Nicotine Withdrawal

Nicotine is one of the most addicting substances known. In fact, the risk of becoming dependent on nicotine following any tobacco use is higher than the risk of becoming dependent on alcohol, cocaine, or marijuana. People who use several drugs often say that quitting tobacco is more difficult than giving up alcohol or cocaine.

Nicotine affects the functioning of the central nervous system, which is made up of the brain and spinal cord. Repeated use of nicotine results in tolerance , and the individual must use higher doses of the drug to obtain the same effects that first occurred at lower doses. As the body becomes tolerant to nicotine's effects, it becomes dependent on nicotine for normal functioning. Removal of nicotine from the body results in feelings of dysphoria . The individual needs to continue using nicotine to feel well and to function normally.

Nicotine Tolerance and Dependence

The cigarette is a very fast and effective way to deliver nicotine to the body. Effects occur after a single inhalation of tobacco smoke. Nicotine quickly crosses the blood-brain barrier. Once in the brain, it interacts with brain chemicals and structures involved in making the user feel pleasure. Nicotine alters moods, causes blood pressure and heart rate to rise (affecting the cardiovascular system), and harms the entire body, including the endocrine system , gastrointestinal tract , and skeletal system .

A person's first exposure to nicotine is usually not a pleasant experience. The person may feel sick and become intoxicated . After a few weeks of daily smoking, the body adapts to nicotine and the un- pleasant effects are less noticeable. Once tolerance and dependence develop, smokers use whatever dose of nicotine (or number of cigarettes) they desire. The higher the dose, the greater the level of dependence.

As smokers become dependent on, or addicted to, smoking, they feel normal, comfortable, and effective when taking nicotine. They feel dysphoric, uncomfortable, and ineffective when lacking nicotine. It becomes difficult for smokers to give up nicotine even for very short periods.

Nicotine Withdrawal Symptoms

Nicotine withdrawal symptoms include: depressed mood; insomnia (inability to sleep); irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain. The severity of the symptoms will depend on the severity of nicotine dependence. Withdrawal symptoms are strongest in the first few days after a person stops smoking and usually diminish within a month, although some smokers may continue to have withdrawal symptoms for many months.

Stopping smoking has other consequences as well. People may lose the ability to think and reason clearly, learn normally, exercise memory, and make good judgments. These effects begin a few hours after the last cigarette (dose of nicotine), peak during the first few days of abstinence (when smokers trying to quit are most likely to start smoking again or relapse), and mostly disappear within a few weeks.

Another symptom associated with withdrawal is craving cigarettes. Cravings may last six months—longer than some of the other symptoms of nicotine withdrawal. Cravings present a major difficulty to someone trying to quit smoking. Because of cravings, the majority of smokers who attempt to quit relapse within the first week of quitting.

Individuals with other problems—such as a history of depression, alcoholism, or illegal substance abuse—are likely to have more severe nicotine withdrawal symptoms. Biological processes play a major role in nicotine withdrawal, but behavioral factors also have a strong influence on the ability to stop smoking. Cigarette smoking becomes a part of people's daily habits, so that many situations prompt them to smoke. For example, having a cup of coffee, relaxing at the end of a meal, watching television, or spending time with friends or family members who smoke can all create the desire to light a cigarette.

Treatment of Nicotine Withdrawal Symptoms

One approach to treating withdrawal symptoms uses medications, either through nicotine replacement therapy or drugs that relieve symptoms. Another approach tries to change the behavior of the smoker so that he or she can quit smoking and avoid relapse.

Nicotine Replacement Therapy. The purpose of nicotine replacement is to substitute the nicotine in tobacco with a safer and more controllable form of nicotine so that the smoker can quit using tobacco. There are various nicotine replacement delivery systems, all of which attempt to reduce the amount of nicotine available during the quitting period so that an individual is weaned gradually from nicotine addiction. Two nicotine replacement therapies are available over the counter (without a prescription): nicotine polacrilex gum and the transdermal nicotine patch. Two other delivery systems are available through prescriptions: an oral nicotine inhalation system and a nasal nicotine spray. Both systems have been proven effective.

Symptom Treatment. A number of drug therapies have been approved to relieve or reduce some of the discomfort of quitting smoking. The best known is an antidepressant , bupropion (Zyban). Bupropion is effective regardless of whether smokers have a history of depression. Another antidepressant, nortriptyline, has also been approved to relieve withdrawal symptoms. Clonidine, originally used to treat high blood pressure, appears to be modestly effective in blocking cravings for nicotine, especially in women. Other medications that may lessen withdrawal symptoms are being tested. These include mecamylamine, and anxiolytics and benzodiazepines , which generally reduce stress and decrease anxiety.

Behavioral Approaches. Behavioral therapists have long tried to help smokers deal with nicotine withdrawal symptoms. Behavioral strategies may require the smoker to sign a contract to quit, with the smoker agreeing to pay a fee if he or she fails to follow through on the contract. Behavioral approaches may offer group support, with individuals holding meetings to support each other in their attempts to quit. Smokers may be taught to think differently about smoking and cigarettes. They may learn relaxation exercises; ways of coping with stressful situations other than through smoking; ways to deal with withdrawal symptoms (deep breathing, drinking water, doing something else); and controlling elements of their environment (getting rid of ashtrays, having a smoke-free home, avoiding places where others will be smoking). Behavioral programs that combine several strategies have had much success in helping smokers quit. In addition, the use of medications is much more successful when combined with behavioral strategies.

see also Nicotine; Tobacco: Dependence; Tobacco: Medical Complications; Tobacco Treatment: Behavioral Approaches; Tobacco Treatment: Medications; Tolerance and Physical Dependence.

IN THEIR OWN WORDS

I just quit smoking less than a day ago. It's hard to quit. They say in promotional campaigns that smoking isn t addicting and anyone can quit. That's not it at all. I would say that on a scale of 1 to 10 smoking by far surpasses 10 and is one of life's most challenging tests.

Amy, 21 years old.