You’re Not Addicted to Smoking. You’re Addicted to Nicotine.

You’re Not Addicted to Smoking

You’re Not Addicted to Smoking. You’re Addicted to Nicotine.

May 31 is World No Tobacco Day. Back in March, Time reported that the best way to quit smoking, according to science, is to quit cold turkey, rather than gradually tapering down.  This makes a lot of sense if you think of smoking as what it is:  an addiction to nicotine.

It is worth noting that nicotine does not cause cancer.  Nicotine is what keeps you smoking. It is the tar and chemicals in the smoke vapor that cause cancer.

There are over 7,000 chemicals in tobacco smoke including ammonia, cyanide, arsenic, and formaldehyde.  About 70 are known or suspected carcinogens. A person who smokes a pack a day of cigarettes will take in about 75,000 doses of these chemicals per year. There is no safe level of exposure to these chemicals.

People who smoke know it is harmful. Moreover, most smokers want to quit. A 2013 Gallup Poll reported that 74% of Americans who smoke want to quit.  In other words, most smokers do not choose to smoke.  They do so because they are addicted.  Not only that, 72% know that they are addicted.

Nicotine Addiction

According to the National Institute on Drug Abuse, drug addiction is “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”

The American Psychiatric Association updated the DSM-5 in 2013 to create a new category:  substance use disorder. Substance use disorder is characterized by, among other things, cravings, persistence in using the substance despite its harmful effects, and withdrawal symptoms.

In the case of nicotine addiction, the withdrawal symptoms include depression, sleeplessness, anxiety, concentration problems, irritability, and anger.

nicotine addiction

How Addictive is Nicotine

The addictive qualities of a drug include dependence, withdrawal, tolerance, reinforcement, and intoxication. The most dangerous of these are dependence and withdrawal.

Five of the most popular addictive drugs in the US are heroin, alcohol, cocaine, caffeine and nicotine. A comparison of the addictive qualities of these drugs shows that nicotine is ranked first for dependence and third for withdrawal, after alcohol and heroin. By these measures, nicotine is more addictive than cocaine.

Why nicotine is so addictive

Nicotine, like all other abused drugs, produces chemical changes that target the brain’s reward pathway.

The nicotine molecules bind to the brain’s acetylcholine receptor sites. Acetylcholine is a neurotransmitter involved in heart rate and arousal.  It also sends messages from the brain to the muscles.  This triggers a rapid release of dopamine, endorphins, and steroid levels.  With nicotine, this release of “feel good” chemicals occurs instantaneously. It is the reason behind what smokers have described as the “nicotine rush” they get from that first cigarette of the day.

According to Dr. Neal Benowitz, a nicotine researcher at San Francisco General Hospital Medical Center, “nicotine in the brain is doing the same thing cocaine or amphetamine is doing.”

Nicotine-based replacement therapies

The whole idea behind nicotine replacement therapies is to make it easier to quit smoking by removing, or lessening, the withdrawal symptoms associated with nicotine addiction.  They are basically nicotine without the cancer-causing effects of the tar and chemicals in cigarettes.

Nicotine-based replacement therapies

Again, nicotine does not cause cancer.  Nicotine is what keeps you smoking.

Nicotine replacement therapies come in numerous different forms, none of which are considered to be superior to the others. These include skin patches, gum, lozenges, inhalers and nasal sprays.

Do they work?

All appear to have roughly the same effectiveness. The use of nicotine replacement therapies in conjunction with an intensive behavioral program can double your chances of quitting. They are also shown to be more effective when used in combination, rather than alone.

Are they safe?

Yes.  All of the afore-mentioned nicotine replacement therapies have been studied and have been shown to have minimal harmful side effects, even in people with some form of heart disease.

What about e-cigarettes?

E-cigarettes, or electronic cigarettes, are devices that put nicotine into a vapor that you can breathe in. This vapor has fewer harmful chemicals than the smoke you would get from a cigarette, but they are not harm free.  There is also no evidence—at least not at this time—that e-cigarettes are a safe or effective aid to quitting smoking.  Plus they are not well-regulated, meaning the various products can differ significantly.

Non-Nicotine Therapies

Non-nicotine therapies work by altering chemicals and receptors in the brain. Right now there are two that have been approved by the FDA.  These are bupropion (brand names: Zyban™ and Wellbutrin™) and varenicline (known under the brand name Chantix™ in the US and Champix™ in the UK). Both require a doctor’ prescription. Neither includes nicotine.


Varenicline, the newer of the two drugs, works in two ways.

First, it interferes with the receptors that respond to nicotine.  This reduces the desire to smoke and lessens the severity of nicotine withdrawal systems.  Second, it releases dopamine in the brain—the same “feel good” chemical released by nicotine.

Does it work?

It appears to be an effective smoking-cessation tool. In several studies, varenicline was shown to more than double a person’s chances of successfully quitting smoking. It has also been proven to be the best smoking cessation aid in preventing relapse and withdrawal symptoms. Moreover, it is easy to use.

Is it safe?

The jury is still out.

The FDA approved varenicline for use in 2006. In 2007, the FDA advised health care providers that studies showed an increased risk of acute heart problems in a small number of people with heart or blood vessel disease. It also reported a small number of individuals who had developed suicidal thoughts, agitation, and unusual behavior changes on varenicline.

Both risks were thought to be small and to outweigh the benefits of quitting smoking.

Recently, however, there has been evidence to suggest that the risk of mood changes and suicidal thoughts may be greater than had been previously thought. FDA recently required the makers of Chantix™ to add a “black-box warning” on the label to alert people to its harshest side effects. A black box warning is the most serious step the FDA takes before deciding to ban a drug entirely.


Bupropion is an extended-release antidepressant. It works by acting on the chemicals in the brain that cause nicotine cravings. It was approved by the FDA in 1997.

Does it work?

Bupropion can be an effective smoking-cessation tool.  Studies suggest, however, that it may not be as effective as Varenicline. It appears to be most effective when used in combination with nicotine replacement therapies.

Is it safe?

Bupropion has been around longer than varenicline, so its effects are more well known. Like varenicline, there is evidence suggesting it can cause mood changes and suicidal thoughts. Also like varenicline, the FDA requires a “black-box warning” on the drug label.

If you are ready to quit smoking, as most smokers are, there are many options to help you do that. All come with benefits as well as risks.  The common denominator of all successful attempts is breaking your addiction to nicotine.


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