Nicotine and tobacco

By Marcello Cherchi, MD PhD

For patients

Nicotine exposure, including nicotine that is inhaled through smoking tobacco, and nicotine that is ingested with chewing tobacco, can affect nearly every organ system in the body.  It can have effects on the inner ear and brain, which a patient may experience as symptoms involving hearing (hearing loss, tinnitus), balance (disequilibrium) and migraine.  Nicotine can also interfere with the treatment of many diseases.

Numerous resources are available to aid with smoking cessation.  Opening a discussion with a primary care physician is an excellent place to start.  Exploring the resources listed below may also be helpful.  Quitting is hard, and it is easy to get discouraged, but bear in mind that most people try quitting several times before they quit permanently.

For clinicians

Overview

Nicotine is usually delivered by tobacco which can be inhaled or chewed.  Nicotine and the numerous other compounds contained in tobacco can adversely affect every organ system.  From the otoneurological perspective, nicotine can have affects on the ear and brain, exacerbating (and perhaps in some cases causing) hearing loss, tinnitus, disequilibrium and migraine.

Introduction

There are now overwhelming scientific data that nicotine, particularly nicotine consumed through tobacco, harms health through its deleterious effects on every organ system in the body.  As of 2022, diseases directly attributable to tobacco consumption accounted for 7 million deaths worldwide annually; in the United States it accounted for 480,000 deaths annually, which amounts to about 1,300 deaths per day, and 1 out of every 5 deaths (Centers for Disease Control and Prevention 2022).

Other physicians can advise a patient on the specific relationships between smoking and health problems such as cardiovascular disease, lung problems and cancer.  Here we provide provide information on the fact that smoking can exacerbate a number of otoneurological conditions relevant to one’s equilibrium and hearing.

Mechanism of disease

Nicotine is a tertiary amine that binds to nicotinic cholinergic receptors; it has numerous downstream effects on several neurotransmitter systems including dopamine, glutamate, GABA and others (Benowitz 2009).

Ocular motor examination

Nicotine exposure can cause spontaneous up beat nystagmus.  This can be subtle, and may only be visible under infrared video oculography.

Otoneurological symptoms and conditions exacerbated by nicotine and tobacco

There is strong evidence that nicotine and tobacco increase the risk of hearing loss (Cruickshanks et al. 1998; Dawes et al. 2014; Ferrite, Santana, Marshall 2013; Mohammadi et al. 2010; Pezzoli et al. 2017; Sharabi et al. 2002; Sumit et al. 2015; Sung et al. 2013; Tao et al. 2013; Wang et al. 2017).

There is strong evidence that nicotine and tobacco increase the risk of developing or exacerbating tinnitus (Bhatt 2018; Kim et al. 2015; Mahboubi et al. 2013; Martines et al. 2015; Paschoal and Azevedo 2009; Shargorodsky, Curhan, Farwell 2010; Sindhusake et al. 2003; Veile et al. 2018).

There is strong evidence that nicotine and tobacco adversely affect ocular motor function (Uchida et al. 1980; Zingler et al. 2007), perhaps by interfering with the vestibulo-ocular reflex (Pereira et al. 2000).  Nicotine is one of the few substances that can induce spontaneous up beat nystagmus on primary position of gaze (Neveling and Kruse 1961; Sibony, Evinger, Manning 1987).

There is strong evidence that nicotine and tobacco adversely affect postural stability (Iki et al. 1994; Pereira et al. 2001; Uchida et al. 1980; Zingler et al. 2007)

There is good evidence that nicotine and tobacco increase the risk of peripheral vestibular disease (Wada et al. 2017).

There is good evidence that nicotine and tobacco can interfere with the treatment of a variety of vertiginous disorders (Lin and Young 2001).

There is strong evidence that nicotine and tobacco increase the risk of migraine (Hershey and Lipton 2010; Lopez-Mesonero et al. 2009; Markush et al. 1975; Rozen 2011).  The majority of studies conclude that smoking is a clear independent risk factor for the development, perpetuation, and worsening of migraine and its sub-types (Hershey and Lipton 2010; Lopez-Mesonero et al. 2009; Markush et al. 1975; Robberstad et al. 2010; Rozen 2011), with very few dissenting opinions (Rasmussen 1993; Ulrich et al. 2000; Volans and Castleden 1976).   Smoking is also a known risk factor for stroke, but in patients with a history of migraine and its sub-types, most studies find that the risk for stroke is increased even further (Del Sette 2010; Kurth 2007; MacClellan et al. 2007; Schurks et al. 2009; Vargas et al. 2008), with very few dissenting opinions (Henrich and Horwitz 1989).

Quantification of nicotine/tobacco use

In medical practice it is common to quantify nicotine/tobacco exposure in “pack years,” where one pack-year is equivalent to smoking one pack (20 cigarettes) per day for 365 days.  While this is not an exact science, some approximate equivalents among different forms of tobacco are listed below (Wood et al. 2005).

There are on-line tools for calculating total pack-year exposure from different forms of nicotine/tobacco consumption, such as https://www.smokingpackyears.com (accessed 5/21/23).

The following are all approximately equivalent to 1 pack-year of nicotine/tobacco exposure:

  • 1 pack of cigarettes per day for 1 year
  • 20 cigarettes per day for 1 year
  • 10 cigarillos per day for 1 year
  • 8 pipe-bowls per day for 1 year
  • 5 cigars/spliffs per day for 1 year
  • 16 minutes water pipe per day for 1 year
  • 4 oz chewing tobacco per day for 1 year
  • 3 g chewing tobacco per day for 1 year

Treatment

It is possible to undertake treatment for the individual consequences of nicotine/tobacco exposure (hearing loss, tinnitus, disequilibrium, migraine), but it is preferable to address the root cause of those symptoms, namely the nicotine/tobacco use itself.

Primary care physicians can offer a patient a variety of strategies to help cease using nicotine, including counseling, psychological treatment, and pharmacological treatment (transdermal or transmucosal nicotine, bupropion, varenicline).  It usually takes several attempts to quit.

References

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Page first published on August 25, 2023. Page last updated on December 30, 2023

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