By Clark Miller, LCSW

National indicators seem to show significant reductions in tobacco use (cigarette smoking) over past years. What does that mean? It’s not clear why smoking has decreased.  Could it be due to increased costs, prevention efforts, switching to e-cigarettes, attention in young people switched to texting and personal devices?

The trend looks like a good thing. If we leave it at that, however, we run the risk of not using this information to shape effective health policies.  A lot of time and money is invested in educating people about the health consequences of substance use, and the health of Americans rests on public education and sound policy. That’s important right now: against concerns of major public health groups like the Centers for Disease Control (CDC), the Food and Drug Administration (FDA) is betting on new harm reduction methods that would actually encourage development and marketing of e-cigarette use. That’s despite preliminary evidence that the rise of e-cigarettes may be drawing more young people to smoking.

Is there really a downward trend for problem tobacco/nicotine use? If we remember that nicotine is the addictive component in tobacco, and look at trends in the delivery of nicotine and its health effects, those apparent gains could be in question.

–          The use of e-cigarettes to deliver nicotine “safely” is booming, including for youth .

–          What are the health risks for e-cigarette use? We need more research but it is clear that it is not an entirely healthy alternative.

What is known about e-cigarettes and nicotine?

–          Nicotine, however delivered, increases risk of onset of type 2 diabetes, increases the risk of onset of serious complications of diabetes, like kidney disease and nerve damage, and of worsening of those complications.

–          Addictive behavior involving nicotine increases risk (AKA the gateway effect) of problem use of other substances (like alcohol and opioids).

–          Compulsive use of nicotine among youth predicts dependence into adulthood

So, it’s not so simple, and there’s more. The tobacco giant Phillip Morris is pushing hard for approval for a new delivery system that will put tobacco back into the e-cigarette. Tobacco will be heated in a way that provides nicotine and the taste of tobacco, but not, reportedly, the toxic chemicals released by combusting tobacco. This would be a new, potent way to get and keep Americans addicted to tobacco.

For individuals who want to stop use of tobacco and nicotine, what are the effective treatments? Nicotine replacement (like patches) as well as some medications can help quitters get through the physical cravings lasting through initial weeks of stopping. Most relapse occurs months to years after stopping, typically in reaction to a major stressful event, and treatment itself, for long-term success, uses talk therapies to target the beliefs, emotional needs, social risk factors, lack of coping skills, and psychological associations underlying risk of using again, as well as strength of motivation for change.

Most people quit without use of replacement or medication aids, sometimes with the help and support of friends and family, or internet resources. The primary factor predicting success is intrinsic motivation which comes from a combination of a growing awareness of personal values and reasons for stopping, and is supported by a type of individual counseling called Motivational Interviewing.

The most effective treatment is not treatment, but prevention, an important topic that highlights the strong, established correlations among: adverse childhood experiences (ACE) and how they affect neurodevelopment in children.  ACEs create increased vulnerability to anxiety and other forms of inner distress, which make self-regulation and impulse control difficult and which increases risk of substance use and other behavioral health problems. Prevention efforts are key to reducing the multitude of behavioral and physical health problems associated with ACE.

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