the patient, this therapy includes a system of positive reinforcement as a universal mechanism of self-regulation and self-control of body functions.

Nicotine Replacement Therapy

Special preparations containing nicotine are widely used as a replacement therapy for nicotine addiction. The effect of nicotine is imitated by using nicotine chewing gum and nicotine in solution. Chewing gum with nicotine should not be considered a panacea. Its use gives a certain effect in a complex of medical, social and other measures in the fight against tobacco smoking.

Drugs containing nicotine cause effects for which patients resort to smoking: maintaining a good mood and working capacity, self-control in stressful situations, etc. According to clinical studies, the drug nicorette affects the symptoms of nicotine withdrawal syndrome - evening dysphoria, irritability, anxiety, inability to concentrate. reduces the number of somatic complaints.

The conducted studies have established that the treatment of nicotine addiction using a nicotine patch is much more effective compared to placebo treatment. A high dose of nicotine in the patch (25 mg) is preferable to a low dose (15 mg). The transdermal approach to nicotine replacement therapy is carried out using a large number of drugs: Habitrol, Nicodermar, Prostep, as well as three types of Nicotrol, containing 7, 14, 21 mg of nicotine, with an absorption duration of 16 or 24 hours.

The effectiveness of smoking cessation therapy can be increased by using a combination of nicotine chewing gum and a nicotine-releasing transdermal system that provides a constant and stable supply of nicotine to the body. The patient uses chewing gum occasionally, as needed. The combination therapy is carried out sequentially. In this case, the patient first uses a mini nicotine patch, and then periodically uses chewing gum to maintain long-term remission.

Nicotine aerosol makes it easier to quit smoking, but only in the first days of its use. Nicotine inhalers are used in the form of a plastic tube with a nicotine capsule for nicotine delivery through the mouth. 4-10 inhalations are used per day. Nicotine inhalations are useful for short-term smoking cessation.

A strong need to smoke during withdrawal syndrome is the reason for unsuccessful attempts to quit smoking. That is why adequate nicotine replacement during acute withdrawal syndrome helps overcome the desire to smoke. The nicotine-containing drugs presented above are used for this purpose. The indication for their use is a strong dependence on nicotine (consuming more than 20 cigarettes daily, lighting the first cigarette within 30 minutes after waking up, unsuccessful attempts to quit smoking: a strong craving for cigarettes in the first week of withdrawal syndrome). Nicotine replacement therapy can also be prescribed to patients with a stable motivation to quit smoking. When using replacement therapy, the need for the usual daily number of cigarettes decreases, and with a one-time cessation of smoking, the withdrawal syndrome is softened. A long course of replacement therapy (2-3 months) does not solve the problem of quitting tobacco. It should be remembered that in case of somatic contraindications (past myocardial infarction, hypertension, hyperthyroidism, diabetes mellitus, renal and hepatic diseases), the use of nicotine patches and nicotine chewing gum is inappropriate. An overdose of nicotine cannot be ruled out in cases of continued smoking, as well as side effects and complications when combined with pharmacotherapy (weakness, headaches, dizziness, hypersalivation, nausea, vomiting, diarrhea).

To develop a negative conditioned reflex to smoking, emetics are used in combination with smoking. We are talking about apomorphine, emetine, tannin, silver nitrate solutions, copper sulfate for rinsing the mouth. Their use when smoking tobacco is accompanied by altered sensations in the body: an unusual taste of tobacco smoke, dizziness, dry mouth, nausea and vomiting.

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Weakening of attraction

In 1997, the FDA approved bupropion as a nicotine craving reduction drug. The new indication for the drug, which was already used as an antidepressant, was based on the results of double-blind trials demonstrating bupropion's ability to reduce cravings and ease the tolerability of nicotine withdrawal. According to the recommended regimen, bupropion is started one week before the intended quit date. During the first three days, 150 mg is taken once a day, then twice a day. After the first week, a nicotine patch is additionally prescribed to ease withdrawal symptoms, and bupropion is combined with behavioral therapy to reduce the risk of relapse. However, no studies have been conducted on the long-term effectiveness of such combination therapy.

Studies have shown that when smoking is stopped with the help of a patch or chewing gum with nicotine, confirmed abstinence after 12 months is noted in 20% of cases. These are lower rates of treatment effectiveness than with other types of addiction. Low effectiveness is partly explained by the need to achieve complete abstinence. If a former smoker “breaks down” and tries to smoke “a little bit”, he will usually quickly return to the previous level of addiction. Thus, the only criterion for success can be complete abstinence. The combined use of behavioral and drug therapy may be the most promising direction.

Reflexology and nicotine addiction

In recent years, reflexology and its modifications (electroreflexotherapy) have been widely used in the treatment of nicotine addiction. These methods are in many ways superior to traditional drug therapy.

The method of electropuncture on biologically active points (corporeal and auricular) is painless, does not cause skin infection, does not give complications, does not require much time (3-4 procedures per course). During the procedure, patients lose the desire to smoke, the manifestations of nicotine withdrawal disappear. After completing the course of treatment, when trying to smoke, patients experience an aversion to the smell and taste of tobacco, the pathological attraction to it disappears. Patients stop smoking. Auricular reflexology is the most effective method of treating nicotine addiction.

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Combination treatment for nicotine addiction

It has been established that a combination of the following treatment methods is very effective for nicotine addiction: acupuncture or alectropuncture to get rid of physical addiction; a session (ideally a course) of individual psychotherapy for mental adjustment to a new life, a new solution to problems associated with emotional experiences: inclusion in a mutual support group to form a new lifestyle; abstinence from smoking for a sufficient period of time (relapse prevention).

A complex method using acupuncture combined with hypnosuggestion quickly and effectively deactualizes the craving for nicotine, this is an important point for many patients determined to get rid of nicotine addiction at once. This approach allows eliminating functional symptoms that provoke craving for smoking.

Acupuncture is performed using the classic "Antitabacco" method developed by the Frenchman Nogier, using mainly auricular points. The goal of a verbal hypnotherapy session is to achieve a shallow sleepy state. The suggestion formulas used take into account not only the patient's motivation to quit smoking, but also his or her idea of the motives for craving tobacco. During a session, which lasts about 30 minutes, the pathological craving for tobacco is stopped. Repeated sessions are performed every other day with the additional inclusion of corporal points of influence, the effect of the needles is enhanced by twisting them.

It is known that stopping smoking causes hormonal-mediator dissociation, which affects the state of mental and physical comfort of a person. The use of reflexotherapy modifications accompanies the normalization of the functional state of the sympathoadrenal system. That is why the use of laser methods of influence, which have a powerful stimulating and normalizing effect, contributes to the rapid restoration of hormonal-mediator dysfunction that occurs during the treatment of nicotine addiction (withdrawal syndrome).

When developing the medical section of the national anti-smoking project, it is necessary to take into account:

• treatment of nicotine addiction requires special knowledge, skills and should be concentrated within the framework of the clinical discipline - narcology;
• when implementing individual sections of treatment programs for smoking cessation, narcologists may involve non-medical specialists (psychologists, sociologists, teachers, etc.);
• treatment of the somatic consequences of smoking is an interdisciplinary problem, its solution must be carried out through integration with narcology of various clinical specialties (cardiology, oncology, pulmonology, toxicology, etc.);
• The implementation of the medical section of the national anti-smoking project requires the creation of centers for outpatient treatment of nicotine addiction and inpatient beds for the treatment of severe forms of nicotine addiction.

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Forecast

Smokers who seek help are the most therapeutically resistant. The effectiveness of treatment programs in these cases does not exceed 20%. At the same time, 95% of people who quit smoking did not receive medical care. Unsatisfactory social adaptation, female gender, high levels of tobacco consumption before treatment, and pronounced manifestations of nicotine addiction are considered prognostically unfavorable factors.

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