Nicotine and related disorders Health Article

Nicotine dependence

In addition to the physical dependence caused by the actions of nicotine on the brain, there is a strong psychological component to the dependency of most users of tobacco products, especially cigarette smokers. Most people who start smoking or using smokeless tobacco products do so because of social factors. These include:

• the desire to fit in with peers
• acceptance by family members who use tobacco
• rebelliousness
• the association of tobacco products with maturity and sophistication
• positive response to tobacco advertising

Such personal factors as mental illness (depression, anxiety, schizophrenia, or alcoholism); the need to reduce stress and anxiety; or a desire to avoid weight gain also influence people to start smoking. Once smoking has become a habit, whether physical addictionoccurs or not, psychological factors play a significant role in continuing to smoke. People who want to stop smoking may be discouraged from doing so because:

• They live or work with people who smoke and who are not supportive of their quitting.
• They believe they are incapable of quitting.
• They perceive no health benefits to quitting.
• They have tried to quit before and failed.
• They associate cigarettes with specific pleasurable activities or social situations that they are not willing to give up.
• They fear gaining weight. Successful smoking cessation programs must treat both the physical and psychological aspects of nicotine addiction.

Nicotine withdrawal

The American Psychiatric Association first recognized nicotine dependence and nicotine withdrawal as serious psychological problems in 1980. Today nicotine is considered an addictive drug, although a common and legalized one.

Studies show that three-quarters of smokers try to quit, but only about 5–10% are eventually successful. Even those who succeed often make between five and ten attempts to quit before finally succeeding. Symptoms of nicotine withdrawal occur in about half the smokers trying to quit who do not use nicotine replacement therapy (nicotine patches, inhalers, or gum).

As former smokers can attest, the combination of physiological and psychological factors make withdrawal from nicotine very difficult. Symptoms of nicotine withdrawal include:

• irritability
• restlessness
• increased anger or frustration
• sleep disturbances
• inability to concentrate
• increased appetite or desire for sweets
• depression
• anxiety
• constant thoughts about smoking
• cravings for cigarettes
• decreased heart rate
• coughing

Withdrawal symptoms are usually more pronounced in smokers than in those who use smokeless tobacco products, and heavy smokers tend to have more symptoms than light smokers when they try to stop smoking. People with depression, schizophrenia, alcoholism, or mood disorders find it especially difficult to quit, as nicotine offers temporary relief for some of the symptoms of these disorders.

Symptoms of nicotine withdrawal begin rapidly and peak within one to three days. Because of this rapid onset of withdrawal symptoms, only about 30% of people who try to quit smoking remain tobacco-free for even two days. Withdrawal symptoms generally last three to four weeks, but a significant number of smokers have withdrawal symptoms lasting longer than one month. Some people have strong cravings for tobacco that last for months, even though the physical addiction to nicotine is gone. These cravings often occur in social settings in which the person formerly smoked, such as at a bar or party, or after sex. Researchers believe that much of this extended craving is psychological.

Demographics

About 60 million Americans smoke cigarettes, cigars, and pipes; and about six million more use smokeless tobacco. Worldwide, there are more than a billion smokers. Although the prevalence of smoking has gradually decreased in the United States and many other industrialized countries since the 1970s, the use of tobacco products is rapidly increasing in the developing nations of Africa and Asia. Use of tobacco products in developing countries is of particular concern, because these countries often lack adequate health care resources to treat smoking-related diseases, let alone support smoking cessation programs.

In the past, the number of American men who smoked outnumbered women, but by 2000, the rate of smoking was almost the same for these two groups— about 35% of the population. Men in the United States greatly outnumber women, however, in the use of smokeless tobacco (14% to 1%). In developing countries, male smokers outnumber women smokers by a margin of eight to one. People who smoke tend to have lower levels of income and formal education than those who don't. About half the patients diagnosed with psychiatric problems are smokers, while more than three-quarters of those who abuse other substances also smoke.

In 2001, the most recent year for which statistics are available, smoking among high school students decreased. Daily use of cigarettes among eighth graders decreased from 7.4% to 5.5% and among tenth graders from 14% to 12.2%—both significant declines. The rate of smokeless tobacco usage stayed constant at about 4% of eighth graders and 7% of tenth graders, almost all of whom were boys. Smoking among women with less than a high school education increased, however. Although African American men overall have the highest rate of smoking in the United States population, smoking among African American high school students has decreased significantly. Only about 19% of African American high school students smoke, compared to about 38% of Caucasian high school students. The change in rates of smoking among different subgroups in the population may reflect to some extent changes in the target groups of the billion-dollar advertising campaigns of cigarette manufacturers.

Recent research suggests that there may be a genetic component to nicotine dependence, just as there is for alcohol dependence. Studies show that girls (but not boys) whose mothers smoked during pregnancy are four times more likely to smoke than those whose mothers were tobacco-free during pregnancy. Other research suggests that the absence of a certain enzyme in the body protects the body against nicotine dependence.