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Smoke and Errors

News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences

Dr. Jack Henningfield
Dr. Jack Henningfield

“If 80 percent of people with serious depression got no help whatsoever and were told, ‘Tough it out on your own,’ there’d be outrage,” says Jack Henningfield. “But with tobacco dependence, that’s pretty much the way it is.”

Psychiatry Professor Henningfield is known internationally for his studies on the biology and public health effects of tobacco use. Long a force within the National Institute on Drug Abuse, he now heads the Innovators Awards program, a Hopkins-based effort sponsored by the Robert Wood Johnson Foundation to spark new policy and research to halt substance abuse. He also advises the WHO on tobacco control. We’ve asked him to speak his mind:

Q. So society doesn’t treat smoking like a “real” disease?

A. Not the serious form of tobacco dependence, no. It could be because it’s so common—nearly a quarter of the adult population smokes. Or it could be that a great many myths are out there, many held by clinicians as well as the general public.

Q. For example?

A. That treatment doesn’t work; that ability to quit depends on a person’s character.

Q. Elaborate, please.

A. Serious tobacco addiction needs treatment, but only 20 to 30 percent who try to quit get help. Yes, what exists isn’t perfect, but that’s not the problem. The difficulty lies in understanding what’s available, in using it well. For most psychiatric illness, you start patients on what makes the most sense and switch to something else if need be—change the medication, change the dose—as you would, say, for high blood pressure. But with tobacco, it’s pretty much one shot. “Oh, the patch didn’t work for you? Too bad.” Yet variety exists now that didn’t before: some patches are good for 16 hours, some 24. Some bring up nicotine levels slowly, some are quicker. We have inhalers, nasal sprays, lozenges, various gums and new medications to dull craving and withdrawal. And the clinical guidelines describe options to combine medications that aren’t mentioned on the labels.

As for character? Tobacco dependence is powerful by any measure, as strong as any other serious addiction in terms of quitting or relapse. PET or fMRI brain scans alone show it’s far more than psychological. Not only nicotine but other chemicals in smoke produce cascades of cellular effects expressed as addiction. There’s an increase of certain brain receptors, energy use in the cerebrum gets altered, as are EEGs. And some neurotransmitters become more available. Unfortunately, people accustomed to that higher level can feel depressed if they quit. Vigilant therapy, however, addresses that.

Q. What’s in the pipeline?

A. Two new medicines could be available by the end of 2006, varenicline and rimonabant. And three different companies have anti-nicotine vaccines in clinical trials—ways to expand our options.

Q. A last word?

A. Because half of your patients with a psychiatric disorder smoke, ask them about it. If something affects so many and you’re not addressing it, that’s not good medicine. As little as two minutes’ discussion could make a difference.  n

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Find other Hopkins Newsletter articles from past issues.