Symptoms of nicotine dependence include:

• Tolerance
• Increased desire to use
• Inability to stop using tobacco products
• Withdrawal symptoms when abstaining from nicotine
• Feeling a need to use tobacco
• Continued use despite negative effects

Withdrawal symptoms include:

• Depression
• Irritability
• Frustration
• Anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Cravings
• Impaired performance
• Increased appetite and weight gain
• Sleep disturbances
• Impatience

Many people use tobacco to help them control their moods, improve concentration, and to enhance their ability to perform certain tasks. A person may also use tobacco to helpreduce stress and anxiety. In other words, a person receives pleasure after the nicotine is absorbed into the body and this is due to chemicals being released in the brain. The reward center in the brain that helps to regulate feelings of pleasure and mood is known as the nucleus accumbens. Dopamine, a neurotransmitter, is released by the nucleus accumbens after nicotine reaches the reward center through the bloodstream. The release of dopamine causes a pleasurable sensation that motivates humans to repeat the behavior that induced the good feeling, in this case, smoking or using tobacco. Subsequent regular use of tobacco leads to an accumulation of nicotine in the body that results in a higher level of tolerance. The increased tolerance causes a person to use more tobacco to get the dopamine release or pleasure reward. The repeated use of nicotine over time results in a chemical dependency that causes withdrawal symptoms if the person goes too long without nicotine or attempts to quit. The symptoms of withdrawal combined with the pleasurable sensation felt while using nicotine leads to a pattern of use that results in nicotine addiction or dependence.

Nicotine dependence begins when someone uses tobacco for the first time and experiences sensitivity or apleasant reaction. This initial sensitivity to tobacco stems from a pleasure center in the brain which reinforces the desire to use tobacco again. Risk factors for nicotine dependence include:

Age. The younger you are when you start smoking the greater chance you will become addicted to nicotine. The majority of people who smoke report that they began smoking when they were either in their teen years or in childhood.

Mental illness. Studies have shown that if you have a mental illness( i.e., depression, post-traumatic stress disorder, schizophrenia) you are more likely to become a smoker.

Substance abuse. People who are addicted to a substance are more likely to develop nicotine dependence especially if they’re trying to quit using their substance of choice.

Genetics. There are genetic factors that may be responsible for an increased risk for dependence. These factors mayinfluence nerve cells in the brain and their response to high doses of nicotine.

Poverty and level of education. Smoking rates are high in people who live below the poverty level and those who have a lower level of education.

If you decide that you are unable to quit tobacco alone, make an appointment with your primary care provider to assess your level of dependency. A physician can not only diagnose your dependence but also provide you with a referral to counseling and medication therapy for withdrawal symptoms. A common diagnostic test to assess nicotine dependency is called the Fagerström Test for Nicotine Dependence (FTND). This test is a questionnaire involving yes/no and multiple-choice questions about tobacco use habits that sum to a total score of 0-10. You can find a table that shows the questions, answers, and scoring for the Fagerström Test here

Smoking is the primary way that people use tobacco and the most harmful due to the inhalation of toxic substances. Most smokers attempt to quit on their own. However, health care professionals can help you quit with the help of counseling and pharmacotherapies that replace the cigarette with a gum, patch, or inhaler.

Various methods exist to help one to stop smoking and are outlined as follows:

Unassisted. This involves quitting “cold turkey” (abruptly) or gradually decreasing the number of cigarettes smoked per day. It is recommended that this approach be used in conjunction with nicotine replacement or other aides to increase the likelihood of success. Unassisted quitting carries approximately a 7% success rate.

Nicotine replacement therapy. Various patches, gums, and lozenges exist that can provide nicotine to the body which would prevent the smoker from craving for a cigarette. Ultimately the amount of nicotine that is used as a replacement is decreased.

Medications. Several antidepressants have been used to decrease the craving for cigarettes and these include bupropion, nortriptyline, and varenicline. Many studies have proven their effectiveness and they can be combined with other forms of therapy. These medications require a doctor’s prescription.

 Support groups. Either online or in-person, support groups and communities have shown to be effective in helping individuals quit smoking.

Alternative therapies. Acupuncture has, thus far, not shown to be effective as a quit aid. Herbal medications lack evidence, as data is inconclusive. Hypnosis, however, does show some promise because in certain cases it can be as effective as nicotine replacement.

E-cigarettes. Electronic cigarettes have been touted as quit aides, but evidence to support this is lacking. Also, various harmful chemicals can be present in the vapor produced by some brands.

Craving the nicotine and the withdrawal symptoms that follow from quitting tobacco use can be exceedingly difficult to manage. You may find yourself managing not only the physical withdrawal symptoms but also the mental and emotional aspects of letting go of addictive behaviors. The good news is these symptoms go away with time, usually in a few weeks.

The following are suggestions to help you manage these symptoms:

• Chew gum, hard candy, or healthy crunchy food
• Reach out to a friend
• Develop a new routine for the times you used to spend smoking
• Breathing technique
• Go for a walk, work out, or practice a new form of exercise
• Seek public places where no smoking is allowed
• Avoid triggers (alcohol, caffeine, other smokers)
• Make a list of the reasons you quit and read it when the urge hits
• Relaxation practice like yoga or dance
• Guided imagery or meditation
• Reward yourself when you hit milestones (dinner, new earrings, mini-vacation)

Mind-body therapies are a form of complementary alternative medicine (CAM) that focuses on using the relationship between brain, mind, and body to promote health and change negative lifestyle behaviors. Yoga, deep breathing, and meditations are all mind-body therapies that have been shown in studies to help relieve pain and treat symptoms of neuropsychiatric disorders.

Meditation. This practice involves creating within yourself a non-judgmental and non-reactive state of awareness that helps to improve your ability to modify negative behaviors. Some forms of meditation are mindfulness and mantra meditation. Mindfulness is a powerful tool you can use to help you self-regulate and draw attention to the beautiful moment of living in the absolute present.

Yoga. This Indian system of philosophy through movement poses has been used for hundreds of years to train the body and mind to reach physical, emotional, and spiritual health. A Western form of yoga involves using breathing exercises, physical exercise, and meditation. Exercise and movement help to treat the withdrawal symptoms and cravings you experience when you quit with a reduced negative effect and severity of your symptoms.

Deep breathing. Simply paying attention to your cycle of breathing can reduce stress, anxiety, and the compulsive urge to use tobacco. When you slow down your breath cycle, your body immediately responds with a state of relaxation that counteracts the ‘fight or flight’ response of the parasympathetic nervous system.

Brain development. Nicotine is harmful to brain development in teens exposed to nicotine, even in small doses. Negative effects of nicotine include causing developmental problems in learning, behavior, memory, attention, and a higher risk for addiction in the future.

Fetal development. Fetal exposure to nicotine increases the risk for sudden infant death syndrome. The chemical impairs fetal brain and lung development and increases the risk for hearing problems, obesity, and behavioral impairments including attention and cognition.

Toxic in high doses. Ingesting large amounts of nicotine can cause nicotine poisoning (especially in children). Symptoms include vomiting, seizures, nausea, and respiratory depressions. Can be fatal in extremely high doses (60mg of nicotine orally can be fatal).

Complications of smoking include:

• Hearing loss
• Eye cataracts, macular degeneration, yellowing of the whites of eyes
• Increases risk of stroke and brain damage
• Loss of sense of smell and taste
• Mouth and throat cancer
• Osteoporosis
• Poor dental health, including decay and loss of teeth
• Shortness of breath
• Emphysema and chronic bronchitis
• Chronic obstructive pulmonary disease
• Stomach and bladder cancers
• Myeloid leukemia
• Hypertension
• Heart disease
• Stomach ulcers
• Impotence
• Damage to blood vessel walls
• Grey appearance
• Early wrinkles
• Irregular periods
• Increased susceptibility to infection
• Slow-healing wounds

Benowitz, Neal L. (2010, August 25). Nicotine addiction. New England Journal of Medicine,362(24), 2295-2303. Retrieved from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/

Carim-Todd, L., Mitchell, S. H. &Oken, B. S. (2013, October 1). Mind-body practices: an alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug and Alcohol Dependence, 132(3), 399-410. Retrieved from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770754/

Centers for Disease Control and Prevention. Health effects of cigarette smoking. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm

Gabbey, A. E. (2018, May 16). Nicotine addiction: What you need to know. Retrieved from:https://www.healthline.com/health/nicotine-and-related-disorders#diagnosis

Harvard Mental Health Writing Staff. (2011, April) Breaking free from nicotine dependence. Retrieved from:https://www.health.harvard.edu/newsletter_article/breaking-free-from-nicotine-dependence

Hatsukami, D. K. (2008, June 14). Tobacco addiction: diagnosis and treatment. Lancet,371(9629), 2027-2038. Retrieved from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4732578/

Mayo Clinic Staff. (2020, March 14). Nicotine dependence. Retrieved from:https://www.mayoclinic.org/diseases-conditions/nicotine-dependence/diagnosis-treatment/drc-20351590

National Institute on Drug Abuse.(2020, January). Do people with mental illness and substance use disorders use tobacco more often? Retrieved from:https://www.drugabuse.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/do-people-mental-illness-substance-use-disorders-use-tobacco-more-often