Nicotine Addictions

Introduction

Cigarette, most known type of nicotine.

Nicotine addiction is a state of dependance to nicotine. It is a chronic disease defined as a compulsive craving to use the drug, despite the social consequences, loss of control after use, and emergence of withdrawal symptoms. Nicotine addiction develops over time as a person keeps using nicotine. As addiction develops, it becomes harder for a person to quit. People lose their motivation to quit and fail as a result. The most known form of nicotine is cigarettes, but all forms of tobacco can lead to nicotine addiction. Nicotine addiction is a very serious public health problem as usage of tobacco is causing more than 8 million deaths per year.Nicotine use adds nicotine receptors to the brain. A smoker’s brain is filled with nicotine receptors. These receptors wait for nicotine to enter the brain. When it does, the nicotine gets attached to the receptors, and a chemical called dopamine gets released. Dopamine makes people feel good, gives a little “hit” or “buzz”. This doesn’t last long. As nicotine fades quickly, the receptors are eager for more nicotine. This is why if a person is addicted to nicotine, they’ll get nicotine withdrawal when they try to quit. Two proven quitting methods are Nicotine Replacement Therapy and prescribed smoking tablets.

Demographics

The World Health Organization (WHO) estimates that there are 1.1 billion smokers globally. In 2015, there were 34 million smokers in the United States, and of this 34 million, 74.6% smoked everyday, indicating they may have nicotine addiction. According to CDC, this number has exceeded 40 million as of 2022, including 2.55 million middle and high school students. Every day, almost 1600 underage kids smoke their first cigarette in the US. Generally, men tend to use any type of tobacco product more than women. In 2015, 16.7 percent of adult males and 13.6 percent of adult females smoked cigarettes. In terms of ethnicities, in 2010-2013, 24.9% of Whites, 24.9% of Blacks, 38.9% of American Indians / Alaska Natives, 22.8% of Pacific Islanders, 10.9% of Asians, and 19.9% of Hispanics were smoking. All these statistics relate to a combination of physiological, sociological, cultural, and behavioral factors. Efforts to increase awareness and prevent usage have mostly been successful in college graduates, showing a direct correlation between the education level and nicotine usage.

Definition

Types of Nicotine Usage

Users can intake nicotine through smoking, chewing, sniffing or absorbing through the skin. The most common form of nicotine consumption is by smoking, with cigarettes being the number one form of tobacco use worldwide. Other smoking products found in the US include vapes, cigars, pipes, hookahs and heat-not-burn products. Products of this category are associated with a higher risk of causing mouth, lip, tongue, throat and lung cancer due to directly exposing the respiratory system to harmful chemicals.

There are also dissolvable and smokeless options that allow users to ingest nicotine without inhaling smoke. Dissolvable tobacco products contain finely processed tobacco that dissolves in the user's mouth or skin. They come in various forms, such as strips, patches, orbs, and lozenges. They are spit-less, making them easy to conceal. As they are new to the market, their health effects are not fully known.

The two primary types of smokeless tobacco products are chewing tobacco and snuff. Chewing tobacco is typically placed in the cheek or between the gum and cheek, and the user sucks on the tobacco and spits out the juices. Snuff, on the other hand, can be sniffed or inhaled into the nose, although most users place it in the cheek or gum in the same way as chewing tobacco. Both types of smokeless tobacco contain an estimated 28 cancer-causing agents and are strongly linked to oral cavity, leukoplakia, and gum recession. Because users spit out the tobacco juices, smokeless tobacco is often referred to as spit or spitting tobacco.

Non-Tobacco Nicotine (NTN) are products that are not naturally derived from tobacco plants. NTN is produced in a lab and contains a "synthetic" nicotine that resembles the molecular makeup of naturally-occurring nicotine. NTN products are marketed as "tobacco-free" products, however, there is other products that aren't synthetic and marketed similarly. Brands - like Velo, on!, Rogue - use misleading claims such as "clean" and "pure. Both NTN and tobacco-derived nicotine products don't contain any tobacco leaf but have important regulatory differences.

Symptoms

Individuals who are addicted to nicotine and going through withdrawal may experience a range of symptoms, including a strong craving for nicotine, irritability, difficulty sleeping, irregular appetite, changes in body weight and decreased concentration. In severe cases, nicotine addiction can lead to more serious health problems, such as heart disease, lung cancer, and other chronic illnesses.

Nicotine addiction is driven by a combination of positive and negative reinforcement. Positive reinforcement effects include stress relief, mood enhancement, increased alertness, and cognitive improvement. Negative reinforcement effects come from the relief of withdrawal symptoms caused by a physical dependence on nicotine. The neurochemical effects of nicotine are similar to those of anti-depressant medications, such as the release of dopamine, norepinephrine, and serotonin, which is why many nicotine users claim it to relieve stress and depression. Repeated exposure to nicotine can increase the number of nicotinic receptors in the brain, leading to a need for higher nicotine intake to achieve the desired effects. This increase in nicotinic receptors alters the brain's reward system functions, causing smokers to develop conditioned behaviors where they associate certain moods, situations, or environments with the pleasurable effects of nicotine. These become triggers that intensify withdrawal symptoms for people trying to quit.

Regulations

FDA

The U.S. Food and Drug Administration (FDA) passed the Family Smoking Prevention and Tobacco Control Act on June 22, 2009. This act gave the FDA the authority to regulate the manufacture, distribution, and marketing of tobacco products.

The FDA put in place restrictions on marketing tobacco products to children and took further action to protect the public health. The FDA banned:

• sales to minors
• vending machine sales (except in adult-only facilities)
• the sale of packages of fewer than 20 cigarettes
• tobacco-brand sponsorship of sports, entertainment, social, or cultural events
• free giveaways of sample cigarettes and brand name non-tobacco promotional items

The Tobacco Control Act requires that smokeless tobacco packages and advertisements have larger and more visible warnings. Smokeless tobacco packages include moist snuff, chewing tobacco, and snus. The warning label statement on the packaging must be located on the two principal sides of the package and cover at least 30% of each side. For advertisements, the warning label statements must cover at least 20% of the area of the ad. The FDA approved warning plan:

WARNING: This product can cause mouth cancer.

WARNING: This product can cause gum disease and tooth loss.

WARNING: This product is not a safe alternative to cigarettes.

WARNING: Smokeless tobacco is addictive.

Additionally, it requires "modified risk" claims to be supported by scientific evidence. This law prohibits tobacco companies from making reduced harm claims like "light", "low", or "mild", without filing an application. The Modified Risk Tobacco Product (MRTP) application approves the marketing and requires renewal. There is a postmarket reporting that allows the FDA to review the accuracy.

The FDA requires that tobacco companies provide detailed information about the ingredients in their products. It also preserves the authority of state, local, and tribal governments to regulate tobacco products in specific respects. The FDA reserves authority over these specific requirements:

• Tobacco company owners and operators must register annually and open their manufacturing and processing facilities to be subject to inspection every two years.
• FDA implements standards such as regulating nicotine and ingredient levels.
• Ban cigarettes with certain flavors, except menthol and tobacco.
• Funds FDA regulation of tobacco products through a user fee on the manufacturers based on their U.S. market share.

The Deeming rule was passed on August 8, 2016. This rule extended FDA's tobacco product authority to more tobacco products, including e-cigarettes. However, this authority was only extended to nicotine made or derived from tobacco. This lead to an increase in the production of NTN products. A federal law went into effect on April 14, 2022 that gave authority to regulate tobacco products containing nicotine from any source. By May 14,2022, nearly one million applications were submitted from more than 200 companies. As of October 7, 2022, more than 889,000 applications di not meet criteria. As of now, no NTN products have received marketing authorizations. In July 2022, FDA announced its first warning letters to manufacturers and retailers illegally selling NTN products. As of October 14, 2022, 60 warning letters were sent to manufacturers and 300 letters to retailers. Failure to comply results in civil money penalties, seizure, and/or injunction.

State Laws

On December 20, 2019, Congress raised the federal Minimum Legal Sales Age (MLSA) for tobacco products from 18 to 21 years. This legislation is known as Tobacco 21 (T21) and became effective immediately. T21 prohibits retailers to sell any tobacco product - including cigarettes, cigars, and e-cigarettes - to anyone younger than 21 years. The MLSA applies to retailers in all states, DC, all US territories, and on tribal lands. There is also no exemption for active duty military personnel or military veterans between the ages of 18 and 20 years. Although all states and US territories must conform this does not mean that all states have increased the MLSA to 21 years. There is more clarity for retailers and enforcement officials when the state and federal MLSA are aligned. As of September 30, 2022, the following states have not increased the MLSA to 21 years:

• Alaska
• Arizona
• Kansas
• Montana
• Missouri
• Mississippi
• North Carolina
• South Carolina
• West Virginia
• Wisconsin
• Puerto Rico
• Virgin Islands
• Marshall Islands

The tobacco retail license (TRL) differs between states. Each state is subject to adopt one or more of the following TRLs:

• Comprehensive statewide Tobacco Retail License covering all tobacco products
• Multiple Tobacco Retail Licenses that cover all tobacco products
• Tobacco Retail License only covers cigarettes and NOT e-cigarettes
• No statewide Tobacco Retail License

Prevention

Activist Groups

There is many nonprofit organizations and advocacies groups that are powered by volunteers. These organizations have a mission to advocate for the negative impacts of nicotine usage and hope to prevent the use. Most of these organizations offer opportunities and information for users to stop using. Down below is a list of some of these activist groups:

• Truth Initiative
• Parents Against Vaping
• We are Truth
• American Vaping Association
• American Lung Association
• End Vaping
• Tobacco-Free Kids

Advocacy has been done through advertisements that showcase the real ingredients, the adverse effects, and real life stories. Moreover, it includes a mix of marketing and advertising tactics across teen-relevant communications channels to reach youth audiences. There is also slogans such as "vaping nicotine, it's a breath of stress air." Other forms are through petitions, campaigns, and outreach programs. Some campaigns have been done through social media using social media hashtags. The most trending hashtags have been #dothevapetalk and #therealcost. These hashtags were used as a platform for people to share their stories encouraging people to stop vaping and smoking. The Real Cost Campaign is an FDA award-winning public education campaign. This campaign continues to prevent youth from starting and continuing to use tobacco products.

Government

In 1999, the CDC's Office on Smoking and Health (OSH) created the National and State Tobacco Control Program (NTCP). It was created to encourage coordinated, national efforts to reduce tobacco-related diseases and deaths. Through this program, funding and technical support is given to state and territorial health departments. NTCP does state and community interventions, mass-reach health communication interventions, tobacco use treatment interventions, and evaluations.

Guideline for Future Work

As there's a target of 1500 words, this casebook chapter had to have a limited scope. We tried to keep the introduction and demographics part very brief. Those parts can be extended. We had two other chapters in mind, however, due to the limit, we couldn't write about them. These chapters are: Causes (Subheadings: Advertising, Status Quo, Tie in regulation with underage kids still being able to purchase), Law(Subheadings: Different Countries Stance, Different Stances Against Different Types of Nicotine), Side Effects. A lot of useful information can be written about these topics to extend this chapter.