Harm reduction in nicotine addiction : helping people who can't quit : a report by the Tobacco Advisory Group of the Royal College of Physicians, October 2007

Harm reduction in nicotine addiction......Page 1 Acknowledgements and copyright......Page 2 Contents......Page 3 Contributors......Page 7 Members of the Tobacco Advisory Group of the RCP......Page 8 Foreword......Page 9 Preface......Page 10 1.2 The history of tobacco use......Page 11 1.3 The smoking epidemic......Page 16 1.4 The health impacts of tobacco smoking......Page 22 1.5 Conclusions......Page 28 2.1 Chemical and pharmacokinetic aspects of nicotine......Page 33 2.2 The physiological functions of nicotinic receptors......Page 35 2.3 Brain nicotinic receptors and cigarette smoking......Page 37 2.5 Regulation of nicotinic receptor expression and function bychronic nicotine exposure......Page 41 2.6 Acute actions of nicotine maintained in habitual cigarette smokers......Page 44 2.7 Effects of nicotine on release of brain dopamine in smokers......Page 45 2.8 Contribution of nicotinic receptor subtypes to the reinforcing effects of nicotine in animal models......Page 47 References......Page 49 3.1 Introduction......Page 55 3.2 Nicotine self-administration in experimental animals......Page 56 3.3 Neurobiology underlying the reinforcing properties of nicotine......Page 57 3.4 The role of the accumbal shell......Page 58 3.5 The role of the accumbal core......Page 60 3.6 The role of conditioned stimuli in nicotine reinforcement......Page 61 3.7 Desensitisation and the neurobiology of addiction......Page 62 3.8 The effects of nicotine withdrawal......Page 63 3.9 The putative role of paracrine dopamine......Page 64 3.10 A unifying hypothesis......Page 67 3.11 Inhibition of monoamine oxidase......Page 69 3.12 Conclusions......Page 70 References......Page 71 4.2 The addictiveness of tobacco products......Page 75 4.3 The role of nicotine as the addictive drug in tobacco......Page 76 4.4 The cycle of human tobacco use and addiction......Page 77 4.5 Developments in imaging and cognitive assessment......Page 86 4.6 Insights from new pharmacological developments......Page 88 4.7 Conclusions......Page 89 References......Page 90 5.1 Available sources of nicotine for human use......Page 98 5.2 Dose and delivery kinetics of nicotine from different sources......Page 102 5.3 Contaminants and additives......Page 107 5.5 Use of alternative nicotine sources as substitutes for cigarettes......Page 109 5.6 Conclusions......Page 110 References......Page 111 6.2 Population trends in smoking prevalence in the UK......Page 114 6.3 Trends in prevalence in other countries......Page 115 6.4 Health risks associated with active smoking......Page 117 6.5 Health risks associated with passive smoking......Page 123 6.6 Effects of smoking cessation......Page 125 References......Page 127 7.2 Local effects......Page 129 7.3 Systemic adverse effects of nicotine replacement therapy......Page 131 References......Page 136 8.1 Introduction......Page 139 8.2 Common types of smokeless tobacco used around the world......Page 141 8.3 Potentially harmful constituents......Page 144 8.4 Overview of health effects of smokeless tobacco products......Page 152 8.5 Health effects of smokeless tobacco compared with cigarettes......Page 165 8.6 Conclusions......Page 171 References......Page 172 9.1 Introduction......Page 177 9.2 Smoked tobacco products......Page 178 9.3 Smokeless tobacco products......Page 184 9.4 New tobacco product formulations and potential reduced exposure products......Page 186 9.5 Medicinal nicotine products......Page 187 9.6 Regulatory imbalance......Page 190 9.7 Approaches to nicotine and tobacco product regulation indifferent countries......Page 191 9.8 Future regulatory options......Page 193 9.9 Conclusions......Page 195 References......Page 196 10.2 Tobacco use among disadvantaged groups......Page 199 10.3 Consumption of tobacco and levels of nicotine dependence......Page 202 10.5 Inequalities in the burden of ill health caused by smoking......Page 204 10.7 Smoking cessation in disadvantaged groups......Page 205 10.8 Exposure to second-hand smoke at work......Page 206 10.10 Smoking and pregnancy......Page 208 References......Page 210 11.1 Background to the harm reduction approach......Page 213 11.2 Components of the harm reduction argument......Page 214 11.3 Harm reduction options for tobacco use......Page 216 11.5 Conclusions......Page 225 References......Page 226 12.1 Introduction......Page 228 12.3 The relative harm of different nicotine products......Page 230 12.4 The effectiveness of medicinal nicotine products as an alternative to smoking......Page 231 12.6 Harm reduction strategies......Page 232 12.7 Current nicotine product regulation and health......Page 234 12.8 How should nicotine products be regulated to improve publichealth?......Page 235 12.9 The consequences of a failure to act......Page 237 12.10 Conclusions......Page 239 References......Page 240 13 Key conclusions and recommendations......Page 242