6.9 Nicotine withdrawal syndrome
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As with other addictive drugs, a withdrawal syndrome including a spectrum of effects is associated with abrupt cessation of tobacco use. These symptoms decrease over time, as the body adapts and returns to its normal, drug-free state.
The unpleasant abstinence syndrome experienced by many smokers when they first quit is mediated by neuroadaptive changes in the activity of dopaminergic neurones innervating the nucleus accumbens, a part of the brain which plays an important role in addiction (described in Section 6.3.1). Behavioural changes are similar to those experienced by many patients with depression, including a diminished ability to respond to pleasurable stimuli. They are thought to arise from reduced dopamine overflow in the outer parts of the nucleus accumbens.2
The major symptoms that have been identified in nicotine withdrawal syndrome are mood changes, including irritability, aggression, anxiety and depression, restlessness, poor concentration, increased appetite, urges to smoke, disturbed sleep, decreased heart rate, and decreased levels of adrenaline and cortisol. Except for slowing of the heart rate and increased appetite, these symptoms are common to withdrawal from other stimulant drugs.61 It is unclear whether increased anxiety occurs as a physical response to nicotine withdrawal, or as a psychological response to the quit attempt, especially if the individual concerned is finding quitting difficult.2 Most symptoms abate by four weeks' abstinence from smoking, with the exception of increased appetite and decreased heart rate, which may persist for longer than 10 weeks.62 However the urge to smoke, especially when under stress, may remain for much longer.1 Most symptoms are known to be reduced by use of nicotine replacement therapy, the exceptions being night-time awakening and decreased adrenaline and cortisol levels, about which more research is needed.2
There is evidence that newborn infants of mothers who smoke heavily during pregnancy experience withdrawal symptoms following birth, measured by neurological assessment after birth, and markers of nicotine exposure.63
Ways of ameliorating tobacco withdrawal are discussed in the Chapter 7.
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