Nicotine is hard to quit

Instead of finger-pointing, smokers need effective support and treatment when they wish to kick their addiction, says Docent Tellervo Korhonen, who has studied smoking and nicotine addiction for more than twenty years.

“Nicotine addiction is a chronic condition with fulfilling the criteria of a disease of its own. It should be viewed as any other chronic disease, with effective therapies made available,” says Docent Tellervo Korhonen.

“Smokers don’t need finger-pointing and disparaging. If there are parties deserving of finger-pointing, it is those that have allowed the production and marketing of tobacco products to continue despite the overwhelming evidence of their harm to individuals and society.  

Nicotine is a very addictive substance, comparable to heroin in that regard. Moreover, the predisposition to developing an addiction has a substantial genetic component: some nicotine  users can get hooked already after a handful of goes, while others never develop a physiological addiction.

Psychological and social habituation is another matter, and not an easy one to break.

“Research indicates that approximately half of smokers are dependent on nicotine. Among alcohol users, the corresponding share is  only about 10%. Yet the discourse on addictive disorders usually revolves around other intoxicants, such as alcohol, whereas smoking is forgotten,” Professor Jaakko Kaprio points out.

Nicotine is a very addictive substance. Particularly addictive it is at a young age.

Nicotine is particularly addictive at a young age. Adolescents start to experiment with smoking usually at the age of 14 or 15, or even earlier, a stage of life when the brain is extremely sensitive to nicotine. Among adults who have become addicted to nicotine, almost all have started smoking at a very young age.

“You could almost call smoking and nicotine addiction paediatric diseases, given its early onset” Kaprio says.  

The true nature of nicotine addiction is not yet understood well enough - even by health care professionals.

“Quitting smoking is not only up to the smoker’s personal motivation. Every other smoker has an addictive disorder, whose tackling requires long-term efficacious treatment and support. This message should be disseminated throughout the health care system down to the grassroots,” says Korhonen. 

Consequences are known, mechanisms of action still under investigation

Smoking is known to cause dozens of diseases, among them  multiple cancers, respiratory diseases and vascular diseases. Some seven million individuals die every year from smoking-related diseases. On average, smokers die ten years younger than non-smokers.

“There is indisputable evidence on the causality between smoking and many diseases. The evidence could not really be any stronger,” Kaprio says.

However, the biological mechanisms of action through which smoking causes diseases are not yet known well enough, nor is the role of nicotine itself in the onset of these diseases. What is known is that nicotine  – a very toxic pyridine alkaloid – impairs the body in a multitude of ways already at low concentrations.

In the body, nicotine binds with what are known as nicotinic acetylcholine receptors. These receptors can be found in several organs, but in particularly large numbers in the brain. In the brain, nicotine binding results in the release of various neurotransmitters, such as adrenaline and dopamine. Indeed, it is dopamine that generates a feeling of satisfaction, while adrenaline affects the heartbeat.

“The short-term effect of nicotine on the brain varies by individual, and situation can also be a variable. Thus, in certain situations nicotine can have a calming effect, helping one to focus, while in another context the effect can be almost stimulating,” says Kaprio.

The short-term effect of nicotine on the brain varies by individual.

“All in all, the neurobiology of tobacco and nicotine addiction is quite a complex and fascinating research topic.”

Recent studies have shown that nicotine also affects the prefrontal region of the brain, which has an important role in the regulation of emotions and behaviour. However, the precise sites of action in the region for nicotine are not yet known.

Snus is smokeless, but not harmless

The prevalence of smoking in Finland has been declining already for some time. In 2017, only about 13% of Finns of at least 15 years of age were smoking daily according to population surveys. According to Kaprio and Korhonen, this does not mean that the problem has been solved and the battle won.

The popularity of snus, a form of smokeless tobacco generally brought from Sweden, has grown, particularly among the adolescents and young adult men. Snus use causes no second-hand effects as smoking does, and many think that it’s also less harmful to users than cigarettes. Korhonen points out the inaccuracy of that notion.

“Snus is as much a nicotine product as cigarettes. Actually, there are smokeless tobacco products available on the black market with much higher nicotine concentrations than in cigarettes. Nicotine is absorbed into the body also from smokeless tobacco, exposing users to all of the health hazards of nicotine, including addiction.”

Smokeless tobacco use also predisposes users to diseases of the mouth, from cavity formation to malignant mucosal disorders.

Nicotine with a side of crème

Electronic cigarettes have been marketed as a healthier alternative to smoking, as well as a tool for weaning oneself from smoking. However, the health effects of e-cigarettes are still poorly known, and the situation is further complicated by the fact that they can contain a wide variety of fluids and substance compounds. The use of electronic cigarettes is commonly called vaping.

Nicotine-free products are available, but it’s very easy to inhale nicotine from an e-cigarette as well.

“At the moment, it looks like e-cigarettes are not very effective in helping to quit smoking altogether. Instead, they are used to a certain extent as a ‘replacement therapy’, or there is dual use of tobacco and vaping,” Kaprio explains.

Initially, e-cigarettes were introduced to the market by a number of small companies, but it didn’t take long for the big tobacco companies to become interested in the product.

Tobacco companies are very innovative in developing nicotine products.

“The e-cigarette technology has advanced at a dizzying speed. Tobacco companies are very innovative in developing nicotine products,” Kaprio says.

For example, the FDA, the US Food and Drug Administration, has expressed concern about the enthusiasm of young people towards vaping. The office has paid particular attention to a trendy new product known as Juul, as reported by the New York Times in September 2018, among others.

Juul is an e-cigarette resembling a memory stick that can be charged by plugging it into, for example, a laptop. “Juuling” is particularly popular in colleges and the IT sector, and accounts for 70% of the market for e-cigarettes in the USA. There are several flavours available, from mango to crème, but they all have one thing in common: Juul contains so much nicotine that its sale is prohibited in Europe. Lower strength Juul is being marketed in the UK.

 “Because long-term effects of e-cigarettes are unknown, as regards vaping, a veritable human experiment is currently taking place,” Korhonen says.

“We practice what we preach”

Professor Kari Reijula, one of the vice-deans of the Faculty of Medicine, is leading the Smoke-free Meilahti project of the Faculty and the Helsinki University Hospital. The goal of the project is a medical campus free of cigarettes and other non-medical nicotine products.


“Health products” by tobacco companies 

In recent years, the tobacco industry has waged a harm reduction campaign: its goal is to introduce new products that are less harmful than traditional tobacco products consumed by smoking. Their justification is that this would reduce the health hazards of tobacco.

E-cigarettes are among these less hazardous products: they may contain nicotine, but at least the smoke hazards of tobacco are eliminated.

The opinions of researchers and experts on these new products range from one extreme to the other. Some think that no tobacco and nicotine products of any kind should be released, since the goal is to get rid of all of them. Others are inclined to believe that less harmful products would steer us in the right direction.

As far as Korhonen is concerned, less harmful nicotine products could be beneficial to those who are unable to shed their nicotine addiction despite repeated intensive treatment efforts..

“However, this group is extremely small at population level, since a significant share of smokers could wean themselves from tobacco with the help of effective treatments and support,” Korhonen says.

According to Korhonen, a large share of support for quitting smoking can be offered through primary health care if the provision of the resources required  – expertise, motivation and time – is guaranteed. Some addicted smokers, however, require even more intensive care and specialised expertise. 

“Unfortunately, this  component of the Finnish tobacco policy is our weakest link, which has been noted even in international tobacco policy evaluations. No wonder smokers addicted to nicotine are fooled by the harm reduction strategy patronised by the tobacco industry.”

When examining the harm reduction strategy on the population level, the overall results can be far from desirable: many individuals with genuine chances of kicking their tobacco and nicotine habits may remain consumers of both products, while products with allegedly less harmful effects may attract a new category of users who would never take up traditional smoking or snus use, Korhonen muses.

“In the end, it’s nicotine that the tobacco industry wants to distribute to the public thanks to its addictiveness and the resulting guaranteed demand for the products.”                                                                                                                        

“It doesn’t look like the tobacco industry is considering abandoning nicotine products. Why would it, when the business remains so profitable?” Kaprio quips.

More about Finnish tobacco policy

Stop smoking before surgery

Everyone knows that smoking causes lung cancer and is also otherwise harmful to the lungs. What is not known to surprisingly many is that it’s very harmful to surgical patients. 

Compared to non-smokers, the surgical wounds of smokers heal more slowly, while their risk of blood clots, brain infarction, infections and pneumonia is greater. All in all, smokers have 40% more surgical complications than non-smokers, and repeat operations are needed much more frequently. Even bones heal slower in smokers.

As much as most people know about the health hazards of smoking and especially the danger of lung cancer, many patients are surprised to hear about problems connected with surgical treatment originating in smoking, explains Docent Karin Blomgren, a head physician leading the Stop Smoking Before Surgery project at the University of Helsinki Hospital.

In terms of surgical complications, it’s not only about cigarettes, since nicotine alone increases them.

“It doesn’t matter where the patient gets nicotine in his or her body – from cigarettes, snus or, for example, e-cigarettes.”

Surveys indicate that the majority of smokers would like to stop smoking. An upcoming surgery may serve as the final impetus to put their wishes into practice.

“In discussions with their doctor, many patients get enthusiastic about quitting, and it’s of utmost importance for the doctor to immediately steer them to a rehabilitation nurse. If the matter is delayed and booking an appointment with the nurse remains the patient’s responsibility, such opportune moments can be lost,” Blomgren says.

“We need more nurses trained in rehabilitation and clear guidelines on how patients are to be guided to receive support. There is an opportunity for significant health benefits and equally significant health care savings with relatively small but accurately targeted investment.”

For now, there are no monitoring data on how many patients permanently quit smoking due to “surgical interventions”, although a follow-up study is currently ongoing.

What if a person absolutely does not want to quit smoking, regardless of the risks?

“If someone definitely wants to smoke, it’s his or her decision. It is not our duty to pressure them, but we must be able to provide support and treatment to those who want to quit,” says Blomgren.