In the past, it was believed that because nicotine does not cause intoxication or impairment, using tobacco was simply a bad habit, not an addiction. Today, nicotine is recognized as the very addictive drug found in tobacco products.
Nicotine dependence (also called tobacco addiction) involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit.
Nicotine releases a chemical called dopamine in the same regions of the brain as other addictive drugs. It causes mood-altering changes that make the person temporarily feel good. Inhaled smoke delivers nicotine to the brain within 20 seconds, which makes it very addictive—comparable to opioids, alcohol and cocaine. This "rush" is a major part of the addictive process.
When the person stops using tobacco, nicotine levels in the brain drop. This change triggers processes that contribute to the cycle of cravings and urges that maintains addiction. Long-term changes in the brain caused by continued nicotine exposure result in nicotine dependence, and attempts to stop cause withdrawal symptoms that are relieved with renewed tobacco use.
Signs & Symptoms
Nicotine dependence involves physical and psychological factors.
Signs of physical dependence on nicotine include:
- the urge to smoke within 30 minutes of waking
- ranking the first cigarette of the day as the most important
- smoking at regular intervals throughout the day.
Tobacco use causes feelings of pleasure and alertness, but people with nicotine dependence become tolerant to the desired effects. They may no longer experience pleasure from using tobacco, but they continue to use it because they have cravings and want to avoid nicotine withdrawal.
Signs and symptoms of nicotine withdrawal include:
- irritability
- restlessness
- anxiety
- insomnia
- difficulty concentrating
- fatigue.
These symptoms usually stop within a couple of weeks, but some people continue to have problems concentrating or experience strong nicotine cravings weeks or months after quitting.
In addition to physical factors involved in nicotine dependence, there are psychological factors. People develop conditioned signals, or “triggers,” for tobacco use. For example, some people always smoke after a meal or when they feel anxious. These triggers lead to behaviour patterns that can be difficult to change.
Causes & Risk Factors
Anyone who smokes or uses other forms of tobacco is at risk of developing nicotine dependence. Various factors influence who is more likely to use tobacco and to develop nicotine dependence:
- Genetics: Heredity may determine how receptors in the brain respond to high doses of nicotine delivered by tobacco products.
- Family and friends: Children with parents who smoke are more likely to eventually take up smoking themselves. Children with friends who smoke are also more likely to try cigarettes.
- Age: The younger a person is when they start using tobacco, the greater the chance that they will continue to smoke and develop nicotine dependence as adults.
- Co-existing mental health problems: People with mental health problems, such as depression, anxiety and schizophrenia, have much higher rates of tobacco use.
- Other substance use: People who use alcohol, cannabis and illegal drugs have much higher rates of tobacco use.
Diagnosis & Treatment
Diagnosis
Health care providers determine whether a person has nicotine dependence, and how severe it is, by asking certain questions. The most important questions are:
- How soon after you wake up do you use tobacco?
- How many cigarettes do you smoke per day?
- Which is the most important cigarette of the day for you?
Treatment
Quitting tobacco use can take many attempts, so it is important to keep trying.
Medications and behavioural counselling are the two main types of tobacco cessation treatment. Combining these two types of treatment is the most successful way to quit tobacco use.
Medications
Stop-smoking medications reduce withdrawal symptoms and nicotine cravings. The choice of medication, dosage and duration of use depend on each person's needs and preferences.
Two types of medications exist for treating nicotine dependence: over-the-counter products that contain nicotine and prescription medications that do not contain nicotine.
- Nicotine replacement therapy (NRT) uses pure nicotine to treat nicotine dependence. NRT products come in different formats: patch, gum, inhaler, lozenge and nasal spray. Some formats work faster than others. The slower-acting NRTs (patch) reduce nicotine withdrawal symptoms. The faster-acting NRTs (gum, lozenge, inhaler, spray) work sooner to reduce both nicotine withdrawal symptoms and cravings. NRT products can be more effective if they are used in combination.
- Varenicline (Champix in Canada) is a prescription medication used to treat nicotine dependence. It works on the brain to reduce nicotine withdrawal and cravings. Varenicline has the highest quit rate of existing treatments for tobacco cessation.
- Bupropion is an antidepressant that can also be prescribed to treat nicotine dependence. (For depression, the medication is called Wellbutrin. For tobacco cessation, it is called Zyban.) Bupropion works on the brain to reduce nicotine withdrawal and cravings.
- Cytisine is an over-the-counter natural health product to aid in smoking cessation. It reduces cravings and makes tobacco products less satisfying if the person uses them. Cytisine is less expensive than NRT or prescription medication.
- Nortriptyline and clonidine: Nortriptyline, an antidepressant, and clonidine, a medication for high blood pressure, can be prescribed for smoking cessation. However, they have risks and side-effects that make them less popular than other stop-smoking medications.
Behavioural counselling
Behavioural counselling teaches the person coping and problem-solving skills they can use to avoid tobacco and prevent relapse. It can also provide social support and encouragement. The more time a person spends in counselling, the more likely that they will succeed in quitting tobacco use.
Various types of counselling are used to treat nicotine dependence:
- Individual face-to-face counselling: This practical counselling involves meeting with a counsellor to develop a quit plan, learn problem-solving skills to help avoid tobacco use and prevent relapse, and get support during the process. The quit plan may include medication in combination with support. Individual counselling can last from five to 30 minutes and can happen in just one or a few sessions.
- Group face-to-face counselling: Meeting as a group to share experiences of trying to quit and to offer one another support can help people stop tobacco use. Trained counsellors often moderate these groups.
- Telephone quitlines: Counsellors may provide brief counselling, direct the caller to self-help material and refer them to community resources. Some quitlines only respond to incoming calls, but others call clients and offer counselling and relapse prevention support. Quitlines are free.
- Web-based programs: Web-based interventions can help with tobacco cessation, relapse prevention and social support. Websites often provide self-guided quitting activities, interactive online communities moderated by trained staff and downloadable self-help material. Text-messaging services send personalized messages that support the person when they are struggling with cravings, triggers or potential relapse.
Some people don't feel ready to quit but are willing to start by cutting down. Cutting down before quitting can lessen nicotine withdrawal symptoms, and it allows the person to change their tobacco behaviours gradually. Strategies for cutting down include delaying cigarettes, smoking fewer cigarettes and smoking less of each cigarette. Although cutting down may reduce some health risks, there is no safe level of tobacco use.
Frequently Asked Questions
Is tobacco a gateway drug?
Most people who use tobacco do not go on to develop other substance use problems, but for some people, tobacco does seem to be a gateway drug.
Nicotine is often the first drug used by people who later develop alcohol or other substance use problems. A history of smoking, particularly daily, increases the likelihood that young adults will use alcohol, cannabis and illegal drugs. More than 80 per cent of youth who have substance use disorders use tobacco, develop nicotine dependence and continue using tobacco as adults.
Can a person in treatment for other substance use problems do tobacco cessation treatment at the same time?
Yes. Some treatment providers think it is unrealistic to expect people to try quitting tobacco at the same time that they are dealing with another substance use problem. They know that quitting tobacco can be even harder than quitting the other substance for which the person is getting treatment. But there are reasons why people can and should try to quit both tobacco and other substances together:
- Many people in treatment for other substances want to stop using tobacco.
- Quitting tobacco use can help the person recover from other substance use problems and can protect against relapse.
- Stopping other substance use can increase the likelihood that the person will succeed in quitting tobacco use.
Nicotine replacement therapy (NRT) contains nicotine, so is there a risk of developing an addiction to NRT products?
It is unlikely that a person will develop an addiction to NRT for two reasons:
- The amount of nicotine in NRT products is low.
- Compared with cigarettes, it takes longer for the nicotine in NRT products to get to the brain and produce the rush that is a big part of nicotine dependence.
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