Quitting #3: The Existence and Relevance of Nicotine Withdrawal

This week I get back to describing how approaching nicotine use disorders as a disease improves the likelihood that a quit attempt will be successful. Let’s start with the biological “track” of the disease – specifically, when a person develops physical dependence on nicotine. This means that withdrawal symptoms will be experienced when the daily, high-dose use of a nicotine-containing product is abruptly stopped. Because nicotine is the most addictive of all drugs – even more so than heroin – withdrawal occurs very frequently among cigarette smokers and vapers.

Our knowledge of the physiology that underlies withdrawal has been growing. Previous research using neuroimaging had revealed that when the body is flooded with substances such as alcohol or opioids, it adapts by increasing the number of neuroreceptors – a process known as “upregulation”. We now know that heavy nicotine use also sets off this same upregulation of (nicotinic acetylcholine) receptors. In other words, the heavy exposure to nicotine actually changes the brain in ways that can be seen by neuroimaging. These receptors become very “hungry” when deprived of nicotine. Because nicotine has a half-life of only 2 hours, nicotine withdrawal can occur after brief event, such as a night of sleep. For many years, the reasons for the familiar discomforts of cravings for nicotine, irritability, and anxiety were poorly understood. Although physical dependence was postulated, not until 1984 was the existence of a classic physical nicotine withdrawal syndrome actually documented.

So, here is the relevance to successful quit attempts: The nicotine withdrawal syndrome, although lacking the drama and danger of alcohol and opioid withdrawal, is sufficiently uncomfortable and persistent that it usually erodes a person’s resolve and determination. Because of this, most unassisted quit attempts last less than one week. This is particularly true when the attempt is made “cold turkey.” Without the use of medication, the success rate of quitting is only 8%. 

The good news is that safe and effective medications are available. First came “nicotine replacement therapy” – medicinal, pharmaceutical quality nicotine in the form of gum (1984), patches (1991), and lozenges – now categorized as “essential medications” by the World Health Organization. In 1997, the antidepressant bupropion (“Wellbutrin”) was found to be effective for smoking cessation and was rebranded for this purpose as “Zyban”. In 2006, varenicline (“Chantix”) – the most effective of all the medications – became available. All FDA approved medications for smoking cessation have been endorsed as safe and effective by the U.S. Preventive Services Task Force.

Even when medication is used, however, overconcern about avoiding nicotine toxicity results in underdosing, unnecessary discomfort, and ultimately poor cessation rates. By contrast, in our Triple Track program, we are finding that by using the proper dose and combination of medications, our patients are succeeding in quitting 90% of the time.

If you are interested in getting help to take the misery out of nicotine withdrawal, please contact us at Triple Track by clicking this link.