Ignoring Consequently the Addictive Nature of Nicotine

The message of cigarette advertising that smoking is a question of lifestyle has been internalized in Germany by the public and medicine. Somehow one knows of the serious health problems associated with smoking and that individual and social advantages could arise from attempting to not smoke. This is especially clear in §34 of the fifth volume of the Social Law Book (Sozialgesetzbuches V), in which medications for weaning from smoking are excluded from reimbursement by the health insurance.

Through a combination of social learning and central rewards, smoking leads to profound molecular effects and to habituation, depending on disposition even after only a few cigarettes and lastingly (3). This cannot be explained only by the effect on nicotine receptors, but according to the Gateway-Theory leads via the transcription factor cyclic AMP response-element-binding protein (CREB) to long-term effects through a CREB-mediated change in chromatin and thus to molecular-genetic changes. Nicotine initiates and promotes further substance abuse (3).

When this double nature of nicotine use is unrecognized, only the conscious decision of the smoker remains as the cause. In the subjective perception, nicotine is played down and the smoker seen as „guilty” as unfavorable factors for breaking the dependency. But accusations are not important – clear framework conditions and offers of help are (2). Citizens have already made their contribution by making smoking bans more stringent, e.g. in Bavaria. Only medicine (and the lawmakers) are lagging behind.

In the Province of Ottawa, Canada, it was demonstrated that a systematic identification and treatment of smokers had significant effects on the outcome of these patients during a hospital stay and that this is meaningfully bound to an aftercare program (4). During the patient’s hospital stay, he undergoes an involuntary smoking stop and the corresponding symptoms of nicotine withdrawal; the hospital can effectively relieve this, for example by treatment with nicotine patches, if the smoking history is taken into account. This markedly reduced the proportion of agitated patients with nicotine withdrawal syndromes, patients cooperated better in treatment, had fewer complications and the length of hospital stay was shortened (4). The corresponding costs were more than covered by the advantages. In addition, on release from hospital, the patients were offered participation in a program to quit smoking, which was well received. Thus, the project in Ottawa under the direction of Dr. Andrew Pipe could set an effective example. Treatment of smoking as a disease brings both social and individual health advantages and reduces costs to the health system.

Strict establishment of a non-smoker policy for all those involved, especially employees in hospitals in Ottawa belong to the concept. Smoking by patients and employees in public, in front of the entrance, on balconies and in the immediate vicinity of hospital buildings is forbidden by law and this is enforced. This is an essential difference from Germany. Here, doctors, nurses and patients still gather in front of the entrances and on clinic balconies to smoke, despite legal regulations.

But it’s not only about controlling smoking, but providing help and support to those affected by strict adherence to bans, by professional dealing with the disease and acceptance of smoking as a disease. The offer of courses, psychological support and medications to help patients on the difficult pathway out of the dependency must be part of the concept (1).

Medicine is called to recognize the scientific evidence and implement this in everyday medical practice, to introduce effective programs in hospitals and not just to leave it all up to the lawmakers.