Nicotine Withdrawal (The Full Article)
Nicotine is an addictive substance found in tobacco. When someone gives up smoking, it is normal for him or her to experience nicotine withdrawal as their body learns to adjust to living without the constant influx of nicotine into their system. Smoking fosters a situation of nicotine dependence that usually occurs over a number of years. Nicotine withdrawal symptoms can include headaches, irritability, nicotine cravings, anxiety, fatigue, depression, and weight gain. If you experience these symptoms after you stop smoking, it can be helpful to understand that you are not alone. Nearly everyone experiences at least some of these symptoms and you should try to remember that, unpleasant as they may be, for most people they are only temporary.
Smoking creates a chemical dependency in the smoker for nicotine. Nicotine can either act as a stimulant or a sedative, depending on the amount taken. The smoker's body finds an acceptable plateau of nicotine in order to experience the pleasurable sensations associated with smoking. The nicotine from cigarettes increases the activity of dopamine in the brain, the chemical that elicits pleasurable sensations. The first cigarette of the day is particularly effective at stimulating the dopamine-sensitive neurons in the brain, which is why smokers often find the first cigarette of the day the most satisfying. During the rest of the day, the nerve cells become desensitised to the effects of nicotine, which is a microcosm of the long-term smoker's tendency to develop a tolerance to nicotine that requires increasingly higher levels of nicotine to be used over time to achieve the same benefits.
As time goes by, even more nicotine is required to maintain this level of satisfaction. The body, and the nervous system in particular, adjusts to constantly receiving this expected level of nicotine and will typically exhibit symptoms of withdrawal without it. Generally speaking, the "heaviness" of ones smoking will have the most impact on the severity of the withdrawal once they quit. Heavy smokers are more likely to experience pronounced withdrawal symptoms than light smokers. The more nicotine you have learned to tolerate in your blood, then the more likely you are to miss it when you stop. This is why a smoker can still experience a mild form of nicotine withdrawal if they cut down on the amount of cigarettes they smoke rather than quitting completely because the body is responding to the reduced amount of nicotine it is receiving.
Our genetic coding can also affect how the brain responds to certain stimuli. Nicotine stimulates neurological receptors throughout the brain, including the pleasure centres of the brain where we experience gratification through pleasurable experiences like sex or eating our favourite food. The nicotine in cigarettes produces pleasurable feelings while at the same time acting as a depressant by interfering with the flow of information between the nerve cells.
To demonstrate the connection between severe nicotine withdrawal and the effect that this has on the pleasure circuits of the brain, it is useful to refer to a study by scientists at The Scripps Research Institute, of La Jolle, California, which was funded by the National Institute on Drug Abuse (NIDA), National Institutes of Health. This study discovered that the brains of laboratory rats exhibited less sensitivity to pleasurable experiences once their nicotine intake was stopped. For several days after they ceased to receive nicotine, the rats experienced anxiety, irritability and depression equivalent to a human going through the same withdrawal. This decreased sensitivity in the pleasure circuits of the brain is a characteristic common to any attempt to stop using an addictive substance.
The rats in the study were able to self-administer pleasurable electrical pulses that stimulated the brain's lateral hypothalamus. The research team, headed by Dr. Athina Markou, measured the reward, or pleasure, sensitivity of this area of the brain for each rat during and after the administration of nicotine. For one week, the rats received the equivalent of a human who smoked one and a half packets of cigarettes a day and there was no significant change in the amount of electrical pulse that the rats administered to themselves.
This changed once the rats were taken off the nicotine. The intensity of the electrical pulse had to be increased by over 40% before the rats achieved the same level of pleasure that they had experienced while on nicotine. This indicated a significant decrease in their sensitivity to pleasurable stimulation as a result of nicotine withdrawal. In fact, the reward sensitivity of the rat's brain, as indicated by the lateral hypothalamus, remained affected for at least four days, with some rats not returning to the baseline sensitivity for more than two weeks after nicotine ceased to be administered.
Nicotine withdrawal entails both a physiological and psychological dimension. The physiological effects are actually the result of your body returning to normal and attempting to purge itself of the harmful chemicals left behind by smoking. The symptoms of this adjustment may be stressful but they do signify an improvement in your health.
The other aspects of the withdrawal dynamic are psychological. The smoker is faced with giving up a habit that has become a compulsive part of their behaviour. Sometimes it is the withdrawal symptoms related to mood and emotion that are the most difficult to overcome. They may also be difficult to differentiate from the other stresses of life. Withdrawal as an emotional reaction has been compared to a period of mourning or grieving where your body misses a stimulus, in this case nicotine, that was considered highly important but was abruptly taken away.
Normally, nicotine or cotinine, which is its metabolite, remain present in the system of a regular smoker for about three to four days. Diet can help remove the remaining nicotine from your system. For example, drinking lots of water and fruit juices will help rehydrate the body and flush the residue nicotine for the system. Nicotine is a water-soluble drug and will be rapidly excreted from the body once it is no longer introduced into your system. Nicotine will begin to leave your system within two hours of you stopping smoking.
The symptoms of nicotine withdraw are usually most pronounced within 48 hours of stopping smoking. It is during this time, when nicotine leaves the body, that these symptoms will be at their most unpleasant. Some people experience nicotine withdrawal symptoms to a point where they find it difficult to function normally during this period. The worst of the withdrawal symptoms are, however, only temporary and you should feel better if you can get through these first few tough days of nicotine withdrawal. These symptoms would usually begin to lessen in three to four days before gradually abating after a few weeks or months. The first two weeks after someone ceases smoking are the often considered the most critical to their success.
How long the symptoms of nicotine withdrawal persist depends on the individual and how much they used to smoke because this is what conditioned their body to expect the level of nicotine that is now absent from their system. For most people, any these unpleasant symptoms will no longer be apparent after six months. In extreme circumstances, however, people may find that these symptoms can come and go for years after they stop smoking. The symptoms of nicotine withdrawal can include any or all of the following:
Headache: Headaches may be caused by increased tension due to the stress of giving up. It can also be due to the body now receiving more oxygen and less carbon monoxide, with an increased blood flow to the back of the brain. Taking a warm shower or bath can help relieve muscle tension, as can doing anything that helps you relax. Some degree of physical activity may provide an outlet for built up tension. The typical duration for this symptom is 1 to 2 weeks.
Nausea, Dizziness: Feelings of nausea may be connected to dizziness that is actually the result of your bloodstream adjusting to carrying more oxygen and less carbon monoxide. The drop in blood pressure once you stop smoking can also result in dizziness. Try to take it easy and not over exert yourself while experiencing these symptoms. The typical duration for this symptom is 1 to 2 days.
Nicotine Cravings: Some smokers quit and never feel compelled to smoke again, while others feel they need constant vigilance to prevent resuming their smoking habit years after they quit. Usually tobacco cravings will often begin within the first 6 to 12 hours after you quit smoking. Those people who have to fight the strong urge to smoke again are comparable to the alcoholic who lives from day-to-day fighting their addiction. In these instances, cravings can continue for a while after you stop smoking. Otherwise, individual cravings may only last a matter of seconds before the urge passes. If you smoked at a particular time each day or in certain social situations then you are more likely to have cravings exacerbated by these factors.
Depression, Dysphoria: Nicotine has antidepressant qualities, although smokers may not realise it, and when you stop smoking, depression can be a symptom of nicotine withdrawal. This is why some types of antidepressants are used to treat nicotine dependence. People who have a pre-existing history of depression are more likely to have difficulty in quitting. Nicotine can actually act as both a stimulant and a depressant depending on your mood and the level of nicotine intake. Try to remain positive through the tough times and keep your self-esteem up. Keep in mind how much better off you will be in the long-run for having quit smoking.
Weight Gain, Increased Appetite: Weight gain can occur once an individual's metabolism returns to normal. Smoking actually increases the amount of calories that your system burns. Smoking also works as an appetite suppressant so once you quit, it is normal for your appetite to increase. Each time nicotine was taken into the body, it caused your body to release stored sugars into the bloodstream. This process may have helped you stave off the natural signals of hunger and suppress appetite. What is more, this process occurs a lot quicker because of smoking than it does naturally by eating, hence the tendency to eat more over a period of time to achieve the same effect. Otherwise it can take as long as twenty minutes to break food down into energy. Mild hypoglycemia, or low blood sugar, can contribute to symptoms of nicotine withdrawal, including an increased sweet tooth. Drinking fruit juices will help stabilise your blood sugar levels. Some people find that eating replaces the hand to mouth action of smoking and fulfils the desire to do something with their hands. Others find that they eat more because, after about two days from having quit smoking, they can actually taste food again as their sense of smell and taste return. It is also possible that the craving for cigarettes may be mistaken for hunger pangs.
The important thing to remember that this weight gain is usually marginal and need only be temporary. A low-calorie and low-fat diet will help will help you remove it. It is actually the result of your body returning to normal so remember to look at the "big picture". It is less of a health risk to gain a little weight than it is to keep smoking. You can exercise and work off any excess weight but the same cannot be said about a cancerous lung.
Irritability, Frustration: This is quite a common symptom of nicotine withdrawal and almost everybody gets a little cranky when they stop smoking. This is usually an offshoot of your craving for nicotine and an inability to stop thinking about smoking. The best thing to do is to find something else to preoccupy your mind, especially activities that you enjoy. This could be work related, exercise, or a hobby and, if possible, should be an activity that gets you away from situations where you used to smoke. Do not undertake anything too strenuous in the first few days. Get plenty of rest and give your body a chance to adjust. Make an effort to drink less coffee and drinks containing caffeine. If you are used to drinking large amounts of caffeine be aware that stopping may entail some withdrawal symptoms of its own. The typical duration for this symptom is 2 to 4 weeks.
Constipation, Flatulence or Diarrhoea: As a stimulant, nicotine can increase intestinal movement and suddenly removing nicotine can temporary slow the system as it returns to a normal state. Flatulence may also become a problem. Drinking plenty of liquids, eating a diet that contains roughage and getting plenty of exercise will help. The typical duration for this symptom is 1 to 2 weeks.
Anxiety, Tension: Anxiety is another common symptom of nicotine withdrawal. Nervousness is actually an indicator of the nervous system returning to normal. When you stop supplying your body with nicotine, you are putting your system under stress. Anxiety is a common trigger for when people would smoke and this only worsens the cycle of anxiety and depression because they invariable focus on the one thing that they cannot have - a cigarette. You need to recognise this and take time out to relax at various times during the day. Periodically taking deep breaths can also be useful if you feel a rising tide of anxiety is about to wash over you. Any activity that releases the build up tension will help you overcome this.
Coughing, Shortness of Breath: This is less of a symptom of nicotine withdrawal and is more an indicator of the lungs returning to normal and it may be associated with a tightness of the chest. Repeated coughing can cause the chest muscles to become sore. Lung function will increase over time and the body will attempt to loosen the debris of smoking. As your heart and lungs improve, you should be able to notice an increase in your energy levels over time. Drinking plenty of fluids, deep breathing, getting plenty of rest and exercise will assist the restorative process. The typical duration for this symptom is 1 week.
Dry mouth, sore throat: This is another symptom that has more to do with the body's attempt to recover from years of smoking. Your body is ridding itself of the mucus that clogged airways and restricted breathing. Both a dry mouth and a sore throat can be brought on by the stress of stopping smoking. Drinking plenty of water or fruit juice will help to relieve these and, in the case of a sore throat, throat lozenges will help. The typical duration for this symptom is 1 week.
Fatigue, Drowsiness or Insomnia: Your body needs to adjust to no longer receiving the stimulant nicotine. Without it, your body's metabolism returns to normal, including a decreased heart rate that may cause feelings of fatigue. Try to combat fatigue by taking frequent, quick power naps. Also, because nicotine affects brain wave function, it can disrupt sleep patterns. Some people even find themselves dreaming about smoking. If you are having trouble sleeping, which is often related to feeling of anxiety, try taking a shower or bath to relax you before going to bed. Do not drink coffee, tea or any other caffeine drink before you go to bed as this may keep you awake. The typical duration for this symptom is 2 to 4 weeks.
Difficulty Concentrating: Some people find it difficult to concentrate after quitting smoking. Nicotine is a stimulant that increases alertness, which was one of the reasons why the use of cigarettes was popular amongst soldiers. Difficulty concentrating is also related to other withdrawal symptoms, including anxiety, depression, irritability, and fatigue, each of which does little to aid ones attentiveness. As the body recovers, quitting may appear to have slowed the activity of certain brain chemicals but this is actually a result of the brain no longer being artificially stimulated by nicotine. Efforts to relax may help one to refocus when they find their concentration waning. The typical duration for this symptom is 2 to 4 weeks.
Many of the symptoms listed above mention a typical duration but keep in mind that these can be highly variable. There are many statistics available that estimate how many people will experience a particular withdrawal symptom and how long it will last. They maintain, for example that about half of all people who quit smoking will experience symptoms of irritability that last less than four weeks, while 60% of people who stop smoking will experience symptoms of depression for less than a month. Unfortunately, these statistics are not particularly helpful in indicating which symptoms a specific individual will actually experience once he or she quits smoking. Some people may only suffer from a few of these symptoms while others will encounter the full spectrum of symptoms. It has been estimated that about 90% of all young people who use tobacco daily and stop will experience at least one symptom of nicotine withdrawal. The only way to truly find out how much you will be affected is to stop smoking.
Professor Timothy Baker's research for the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School in Madison examined the duration and intensity of nicotine withdrawal symptoms amongst smokers trying to quit. This research studied the tendency of some smokers to experience cravings for cigarettes months after the symptoms of nicotine withdrawal should have subsided. It was noticed that, rather than necessarily entailing a progressive improvement in nicotine withdrawal symptoms, it was possible for the withdrawal symptoms to persist over time, and even worsen.1
Participants were asked to carefully record the nature of their withdrawal symptoms over a longer period of two to three months, noting how they changed over time. While some people experienced the worse symptoms in the first few days and then improved, there were others whose experience was more atypical. The "withdrawal trajectory", defined three "clusters" of withdrawal symptoms, of which the later second and third clusters were considered atypical because they differed from the conventional pattern of withdrawal. For these smokers, the symptoms of nicotine withdrawal either failed to dissipate or actually increased weeks after they had quit smoking. Because of the late surge in the intensity of the withdrawal symptoms, these smokers were often the most likely to relapse into smoking. This was because, faced with a situation that was contrary to what they had been led to believe would happen, they doubted whether things would ever get better and could not envisage suffering these symptoms for an extended period of time.
The study discovered that mood played an important role in people's ability to resist giving in to their cravings for cigarettes and those people with the clearest and most defined reason for quitting, be it their family or being diagnosed with a smoking related disease, tended to be the most successful at stopping smoking. People were more likely to resume smoking if they were feeling anxious or depressed and the atypical withdrawal cycles were often influenced by variations in a smoker's environmental stressors.
It should not be surprising that mood plays such an important role in the chances of successfully quitting smoking. This is because irritability, stress and depression are often reasons why people start smoking in the first place. The desire to smoke may persist in some people for years after they stop smoking, especially during moments of stress. It has been estimated that about 20% of ex-smokers will still experience an occasional craving for a cigarette, even after years of non-smoking.
Professor Baker's research shows that there is no cast-iron pattern of nicotine withdrawal that everyone will experience to the same degree or for the same length of time. Just because a particular smoker's experience with withdrawal symptoms does not match the perceived "norm" does not mean that they will not be able to quit if they persevere and that they should just capitulate to their cravings for nicotine.
Another facet of nicotine withdrawal relates to the observation that if cognitive function is improved by nicotine then it will seem impaired once the smoking has stopped. One study, jointly administered by staff at the University of Pittsburgh and Purdue University, looked at the impact of nicotine withdrawal on light but long-term smokers, referred to as "chippers".2 Cognitive assessments using palm-top computers were administered to "chippers" and regular smokers while both groups were either smoking or abstaining over two-day blocks.
While the performance of "chippers" did not deteriorate noticeably during the period of abstinence, the results for the regular long-term smokers demonstrated a decline in cognitive performance while they were experiencing nicotine withdrawal. The study also noted that the regular smokers exhibited more distinct variations in mood, cravings, and sleep patterns during this period. The results seem to reinforce the argument that it is the number of cigarettes smoked rather than the length of time that someone has smoked that is a more important determinate factor in how much they will be affected by nicotine withdrawal once they stop smoking.
It has been observed that women are also more likely than men to experience nicotine withdrawal symptoms. One reason for this is that depression, a recognised symptom of nicotine withdrawal, is a psychiatric disorder that is more prevalent in women. An investigation into the effects of nicotine withdrawal on women with psychiatric illnesses showed that they were more like to experience severe nicotine withdrawal, making it even more difficult for them to quit. Headed by Dr. Pamela A. F. Madden, a research instructor of psychiatry, and Dr. Nicholas G. Martin, professor and senior research fellow of epidemiology at the Queensland, Australia, the findings of the study, which included over 550 women, were reported in the July 1997 edition of the journal Addiction. It was found that those women who experienced severe nicotine withdrawal were more likely to have a psychiatric disorder, while there was little correlation between psychiatric disorders and those who experienced only mild to moderate levels of withdrawal.
At Penn State University in Pennsylvania, a study conducted by Dr. Elizabeth Corwin and Dr. Laura Klein demonstrated that heavy to moderate smokers who stop smoking exhibit the same symptoms as someone experiencing an anti-inflammatory response. This is because quitting smoking is a significant physical and psychological stressor that affects multiple parts of the body, including the immune system.
During an inflammatory response to illness, the body's white blood cells produce increased numbers of cytokines. The Penn State study wanted to see whether a similar elevation in the levels of cytokines could be responsible for some of the nicotine withdrawal symptoms experienced by smokers who quit. Blood samples were taken from a sample of heavy to moderate smokers, both while they smoked and 24 hours after they stopped smoking. This was compared against blood samples from a control group of non-smokers. Both groups also completed questionnaires relating to the level of fatigue, depression, muscle aches and appetite they experienced. These self-reports revealed that during nicotine withdrawal the smokers had experienced a noticeable increase in all symptoms except fatigue. While the smokers' fatigue scores stayed relatively constant, it should be remembered that these occupied an already elevated level at the beginning of the study when compared to that of the non-smokers.
Further analysis of the blood samples showed that the levels of two types of cytokines, interleukin-1 beta (IL-1b) and interleukin-6 (IL-6) could help predict the incidence of depression, as well as the presence of muscle aches and an increased appetite in smokers who had quit. Additional studies were to focus on whether certain types of anti-inflammatory medications could help alleviate these symptoms in order to provide support to smokers who quit.
In conclusion, it is important to know what to expect when you give up smoking even though nicotine withdrawal is a personal experience. As they say, "Knowledge is power". The more you know and understand the symptoms that you are likely to experience with regards to nicotine withdrawal, then the more prepared you will be to successfully handle the situation. Even if you experience a sudden surge in nicotine withdrawal symptoms well after you think that the worst of it is over, do not take it as a sign that you are "one of those people who just cannot quit" and use it as an excuse to begin smoking again. The symptoms may rise and recede in a cyclical fashion but if you remain resolute you will be able to see off such fluctuations. Remember that Nicotine Replacement Therapy (NRT) is very useful for reducing the symptoms of nicotine withdrawal, especially if you find any or all the symptoms mentioned above to be particularly severe. NRT slowly supplies your body with small, controlled amounts of nicotine that allows you to wean yourself off nicotine incrementally.
That is it for our three-part article on nicotine withdrawal. If you missed any of the other previous two instalments on this topic, remember that you can now view them online at Stopsmokingtoday.com by clicking here.
* Thomas M. Piaseckiki, Michael C. Fiore, and Timothy B. Baker, 'Profiles in discouragement: two studies of variability in the time course of smoking withdrawal symptoms', Journal of Abnormal Psychology, 1998, Vol.107, No.2 pp. 238-251.
* (2) Shiffman, S., Paty, J. A., Gnys, M., Kassel, J. D. & Elash, C. (1995). 'Nicotine withdrawal in chippers and regular smokers: Subjective and cognitive effects.' Health Psychology, Vol. 14, No. 4., pp. 301-309.