Nicotine Use Disorder

What is nicotine use disorder?

Nicotine use disorder or nicotine addiction generally occurs through the repeated use of smoked tobacco products, thus taking in nicotine and several other ingredients through the lungs. Nicotine addiction can occur with any amount of nicotine.

Nicotine is the feel-good chemical in tobacco products that reaches the brain within seconds to boost dopamine levels. This rush is a reward that occurs quickly but subsides fast, so the user will reach out for the product to experience the sensation again and again. Over time, the brain is rewired to require the chemical and stress occurs when this is not present. Nervousness, feelings of depression, and agitation occur when the product cannot be obtained.

Nicotine use disorder, sometimes called NUD, is a psychiatric diagnosis that refers to a compulsive pattern of nicotine use despite harmful consequences. Nicotine is most commonly consumed through cigarettes, but it can also be consumed in other ways, such as chewing tobacco, snuff, or electronic cigarettes.

Among those who smoke daily, around 50% have tobacco or nicotine use disorder. However, it is uncommon in those who do not smoke every day.^[1]

People with NUD often feel unable to quit nicotine and may continue using it despite negative consequences, such as financial problems or social and relationship difficulties. NUD is a severe problem that can lead to many health complications, including cancer, heart disease, and stroke.

People with NUD need help from a healthcare provider to quit nicotine and reduce their risk of developing these serious health problems.^[2]

Complications of nicotine use disorder

While many people are aware of the dangers of smoking, they may not be aware of the potential side effects of nicotine use disorder. For these reasons, it is crucial for people who smoke to be aware of the possible side effects of nicotine use disorder and seek help if they feel they are struggling with an addiction.

Additionally, nicotine use disorder can increase the risk of developing cancer and other serious health conditions due to the numerous cancer-causing and harmful chemicals in tobacco products, whether these are smoked or not.

Side effects and long-term complications can include:

• Cancer, especially in the respiratory system, such as lung cancer
• Chronic bronchitis
• Emphysema (a lung disease that causes shortness of breath and, over time, destroys the air sacs)
• Heart disease
• Eye disease, e.g., macular degeneration or cataracts
• Kidney disease
• Infertility
• Impotence (the inability to get or maintain an erection)
• Decreased immune response
• Respiratory infections
• Peptic ulcer disease (perforations along the digestive tract, such as in the lining of the stomach or the small intestine) ^[3]

One must also remember the side effects or complications of those inhaling smoke without smoking. This is known as second-hand smoking.

• Asthma, wheezing, coughing
• Respiratory infections
• Ear infections
• Sudden infant death syndrome (SIDS) can occur when women smoke during pregnancy or through second-hand smoke after birth. It is the leading cause of death in otherwise healthy infants.
• Low birth weight in infants whose mothers smoked during pregnancy
• Other illnesses, such as heart disease and lung cancer, are also possible through second-hand inhalation of nicotine products^[4]

Symptoms of nicotine use disorder

The signs of nicotine use disorder are:

• Being unable to stop smoking or using tobacco products
• Getting withdrawal symptoms when use stops
• Craving cigarettes even though they cause health complications
• Continuing to use the product despite negative consequences in your life, e.g., arguments with a spouse, difficulties at work, having to stop socializing with some friends, being unable to take long flights

Causes of nicotine use disorder

Even infrequent and little use of nicotine or tobacco products can lead to dependence because it is a highly addictive drug. It is also possible for smoking cessation aids, such as nicotine gum or nicotine patches, to lead to dependence. To make matters worse, the body quickly becomes accustomed to nicotine, and the more you use, the more you will need to feel good.

Nicotine becomes intertwined with daily routines, and the ritual of smoking becomes a habit as well as an addiction. Certain situations will trigger a craving to smoke. For example, some people will smoke first thing in the morning as soon as they wake up. Others will smoke whenever they take a break at work. Socialising often plays a role in smoking as people will go outside together at the office or the bar to smoke.

The risk factors of nicotine use disorder include:

• Starting smoking at an early age
• A family history of nicotine addiction
• Co-occurring personality or depressive disorders
• Living in low socioeconomic areas
• Having a low educational background
• Growing up in homes with tobacco users
• Children with friends who smoke are more likely to do it
• Those with other addictions or a history of substance use disorders, including alcohol use disorder^[5][6]

Prevention of nicotine use disorder

The most effective way to prevent nicotine use disorder is not to smoke at all. Unfortunately, even the smallest amount of nicotine in your system can lead to cravings and addiction. Another crucial thing to do is to avoid environments where people are smoking. Children who grow up in households with smokers are more likely to take up the habit themselves.

If you are an ex-smoker and want to avoid developing nicotine use disorder, then you must avoid your triggers. For example, some people are more likely to smoke when drinking alcohol or when they are in the company of smokers.

If you are a new smoker, it is best to nip the habit in the bud, as the body develops a dependence to nicotine and tobacco products very quickly, especially (but not only) if you are prone to substance abuse.

Diagnosing nicotine use disorder

According to the DSM-5, a pattern of nicotine/tobacco use is problematic when it leads to significant impairment or distress, as shown by at least two of the following patterns over twelve months:

• The product is taken in larger amounts than intended or for a longer time
• Cravings for nicotine are persistent and attempts to cut down unsuccessful
• A significant amount of time is spent procuring or using the product
• Desire to use the product is strong
• Use of product interferes with responsibilities
• Continued use despite social or interpersonal problems
• Missing or reducing important activities due to use
• Recurrent use in which the user is in dangerous situations, e.g. smoking in bed, or near flammable materials
• Use of the product despite knowledge of having a physical or psychological problem that is caused or made worse by nicotine/tobacco
• Tolerance of the product as seen by increasing amounts needed to achieve the desired effect or by a diminished effect with continued use of the same amount
• Symptoms of nicotine withdrawal are seen on cessation of the product, where the substance relieves the symptoms

A healthcare professional will assess by asking the patient questions about the above points.

Treatment for nicotine use disorder

Quitting smoking is the best way to reduce the risks associated with nicotine use disorder, but it can be challenging to do so without support. Most smokers have tried to quit at least once, and although some manage on the first try, it is rare to stop on the first attempt without getting help.

It's vital to remember that addictions are very powerful. This means that if you don't succeed at first, you should not feel ashamed or too defeated to try again.

There are many resources available to help people quit smoking:

Medications

• Nicotine replacement therapies include gum, patches, lozenges, inhalers, or nasal sprays that help decrease nicotine cravings and withdrawal symptoms. These are available as prescription items, and you should talk to your doctor or pharmacist about the best dose to start with and the schedule to follow. This will depend on the number of cigarettes you smoke and your daily habits.
• Tablets such as Zyban (bupropion) or Chantix (varenicline tartrate) are non-nicotine prescription medicines taken as a course under the supervision of a healthcare professional. Before starting the therapy, you will be assessed for health risks and contraindications.^[7]

Counseling

• Counselling, including cognitive behavioral therapy (CBT) helps you recognize thought patterns, situations, and people that trigger your substance misuse. The therapist helps you build strategies to tackle these and improve your chances of stopping.
• In motivational interviewing, a counsellor helps to motivate you to improve your health through lifestyle changes.
• Mindfulness will help you manage stress and negative thoughts and will lead you to detach from craving nicotine/tobacco.
• Support groups introduce you to peers experiencing the same dependence so that together you can navigate the stress related to quitting smoking.
• App-based, web-based, or social-media-based motivation harnesses the use of the internet or your phone to motivate you to kick the habit. ^[8]

These counselling tools are successful when combined with other smoking cessation methods.

Methods to avoid

• Even though some people quit 'cold turkey' (all at once, with no medical help or counselling), this method is often unsuccessful and may not be right for you, even if you have the required motivation. It can also discourage some people trying to quit for the first time.
• Electronic cigarettes have not proved safe or effective, nor has the use of other forms of tobacco, such as chewing tobacco, lollipops, cigars, or hookahs.^[9]

Nicotine withdrawal symptoms

Nicotine withdrawal is a set of symptoms that can occur when someone who uses tobacco products regularly suddenly stops using them. These symptoms can range from mild to severe and typically peak within the first week of quitting. Common symptoms include cravings, irritability, anxiety, difficulty concentrating, and increased appetite.

While nicotine withdrawal is not life-threatening, it can be challenging to manage and may negatively impact the quality of life. However, some treatments can help ease the process of quitting and make withdrawal symptoms more manageable. For example, medications can help to reduce cravings and other withdrawal symptoms while the individual adjusts to life without tobacco products.

Self-care for nicotine use disorder

One important self-care strategy is to avoid triggers that may cause cravings, e.g., the smoking areas in your place of work. Common triggers include stress, boredom, and social situations. For example, it may help you to take up a healthy habit away from triggers, such as exercising or cooking healthy meals.

It's also essential to have a support system in place, such as friends or family members who can provide encouragement and understanding. Additionally, many helpful resources are available, such as quit-smoking programs and support groups.

Helping someone with nicotine use disorder

If you're trying to help someone quit nicotine, it's crucial to understand the disorder. Quitting smoking is a highly challenging activity, even if the person is determined and motivated to do so.

• Try to stay positive and motivate them, even if they fail a few times or have failed in the past
• Offer to be there and do things together, activities that will keep them away from triggers
• Set goals and celebrate success
• Encourage them to get rid of any cigarettes or smoking accessories
• If your loved one is using a medication, check in on them to make sure they have taken it

FAQs about nicotine use disorder

How common is nicotine use disorder?

The prevalence of nicotine/tobacco use disorder is estimated to be 13% in the United States.^[10]

What is the outlook for people with nicotine use disorder?

Like with other addictive substances, unfortunately, nicotine use disorder is never really cured. Those with nicotine use disorder are prone to relapse on quitting cigarettes, and this relapse rate tends to be high. This is especially true in the first six months and in those who opt for a shorter withdrawal treatment. Smoking relapse should not be seen as a complete failure to quit, but a temporary setback can also be overcome; research has shown that the more someone tries to quit, the more they are likely to suceed in kicking the habit.^[11]