Pregnancy Special Therapeutic Situations

women฀who฀smoke฀than฀during฀smoking฀cessation฀therapy฀with฀NRT,฀the฀women฀in฀ques- tion฀ should฀ agree฀ to฀ NRT฀ if฀ non-drug฀ interventions฀ fail฀ to฀ achieve฀ smoking฀ cessation.฀ Meticulous฀research฀into฀this฀question฀is฀required฀in฀the฀years฀ahead฀see฀ [71,฀73] .

11.5.3 Weight Gain

For฀a฀variety฀of฀reasons,฀many฀smokers฀lose฀weight฀over฀the฀course฀of฀many฀years฀of฀ smoking฀reduced฀appetite,฀increased฀fatty฀acid฀oxidation,฀deteriorating฀insulin฀resistance,฀ increased฀plasma฀insulin฀concentrations,฀although฀tobacco฀smoke฀does฀not฀appear฀to฀be฀an฀ anorectic฀agent฀ [165] .฀Conversely,฀smoking฀cessation฀in฀response฀to฀nicotine฀administra- tion฀brings฀an฀improvement฀in฀insulin฀resistance฀with฀a฀simultaneous฀weight฀gain.฀This฀ weight฀gain฀on฀smoking฀cessation฀is฀clearly฀associated฀not฀with฀the฀withdrawal฀of฀nicotine฀ but฀of฀other฀unidentiied฀components฀of฀cigarette฀smoke฀ [166] .฀Moreover,฀the฀presence฀of฀ nicotine฀has฀been฀shown฀to฀increase฀concentrations฀of฀leptin฀ [167] ฀which฀evidently฀acts฀to฀ reduce฀body฀weight฀ [168] .฀While฀changes฀in฀body฀weight฀following฀smoking฀cessation฀are฀ a฀major฀concern฀for฀many฀smokers,฀the฀transient฀body฀weight฀luctuations฀often฀balance฀ out฀again฀within฀a฀few฀years฀ [169] . In฀particular,฀women฀who฀eat฀more฀in฀stress฀situations฀frequently฀the฀reason฀for฀smok- ing฀ [170,฀171] ฀or฀who฀are฀going฀through฀the฀perimenopause฀ [172] ฀are฀predestined฀to฀gain฀ weight฀when฀they฀stop฀smoking.฀Dietary฀advice฀should฀be฀given฀at฀the฀start฀of฀smoking฀ cessation฀and฀efforts฀should฀be฀made฀to฀encourage฀greater฀physical฀activity,฀since฀this฀has฀ been฀shown฀to฀minimise฀weight฀gain฀in฀middle-aged฀women฀ [173,฀174] .

11.5.4 Alcohol Consumption

A฀close฀association฀exists฀between฀alcohol฀dependence฀and฀nicotine฀dependence.฀The฀vast฀ majority฀of฀alcoholics฀also฀smoke,฀whereas฀only฀5–10฀of฀smokers฀are฀alcohol-dependent.฀ Combined฀dependence฀is฀associated฀with฀an฀increased฀incidence฀of฀head฀and฀neck฀tumours฀ [175] .฀It฀is฀thought฀that฀daily฀cigarette฀consumption฀is฀increased฀during฀recovery฀from฀ alcoholism฀ [176] .฀ In฀ addition,฀ tobacco฀ is฀ the฀ more฀ common฀ cause฀ of฀ death฀ in฀ former฀ patients฀of฀drug฀dependence฀centres฀ [177] .฀According฀to฀several฀studies฀including฀two฀ controlled฀trials฀ [175] ,฀smoking฀cessation฀withwithout฀NRT฀is฀reported฀to฀have฀no฀adverse฀ consequences฀on฀the฀absence฀of฀drinking฀behaviour฀in฀former฀alcoholics฀ [16] .฀In฀this฀ context,฀there฀is฀evidence฀to฀suggest฀that฀NRT฀has฀no฀adverse฀consequences฀on฀simultane- ously฀implemented฀alcohol฀withdrawal฀ [177] .

11.5.5 Organic Depression and Schizophrenia

A฀generally฀pro-smoker฀atmosphere฀dominates฀in฀psychiatric฀clinics฀ [177] .฀The฀percentage฀ of฀patients฀who฀smoke฀increases฀with฀longer฀hospitalisation,฀although฀this฀tendency฀was฀ only฀in฀evidence฀in฀non-schizophrenics฀ [178] .฀Basically,฀smoking฀cessation฀is฀easier฀for฀ psychiatric฀ patients,฀ the฀ more฀ actively฀ they฀ cooperate฀ and฀ the฀ more฀ independent฀ their฀ behaviour฀is.฀Accordingly,฀ex-smokers฀with฀mental฀illnesses฀have฀lower฀Brief฀Psychiatric฀ Rating฀Scale฀BPRS฀scores฀than฀smokers฀ [179] .฀The฀analysis฀of฀data฀on฀4,411฀respondents฀ aged฀from฀15฀to฀54฀years฀demonstrated฀that฀smokers฀with฀any฀history฀of฀mental฀illness฀had฀ a฀self-reported฀quit฀rate฀of฀37.1,฀and฀smokers฀with฀past-month฀mental฀illness฀had฀a฀self- reported฀quit฀rate฀of฀30.5฀compared฀with฀smokers฀without฀mental฀illness฀42.5.฀The฀ ORs฀for฀current฀and฀lifetime฀smoking฀in฀respondents฀with฀mental฀illness฀in฀the฀past฀month฀ vs.฀respondents฀without฀mental฀illness,฀adjusted฀for฀age,฀sex฀and฀region฀of฀the฀country,฀ were฀2.7฀2.3–3.1฀vs.฀2.7฀2.4–3.2.฀Persons฀with฀a฀mental฀disorder฀in฀the฀past฀month฀ consumed฀ approximately฀ 44.3฀ of฀ cigarettes฀ smoked฀ by฀ this฀ nationally฀ representative฀ sample฀ [180] .฀In฀treatment฀with฀nicotine฀patches,฀the฀smoking฀withdrawal฀results฀for฀208฀ psychiatric฀outpatients฀were฀no฀worse฀than฀for฀non-patients฀ [181] .฀Patients฀treated฀with฀ antidepressants฀and฀neuroleptics฀consume฀more฀cigarettes฀than฀patients฀not฀treated฀with฀ these฀substances.฀Clearly,฀the฀anticholinergic฀effect฀of฀these฀medicines฀is฀also฀at฀least฀atten- uated฀by฀increased฀nicotine฀administration,฀or฀else฀increased฀cigarette฀consumption฀accel- erates฀the฀hepatic฀metabolism฀of฀neuroleptics,฀thus฀reducing฀the฀unwanted฀effects. A฀no-smoking฀policy฀in฀psychiatric฀clinics,฀with฀the฀attendant฀withdrawal฀symptoms,฀ does฀not฀have฀a฀negative฀effect฀on฀mental฀illnesses฀ [182] .฀Another฀compromise฀method฀is฀to฀ put฀restrictions฀on฀the฀smokers฀in฀these฀clinics,฀although฀this฀does฀not฀encourage฀them฀to฀stop฀ smoking฀ [183] .฀It฀is฀certainly฀no฀easy฀matter฀to฀enforce฀a฀no-smoking฀policy฀in฀a฀psychiatric฀ clinic,฀although฀no฀threatening฀consequences฀result฀for฀the฀patients.฀What฀does฀make฀sense฀ is฀to฀couple฀smoking฀prohibition฀with฀NRT฀to฀facilitate฀smoking฀cessation฀ [183] .

11.5.5.1 Organic Depression

Co-morbidity฀of฀psychiatric฀illnesses,฀especially฀depression,฀in฀conjunction฀with฀the฀use฀of฀ illicit฀drugs,฀is฀more฀common฀than฀was฀previously฀assumed฀ [184,฀185] .฀This฀also฀applies฀ for฀nicotine฀dependence฀in฀the฀form฀of฀cigarette฀smoking. Of฀a฀group฀of฀120฀chronic฀smokers,฀62.3฀were฀mentally฀ill฀mood,฀anxiety,฀or฀sub- stance฀abuse฀disorders.฀Although฀these฀smokers฀were฀more฀“stressed”฀at฀the฀time฀of฀treat- ment฀high฀levels฀of฀nicotine฀dependence,฀depressive฀mood,฀they฀achieved฀the฀same฀level฀ of฀cessation฀success฀as฀the฀non-patients฀ [186] ,฀so฀that฀it฀was฀not฀possible฀to฀establish฀an฀ association฀between฀smoking฀cessation฀and฀mental฀illness. An฀existing฀depression฀diminishes฀the฀success฀of฀smoking฀cessation฀compared฀with฀ persons฀not฀suffering฀from฀this฀condition฀ [187] .฀According฀to฀a฀large฀Finnish฀study฀ [188] ,฀ the฀motivation฀for฀smoking฀cessation฀is฀reportedly฀stronger฀in฀depressive฀patients,฀suggest- ing฀ a฀ large฀ pool฀ of฀ depressive฀ smokers.฀ Depressive฀ symptoms฀ that฀ occur฀ during฀ with- drawal฀are฀of฀decisive฀signiicance฀in฀terms฀of฀relapses฀and฀should฀therefore฀be฀treated฀ concurrently฀ [189] .฀Concurrent฀depression฀was฀the฀indication฀for฀smoking฀cessation฀ther- apy฀in฀elderly฀women฀ [190] .฀In฀these฀patients,฀it฀proved฀possible฀to฀control฀smoking฀absti- nence฀relatively฀arbitrarily฀by฀means฀of฀monetary฀rewards฀set฀for฀various฀time฀periods฀ [191] .฀Subsequently,฀however,฀the฀relapse฀rate฀was฀not฀determined฀by฀the฀duration฀of฀absti- nence฀but฀rather฀by฀psychopathological฀criteria฀only.