Overview

According to Merriam-Webster dictionary, the meaning of craving is an intense, urgent, abnormal desire or longing.

Nicotine addiction has been a health concern, wherein the withdrawal symptoms are challenging for individuals wanting to quit the habit. The cravings are sometimes so severe that the individual goes into relapse.  According to the World Health Organisation (2021), tobacco kills more than 8 million people each year.¹⁶

People exposed to secondhand smoke are also at risk of death due to tobacco. The reported cases are around 880000 worldwide.¹ Throughout this article, we attempted to explore mechanisms and the strategies to overcome them.

Nicotine addiction involves not only smoking, but also tobacco use in other forms, such as chewable, vaping, etc. Tobacco usage and nicotine dependence cause cancer in almost every organ system of the body. 

Apart from cancer, chronic obstructive pulmonary disease and asthma are also by-products of nicotine addiction.^1,3 It is also associated with cardiovascular disease and atherosclerosis.²

Nicotine cravings

Nicotine cravings work on the physical as well as the psychological levels. They start within a few hours of cessation of smoking and peak in the first few days. These can occur intermittently for weeks or even months, depending upon the intensity and duration of the habit.

The most common symptoms associated with nicotine cravings are:

• Irritation
• Anxiety
• Loss of concentration
• Restlessness
• Depression
• Mood swings

The neuroscience of nicotine cravings

Nicotine’s impact on the brain

Nicotine causes addiction through its interaction with nicotinic acetylcholine receptors (nAChRs) in the brain. On activation by nicotine, these receptors stimulate the release of neurotransmitters, such as dopamine, which is associated with pleasure and reward. 

Development of dependence

Neuroadaptations are caused by repeated exposure to nicotine, which includes an increase in the receptor density. It also alters neurotransmitter release. This indicates that repeated exposure to nicotine only strengthens the dependence to nicotine, whereas during withdrawal, due to the altered brain chemistry, there are intense cravings, making it difficult to quit.

Cravings

Cravings develop specifically in response to environmental cues. There is usually a set time or a daily routine, e.g., coffee break or lunchtime, which is associated with the habit of nicotine use. The same timings and environmental settings can trigger cravings. These are mediated by the amygdala and the hippocampus, which are regions in the brain associated with memory and emotion.

How to overcome nicotine addiction

Nicotine replacement therapy

Nicotine patches, gums, lozenges, nasal sprays, and inhalers are a few of the methods to provide controlled doses of nicotine at specific times to reduce withdrawal symptoms and cravings. 

It has been shown that the chances of quitting can range between 50-70% due to their usage. These can also be provided by quitlines free of cost or for a nominal fee, making it more accessible and acceptable.

Pharmacological interventions

Includes medication such as: ⁵

• Bupropion
• Varenicline

Bupropion

It reduces the cravings and withdrawal symptoms by modulating neurotransmitter levels.

Varenicline

In addition to reducing the cravings and withdrawal symptoms, it also reduces the rewarding effects of nicotine.

Behavioural therapies

Cognitive behavioural therapy (CBT)  

Focuses on identifying and modifying the thought patterns associated with smoking. It is very effective in smoking cessation.⁵

The various techniques include:

• Coping strategies
• Stress management
• Relapse prevention.

Behavioural therapies in conjunction with pharmacological intervention increase the likelihood of quitting smoking. ⁵

Motivational interviewing

It implies a type of counselling that is patient-centred, there is no judgment involved, and it is highly collaborative. It is useful for people who aren’t ready to quit smoking.⁵

Acceptance and commitment therapy

It involves the person attempting to quit accepting the physical and emotional changes that are affecting them during the course of quitting.⁵ 

The person is asked to note what is most important to them and to leverage that into committing to quitting smoking. Acceptance and commitment therapy has been tested as a smartphone application to help reduce smoking.⁵

Contingency management and monetary initiatives

A reward system that includes monetary benefits if a person registers and uses a program to quit smoking shows definite results in reducing the habit. It increases compliance.⁵

Quitline counseling

This initiative is free, confidential, and convenient for those who do not have access to in-person or group counselling sessions. It can have a broader reach with higher compliance rates. Nicotine replacement therapy can be supplied through quitlines and can be more cost-effective.⁵

Mobile health intervention strategies

Since more than 95% of the population anywhere in the world has access to a cell phone, mobile health (mHealth) can reach the remotest areas. mHealth is a technology used to monitor, track, intervene, or deliver health-related events. It can be very cost-effective as compared to other behavioural interventions.⁵

Counselling 

In the form of individual, group or telecounselling.⁵ 

In individual counselling sessions to counter the physical, physiological, and behavioural aspects of the nicotine addiction, take about 30-45 minutes per session over 6-12 weeks.

Group therapies may take around 60 minutes per session. Here, the person is surrounded by fellow people who are struggling to end the addiction, providing a strong support system.

Telecounseling can be used for those emergency times when the counsellor may not be available in person, or an emergency intervention is required during the quitting phase.

Mindfulness and meditation in stress management

Yoga nidra, Vipassana, and other meditation techniques have been found useful in handling stress. Yoga nidra, in particular, can help make a mental shift in the personality and determination to quit the habit. 

It can be used in conjunction with counselling and pharmacotherapy in the management of nicotine addiction ¹⁵

Lifestyle modifications

Regular physical activity

In the form of yoga, zumba, aerobics, or pilates.  A person who wants to quit smoking needs to adopt some sort of daily exercise through individual or team sport to get the mind off the habit as well as raise the levels of oxytocin and serotonin, the happiness hormones, which will help them come out of depression.

Healthy diet

A well-balanced diet including carbohydrates and good amounts of protein is essential for the feeling of fullness and satiety. Healthy foods, according to one’s taste, should be consumed at regular intervals. An effort should be made to have a consistent schedule of food and exercise, wake and sleep times, so as to have a certain sense of control during the day.

Support systems

Involve close friends and family for help during the most trying times of quitting. The person wanting to quit should ask their family not to buy tobacco in any form for them, even when specifically asked. Also, the withdrawal symptoms and irritability during the quitting phase can cause a strain in relationships.

Role of the physician

The general physician should be able to identify potential chain smokers or nicotine addicts through a thorough medical and family history, present challenges, and any detectable symptoms. 

The concerned patient should be referred for counselling, either face-to-face counselling or group counselling. Early intervention is absolutely crucial to avoid the long-term ill effects of nicotine addiction. 

Summary

The best way to avoid smoking-related health issues is to refrain from the habit entirely or, if initiated, to quit it as soon as possible. It is indeed a difficult path to follow, but the promise of improved health and enhanced quality of life makes it worthwhile. 

Smoking is not merely a habit, and willpower is not the only thing required to overcome it. It is an addiction and requires to be treated as such.