Nicotine (smoking) addiction

In 2019, almost 7 million people aged 18 and older in the UK – some 14.1% of the adult population – were cigarette smokers (Office of National Statistics, 2020). The dangers of smoking are well-documented and are mainly caused by tobacco rather than nicotine (Action on Smoking and Health, 2022).

However, it is the nicotine component in cigarettes that is addictive.

People experience physical and psychological symptoms of nicotine dependence when the level of nicotine in their blood falls. These are known as withdrawal symptoms, and they include:

• nicotine cravings (the urge to smoke)
• headaches
• feeling restless and irritable
• anxiety
• depression
• difficulty concentrating
• dizziness
• feeling lightheaded
• slowing heartrate
• disturbed sleep
• increased appetite
• weight gain
• constipation (Payne, 2017)

Withdrawal symptoms typically start within a few hours after a person last smoked a cigarette, and are eased when they smoke again (Payne, 2017).

More intense withdrawal symptoms tend to be associated with attempting to quit smoking. The most common smoking cessation-related symptoms are nicotine cravings and increased appetite, with 70% of people reporting these – lasting more than 2 weeks and more than 10 weeks respectively (National Institute for Health and Care Excellence (NICE), 2022a).

The way nicotine is delivered through tobacco smoke makes it particularly addictive as this is the fastest route into the bloodstream. Nicotine separated from tobacco does not yield the same addictive properties (Action on Smoking and Health, 2022).

When a person smokes, the nicotine they inhale goes into the bloodstream where it travels to the brain within 10 seconds and activates certain neurotransmitters, including dopamine (Mental Health Foundation, 2021). Dopamine is associated with pleasure, so when the brain releases dopamine it triggers a sense of relaxation and contentment.

The more a person smokes, the less able the brain is to release dopamine naturally without being stimulated by nicotine.

This leads to withdrawal symptoms when they don’t smoke, which are relieved by the next dose of nicotine. Hence, they become addicted (Payne, 2017).

Some people are more likely to take up smoking than others, and therefore more likely to experience nicotine

There is not one single method of diagnosing or assessing nicotine dependence. It can be measured in several ways – perhaps the most reliable of which is a patient expressing a desire to give up smoking yet continuing to smoke because they cannot seem to stop.

Sometimes, an objective measure of nicotine addiction is helpful. One such method that is often used is the Fagerström Test for Nicotine Dependence, which asks a series of questions about a person’s smoking habits (Fagerström, 2012).

The first question asks how soon after waking a person has their first cigarette – also known as time to first cigarette, with scores given as follows:

In 2016, nearly half (44.2%) of smokers in Britain aged 16 and over reported having their first cigarette of the day with 30 minutes of

The best treatment for nicotine addiction is to give up smoking, but the addictive nature of the nicotine in cigarettes makes smoking cessation difficult.

Quitting smoking also has numerous health benefits, since smoking is the leading cause of preventable illness and premature death in the UK and causes or is associated with a range of diseases, including (but not limited to): cancers, cardiovascular disease, musculoskeletal problems, cognitive decline, infertility and chronic obstructive pulmonary disease (NICE, 2022a).

The most successful method of giving up smoking is with a combination of behavioural support and medication (NICE, 2022b).

NHS Stop Smoking services can provide evidence-based group or individual support, advice and encouragement to stay on track, and information about and access to smoking cessation treatments, including nicotine replacement therapy and medication (NICE, 2022b).

Nicotine replacement therapy

Because nicotine itself is not addictive, nicotine replacement therapy can be used to assist a person’s attempt

References

Action on Smoking and Health. Smoking statistics. 2021. https://ash.org.uk/resources/view/smoking-statistics (accessed 16 December 2022)

Action on Smoking and Health. What's in a cigarette? 2022. https://ash.org.uk/resources/view/whats-in-a-cigarette (accessed 16 December 2022)

Fagerström, K. Determinants of Tobacco Use and Renaming the FTND to the Fagerström Test for Cigarette Dependence. Nicotine & Tobacco Research. 2012; 14(1):75–78. https://doi.org/10.1093/ntr/ntr137 

Mayo Clinic. Nicotine dependence – Overview. 2022. https://www.mayoclinic.org/diseases-conditions/nicotine-dependence/symptoms-causes/syc-20351584 (accessed 25 July 2022)

Mental Health Foundation. Smoking and Mental Health. 2021. https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/smoking-and-mental-health (accessed 25 July 2022)

National Centre for Smoking Cessation and Training (NCSCT). Dependence on Smoking (based on Fagerstrom Test of Nicotine/Cigarette Dependence. 2012. https://www.ncsct.co.uk/usr/pub/Dependence%20on%20Smoking%20.pdf (accessed 25 July 2022)

National Institute for Health and Care Excellence. Smoking cessation: What are the harms caused by smoking?. 2022a. https://cks.nice.org.uk/topics/smoking-cessation/background-information/harms-caused-by-smoking/ (accessed 25 July 2022)

National Institute for Health and Care Excellence. Smoking cessation: Scenario: Adults. 2022b. https://cks.nice.org.uk/topics/smoking-cessation/management/adults/ (accessed 25 July 2022)

National Institute for Health and Care Excellence. Smoking cessation: Nicotine replacement therapy (NRT). 2022c.