Tobacco Prevention

Continuing education online course in Tobacco Prevention and Cessation

D12. Tobacco Prevention: 3 CE-hours


Professor Rudolf Klimes, PhD, welcomes you to this online course. Keep going.

START the course here. TAKE the exam at the end. PAY after the exam.

Course Description: The course describes nicotine, its use and risks, and method of preventing tobacco addiction.

Objectives: At the end of the course, participants will describe and explain 1. the characteristics and problems with nicotine, 2. the risk factors to smoking, 3. and methods of preventing tobacco addiction.

Course Format: Online linked resources and lectures that you can use anytime 24/7. One multi-choice test.

Course Developers and Instructors: R. Klimes, PhD, MPH (John Hopkins U), author of articles on Tobacco Prevention and Overall Health and Wellness.

Course Time: About 3 hours for online study, test taking with course evaluation feedback and certificate printing.


Course Test: Click here for the self-correcting test that requires 75% for a passing grade.


Warm-up Exercise: How much do you already know?

This exercise is for self-study. Do not submit your answers.

(1) Describe the types and extent of tobacco use among various populations.

(2) True or False?

  • Clove cigarettes are nearly harmless.
  • Smoking is the most prevalent cause of US deaths.
  • Heart attacks are the leading cause of death for smokers.
  • Tobacco dependence may be more powerful as heroin dependence.




1.1 Long Term Effects of Nicotine

NIDA Research Report Series: Nicotine Addiction
NIH Publication Number 01-4342, July, 1998

What Happens When Nicotine is Taken for Long Periods of Time?

Chronic exposure to nicotine results in addiction. Research is just beginning to document all of the neurological changes that accompany the development and maintenance of nicotine addiction. The behavioral consequences of these changes are well documented, however. Greater than 90 percent of those smokers who try to quit without seeking treatment fail, with most relapsing within a week.

Repeated exposure to nicotine results in the development of tolerance, the condition in which higher doses of a drug are required to produce the same initial stimulation. Nicotine is metabolized fairly rapidly, disappearing from the body in a few hours. Therefore some tolerance is lost overnight, and smokers often report that the first cigarettes of the day are the strongest and/or the “best.” As the day progresses, acute tolerance develops, and later cigarettes have less effect.

Cessation of nicotine use is followed by a withdrawal syndrome that may last a month or more; it includes symptoms that can quickly drive people back to tobacco use. Nicotine withdrawal symptoms include irritability, craving, cognitive and attentional deficits, sleep disturbances, and increased appetite and may begin within a few hours after the last cigarette. Symptoms peak within the first few days and may subside within a few weeks. For some people, however, symptoms may persist for months or longer.

An important but poorly understood component of the nicotine withdrawal syndrome is craving, an urge for nicotine that has been described as a major obstacle to successful abstinence. High levels of craving for tobacco may persist for 6 months or longer. While the withdrawal syndrome is related to the pharmacological effects of nicotine, many behavioral factors also can affect the severity of withdrawal symptoms. For some people, the feel, smell, and sight of a cigarette and the ritual of obtaining, handling, lighting, and smoking the cigarette are all associated with the pleasurable effects of smoking and can make withdrawal or craving worse. While nicotine gum and patches may alleviate the pharmacological aspects of withdrawal, cravings often persist.

Excerpted from: NIDA Research Report Series: Nicotine Addiction, NIH Publication Number 01-4342, July, 1998 Source

1.2 How Nicotine Affects the Brain

How Does Nicotine Act in the Brain?

Nicotine acts on your brain. Your brain is made up of billions of nerve cells. They communicate by releasing chemical messengers called neurotransmitters. Each neurotransmitter is like a key that fits into a special “lock,” called a receptor, located on the surface of nerve cells. When a neurotransmitter finds its receptor, it activates the receptor’s nerve cell.

The nicotine molecule is shaped like a neurotransmitter called acetylcholine. Acetylcholine and its receptors are involved in many functions, including muscle movement, breathing, heart rate, learning, and memory. They also cause the release of other neurotransmitters and hormones that affect your mood, appetite, memory, and more. When nicotine gets into the brain, it attaches to acetylcholine receptors and mimics the actions of acetylcholine.

Nicotine also activates areas of the brain that are involved in producing feelings of pleasure and reward. Recently, scientists discovered that nicotine raises the levels of a neurotransmitter called dopamine in the parts of the brain that produce feelings of pleasure and reward. Dopamine, which is sometimes called the pleasure molecule, is the same neurotransmitter that is involved in addictions to other drugs such as cocaine and heroin. Researchers now believe that this change in dopamine may play a key role in all addictions. This may help explain why it is so hard for people to stop smoking.

Easy to Start, Hard to Quit

Smoking is easy to start, hard to quit. Did you know that nicotine is as addictive as heroin or cocaine? If someone uses nicotine again and again, such as by smoking cigarettes or cigars or chewing tobacco, his or her body develops a tolerance for it. Eventually, a person can become addicted. Once a person becomes addicted, it is extremely difficult to quit. People who start smoking before the age of 21 have the hardest time quitting, and fewer than 1 in 10 people who try to quit smoking succeed.

When nicotine addicts stop smoking they may suffer from restlessness, hunger, depression, headaches, and other uncomfortable feelings. These are called “withdrawal symptoms” because they happen when nicotine is withdrawn from the body.



Describe how the use of tobacco has affected you or someone close to you.

2.1. Healthy People

How does tobacco use relate to other drug use? How do bad lifestyle choices contribute to smoking?

2.2. What is tobacco dependence?


2.3. What are the main tobacco-related diseases?

How are these diseases effected by smoking cessation? How do these diseases inter-relate?

2.4. How does the population vary in tobacco-use?

Nicotine is one of the most heavily used addictive drugs in the United States. Cigarette smoking has been the most popular method of taking nicotine since the beginning of the 20th century. In 1998, 60 million Americans were current cigarette smokers (28 percent of all Americans aged 12 and older), and 4.1 million were between the ages of 12 and 17 (18 percent of youth in this age bracket).

In 1989, the U.S. Surgeon General issued a report that concluded that cigarettes and other forms of tobacco, such as cigars, pipe tobacco, and chewing tobacco, are addictive and that nicotine is the drug in tobacco that causes addiction. In addition, the report determined that smoking was a major cause of stroke and the third leading cause of death in the United States.

Nicotine is highly addictive. It is both a stimulant and a sedative to the central nervous system. The ingestion of nicotine results in an almost immediate “kick” because it causes a discharge of epinephrine from the adrenal cortex. This stimulates the central nervous system, and other endocrine glands, which causes a sudden release of glucose. Stimulation is then followed by depression and fatigue, leading the abuser to seek more nicotine. Nicotine is absorbed readily from tobacco smoke in the lungs, and it does not matter whether the tobacco smoke is from cigarettes, cigars, or pipes.

Nicotine also is absorbed readily when tobacco is chewed. With regular use of tobacco, levels of nicotine accumulate in the body during the day and persist overnight. Thus, daily smokers or chewers are exposed to the effects of nicotine for 24 hours each day. Nicotine taken in by cigarette or cigar smoking takes only seconds to reach the brain but has a direct effect on the body for up to 30 minutes.

Research has shown that stress and anxiety affect nicotine tolerance and dependence. The stress hormone corticosterone reduces the effects of nicotine; therefore, more nicotine must be consumed to achieve the same effect. This increases tolerance to nicotine and leads to increased dependence. Studies in animals have also shown that stress can directly cause relapse to nicotine self-administration after a period of abstinence.

Other studies have shown that animals cannot discriminate between the effects of nicotine and the effects of cocaine. Studies have also shown that nicotine self-administration sensitizes animals to self-administer cocaine more readily. Addiction to nicotine results in withdrawal symptoms when a person tries to stop smoking. For example, a study found that when chronic smokers were deprived of cigarettes for 24 hours, they had increased anger, hostility, and aggression, and loss of social cooperation. Persons suffering from withdrawal also take longer to regain emotional equilibrium following stress. During periods of abstinence and/or craving, smokers have shown impairment across a wide range of psychomotor and cognitive functions, such as language comprehension.

Women who smoke generally have earlier menopause. If women smoke cigarettes and also take oral contraceptives, they are more prone to cardiovascular and cerebrovascular diseases than are other smokers; this is especially true for women older than 30. Pregnant women who smoke cigarettes run an increased risk of having stillborn or premature infants or infants with low birth-weight. Children of women who smoked while pregnant have an increased risk for developing conduct disorders. National studies of mothers and daughters have also found that maternal smoking during pregnancy increased the probability that female children would smoke and would persist in smoking.

Adolescent smokeless tobacco users are more likely than nonusers to become cigarette smokers. Behavioral research is beginning to explain how social influences, such as observing adults or other peers smoking, affect whether adolescents begin to smoke cigarettes. Research has shown that teens are generally resistant to many kinds of anti-smoking messages.

In addition to nicotine, cigarette smoke is primarily composed of a dozen gases (mainly carbon monoxide) and tar. The tar in a cigarette, which varies from about 15 mg for a regular cigarette to 7 mg in a low-tar cigarette, exposes the user to a high expectancy rate of lung cancer, emphysema, and bronchial disorders. The carbon monoxide in the smoke increases the chance of cardiovascular diseases. The Environmental Protection Agency has concluded that secondhand smoke causes lung cancer in adults and greatly increases the risk of respiratory illnesses in children and sudden infant death.



Lessons from Prevention Research

Prevention programs should be designed to enhance “protective factors” and move toward reversing or reducing known “risk factors.” Protective factors are those associated with reduced potential for drug use. Risk factors are those that make the potential for drug use more likely:

  • Protective factors include strong and positive bonds within a pro-social family; parental monitoring; clear rules of conduct that are consistently enforced within the family; involvement of parents in the lives of their children; success in school performance; strong bonds with other pro-social institutions, such as school and religious organizations; and adoption of conventional norms about drug use.
  • Risk factors include chaotic home environments, particularly in which parents abuse substances or suffer from mental illnesses; ineffective parenting, especially with children with difficult temperaments or conduct disorders; lack of mutual attachments and nurturing; inappropriately shy or aggressive behavior in the classroom; failure in school performance; poor social coping skills; affiliations with deviant peers or peers displaying deviant behaviors; and perceptions of approval of drug-using behaviors in family, work, school, peer, and community environments.

The following are critical areas for prevention planners to consider when designing a program:

  • Family Relationships – Prevention pro grams can teach skills for better family communication, discipline, and firm and consistent rule-making to parents of young children. Research also has shown that parents need to take a more active role in their children’s lives, including talking with them about drugs, monitoring their activities, getting to know their friends, and understanding their problems and personal concerns.
  • Peer Relationships – Prevention pro grams focus on an individual’s relationship to peers by developing social-competency skills, which involve improved communications, enhancement of positive peer relationships and social behaviors, and resistance skills to refuse drug offers.
  • The School Environment – Prevention programs also focus on enhancing academic performance and strengthening students’ bonding to school, by giving them a sense of identity and achievement and reducing the likelihood of their dropping out of school. Most curriculums include the support for positive peer relationships (described above) and a normative education component designed to correct the misperception that most students are using drugs. Research has also found that when children understand the negative effects of drugs (physical, psychological, and social), and when they perceive their friends’ and families’ social disapproval of drug use, they tend to avoid initiating drug use.
  • The Community Environment – Prevention programs work at the community level with civic, religious, law enforcement, and governmental organizations and enhance antidrug norms and pro-social behavior through changes in policy or regulation, mass media efforts, and community-wide awareness programs. Community-based programs might include new laws and enforcement, advertising restrictions, and drug-free school zones – all designed to provide a cleaner, safer, drug-free environment.



Describe the steps that you will take to quit tobacco use or to help someone close to you to quit.

What are the best approaches in rejecting tobacco? What are the best approaches to prevent tobacco use? Do nicotine patch or gum work and how effective are they? Is support and encouragement a smoking cessation method? How can one learn how to handle urges to smoke and stress?  See

Treating Tobacco Use and Dependence, 2000

1. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence.

2. Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments. 

  • patients willing to try to quit tobacco use should be provided treatments identified as effective in this guideline.
  • Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.

3. It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting.

4. Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.

5. There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness.Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of contact).

6. Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation:

  • Provision of practical counseling (problem-solving/skills training).
  • Provision of social support as part of treatment (intra-treatment social support).
  • Help in securing social support outside of treatment (extra-treatment social support).

7. Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.

Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates: Bupropion SR. Nicotine gum. Nicotine inhaler. Nicotine nasal spray. Nicotine patch.

Two second-line pharmacotherapies were identified as efficacious and may be considered by clinicians if first-line pharmacotherapies are not effective: Clonidine.Nortriptyline. Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.

8. Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions.

The U.S. Surgeon General, Dr. David Satcher, has released a new set of guidelines for primary care practitioners, “Treating Tobacco Use and Dependence: A Clinical Practice Guideline.” The guidelines, released in June, are based on an evaluation of nearly 6,000 peer-reviewed research studies. They recommend pharmacotherapies such as nicotine replacement therapy by patch, gum, inhaler, and nasal spray, and sustained release bupropion, as well as behavioral therapy, counseling, and support programs to help patients overcome their addiction to nicotine.

People who use tobacco and are willing to quit should be treated using the “5 A’s” (Ask, Advise, Assess, Assist, and Arrange). People who use tobacco but are unwilling to quit at this time should be treated with the “5 R’s” motivational intervention (Relevance, Risks, Rewards, Roadblocks, and Repetition). People who have recently quit using tobacco should be provided relapse prevention treatment.

Studies have shown that these five steps will help you quit and quit for good. You have the best chances of quitting if you use them together: Get ready. Get support. Learn new skills and behaviors. Get medication and use it correctly. Be prepared for relapse or difficult situations.

Source for this and above:


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