32% of Americans nicotine dependent

Nicotine dependence has reached a 15-year high, with nearly 75 percent of people currently seeking tobacco-dependence treatment categorized as highly nicotine dependent. New research, presented at CHEST 2008, the 74th annual international scientific assembly of the American College of Chest Physicians (ACCP), reports that nicotine dependence severity has increased 12 percent between 1989 and 2006, while the proportion of people classified as highly nicotine dependent has increased 32 percent.

The study's lead author, David P. Sachs, MD, of the Palo Alto Center for Pulmonary Disease Prevention, was not surprised by the findings. "After treating tobacco-dependent patients for the last 25 years and conducting many tobacco dependence clinical treatment trials, I began to see a shift in severity of physical, nicotine dependence that required me to develop more intensive treatment plans for my patients," he said.

Dr. Sachs joined forces with colleagues from the Palo Alto Center for Pulmonary Disease Prevention in Palo Alto, CA and St. Helena Hospital in Napa, CA, to identify if there had been a true shift in nicotine dependence in the last 15 years. To do this, they compared pretreatment nicotine dependence severity, as measured by the Fagerström Tolerance Questionnaire (FTQ) scale (0 to 11 points), in three different cohorts from 1989 to 2006: (1) Nicotine Patch Study (NPS), n=220, enrolled December 1989 through April 1990; (2) Bupropion SR Study (BSRS), n=206, enrolled September 1994 through December 1994; and (3) St. Helena Hospital Center for a Smoke-Free Life (CSFL), n=204, enrolled February 2005 through October 2006.

The analysis showed that pretreatment FTQ scores increased by 12 percent over the 15-year study period: 1989 (NPS), 6.65±1.72; 1994 (BSRS), 7.02±1.80; and 2006 (CSFL), 7.44±1.80. Also, the proportion of patients with a high FTQ score (7 to 11 points) increased 32 percent from 1989 to 2006: NPS, 55.5 percent; BSRS, 65.5 percent; and CSFL, 73.0 percent.

Although Dr. Sachs and his team identified a definite increase in tobacco dependence, the reason for this increase is still unclear.

"Previous studies suggest that individuals who have less severe nicotine dependence have already been successful at quitting smoking, which leaves a larger percentage of patients who are highly nicotine dependent among the greater tobacco-using community." Smokers who are highly addicted to nicotine may not even realize they are addicted but see their tobacco use as a "bad habit," and, consequently, never attempt smoking cessation or try to quit on their own.

"A person cannot know what his or her blood pressure is without measuring it. Similarly, a cigarette user cannot know how severe his or her nicotine dependence is without measuring it," said Dr. Sachs. "Many factors can identify someone as highly nicotine-addicted; however, as a quick 'bedside' test, if you light up your first cigarette within the first 30 minutes of awakening, you are most likely highly nicotine dependent."

The results of the study suggest that more individualized tobacco-dependent treatments are needed to address the increase in addiction severity.

"The more severely nicotine dependent a person is, the greater the medical need for more intensive tobacco-dependent therapies," said Dr. Sachs. "Today's severely nicotine-dependent patient may not respond to the current 'standard' in tobacco dependence treatment, much of which is based on nicotine dependence data and outmoded treatment concepts from 15 years ago."

To address the increase in nicotine dependence, Dr. Sachs suggests that physicians may need to increase pharmacologic doses and duration of medication use, try different combinations of pharmacotherapy, and place more emphasis on minimizing withdrawal symptoms in order to avoid treatment failure.

"All Fellows of the ACCP take the 'no tobacco' pledge, stating that they will remain tobacco-free and encourage their patients to do the same," said James A. L. Mathers, Jr., MD, FCCP, President of the American College of Chest Physicians. "The results of this study will give health-care providers more insight into the severity of nicotine dependence and the importance of individualized treatment plans for tobacco dependence. The study will also benefit ACCP members as they continue to fulfill their pledge of helping patients stop smoking."