Introduction

Nicotine is a highly addictive substance found in tobacco products, such as cigarettes. Its dependence affects the body both physically and mentally, leading to a state of reliance that makes it difficult to quit.¹ 

Nicotine has an effect on the brain, triggering the release of a chemical called dopamine otherwise known as the “happy hormone”. Within seconds of inhalation, nicotine reaches the brain and makes the individual feel good for a short period of time. Its speed of action is a contributing factor as to why people like it.¹

When you quit smoking and are no longer inhaling tobacco, the amount of nicotine in your brain decreases and, by association, the level of dopamine drops. This change in brain chemistry triggers events in the body that result in nicotine cravings, which fuels the addiction further. The longer you have been smoking, the harder it is for you to stop, as the brain has become used to, i.e., dependent on, nicotine. You may not feel pleasure in smoking anymore, but continue to smoke to appease the cravings, and attempts to stop smoking are difficult as you experience withdrawal symptoms that can only be relieved by smoking more nicotine.¹ 

However, as difficult as it is, giving up smoking can improve health outcomes, and even reverse some of the damage that inhaling cigarette fumes can do. It can take many attempts and a long time before the urge to smoke no longer occurs – it isn’t a sprint but rather a journey you’re taking day by day.¹

If you’ve decided to quit smoking, you’ve already taken the first step by recognising that you have a habit that you want to kick. The next step is to research what can help you get there. If you’re reading this article, you’re meeting the 2nd step too. Let’s have a look into a few medical interventions and behavioural techniques that can help fight nicotine withdrawal, and some strategies to prevent relapse.

Understanding nicotine withdrawal

Nicotine withdrawal can present itself as an array of symptoms, affecting not only the body but also the mind. It happens when you have nicotine dependence and suddenly reduce or stop your intake of nicotine.²

Common symptoms include:²

• Nicotine cravings
• Irritability
• Restlessness
• Anxiety
• Depression
• Fatigue
• Difficulty focusing
• Difficulty sleeping

Symptoms vary from person to person, and you may experience some or all of them. They can be affected by:²

• How much you smoke
• How often you smoke
• How long you have been smoking
• Your family history and overall health
  

Withdrawal symptoms are initially more intense and reduce over time as your body becomes used to not having nicotine. It can take several months before your body has adjusted to its new-normal but the average timeframe is:²

Withdrawal symptoms can be difficult to deal with. They can affect your mood, relationships and work. The struggle to deal with symptoms, coupled with the temptation to smoke can lead to increased chances of relapse, especially without the correct support, motivation or techniques.²

Risk factors for relapse

Risk factors that make it difficult to stop smoking can be grouped under 3 umbrellas:

1. Psychological triggers: those that affect your mood and mental health
   The release of dopamine caused by smoking leaves you feeling happier and more relaxed, which is why people often smoke when they are stressed. Facing stressors may trigger you to remember your coping mechanism of smoking. Moreover, taking away the nicotine can cause negative feelings such as depression or anxiety which may make you question whether you should start smoking again to counteract these horrible feelings. Similarly, if you’re bored, it may seem tempting to reach for a cigarette to pass time. As these triggers can’t always be controlled or avoided, it would be important to find other coping mechanisms and ways to feel better when dealing with these triggers.
   
2. Environmental and social triggers: the people and place around you
   The people around you make a big impact on whether or not you succeed in quitting. Being in social settings such as bars, pubs, clubs or parties can make it much harder as you are more likely to be surrounded by people who are smoking. Moreover, if you are a social smoker, drinking alcohol may trigger you to reach for a cigarette. Environmental triggers can be addressed by avoiding the locations and people who encourage smoking.
   
3. Habitual and behavioural cues: association with your routine
   Those that smoke regularly often do so as part of their routine. Smoking is tied to behaviours, certain times of day and activities. Whilst everyone's routines would be different, examples of triggers would be going for a cigarette after eating, or during a coffee break. A way to address this trigger could be to find another activity to pass that time. For example, find a short activity to do instead, such as going for a walk or doing a crossword puzzle.

Evidence-based relapse prevention strategies

Cognitive-behavioural approaches (CBT)

This is a type of therapy that focuses on identifying and changing thought processes and behaviours. It has been proven to work in specific populations such as pregnant women or those with HIV, alongside being trialled in other groups too, showing positive results. An additional benefit of CBT is that it has also helped to motivate people to quit smoking.³

CBT can help you develop coping skills to manage difficult situations, such as being surrounded by other smokers, or what to do when the urge to smoke occurs.³

Mindfulness and stress management

Breathing techniques, meditation, yoga and mindfulness are all ways to help manage the stress felt while quitting smoking. Mindfulness works by teaching you to become aware of your environment, thoughts, emotions and physical sensations. Training in these techniques can teach you how to deal with the discomfort that occurs when you get a craving for a cigarette. Research has indicated that these techniques are effective when trying to quit smoking.³

Nicotine replacement therapy (NRT) and medications

NRT works to provide your body with nicotine, the addictive substance, without the other harmful toxins found in cigarettes. It also provides lower levels of nicotine and is delivered to the body in a less addictive form. This way, you’re able to tackle the withdrawal symptoms by coming off slowly, and controlling the purity of what you are taking. There are different forms of NRT, long acting and short acting, which can be used in combination to increase the chances of preventing withdrawal symptoms. Patches stay on the skin for 16 - 24 hours and release a little bit of nicotine over time. Other options such as lozenges, sprays and gums work faster and are better options for satisfying those cravings immediately.²

Prescription medications such as varenicline or bupropion are effective options and should be offered alongside behavioural recommendations. Varenicline is the preferred option as it is more effective. The medication prescribed will be discussed with you but will depend on factors such as previous treatment, side-effects and your preference.²

Healthy habit formation

Your habit to smoke can be replaced with a healthier lifestyle. Physical activity would be good for the body as well as being a distraction to smoking. Moreover, a well-nourished, hydrated, and well-rested body is better equipped to cope with withdrawal symptoms.

Support systems and resources

The right support can help motivate you to quit smoking, and keep you on the correct track.

Social support

This is provided by family and friends, who can remind you why you started this journey and give you encouragement. Support groups, either online or face to face, are critical as they surround you with other people who can relate to what you’re going through.

Professional support

Counselling or therapy gives you the opportunity to talk to a professional who can help you with techniques such as CBT. Furthermore, calling the smokefree hotline (0300 123 1044) can provide you with advice and encouragement or help you to book meetings. Finally, the smokefree app (for London users) can be used for on-the-go support.

Accountability tools

Aids such as quit smoking tracker apps and progress logs can show you how far you have come. It can put your journey into perspective to motivate you to keep going. Furthermore, rewarding yourself for meeting milestones can also positively reinforce your behaviour and decisions. For example, when you cut down from 20 cigarettes a day to 10, then 5, treat yourself to a day out, or something you enjoy.

Coping with setbacks

Despite the treatment being successful, it is important to understand that cravings can occur and sometimes it may be hard to avoid them. Distinguish between a slip (which can happen on occasion, and doesn’t affect your motivation, treatment plan or results) and a full relapse (when you start smoking more and more, similar to old patterns, that you often need to start your journey again and re-motivate yourself). 

Long-term maintenance

Staying motivated is crucial as time goes on, even as your body gets over the worst of the withdrawal symptoms. Celebrate every time you reach milestones to reward yourself for what you have overcome. You should also regularly remind yourself of why you decided to quit smoking, to be your constant motivation.

As your withdrawal symptoms stop, don’t lose your guard. Remain vigilant and away from tempting situations. 

Summary

Quitting isn’t always a smooth process. It can involve slips and relapses, and is a continuous process. There might always be temptation, and sometimes you might not be able to say no – we’re all human at the end of the day. Be understanding of your circumstances, and start your chapter again. 

A dual approach of medication as well as behavioural measures is the most effective way to reduce smoking. 

Another recommended method is the “stop in one go” approach, which involves you stopping on a date of your choosing. This has a higher success rate than gradually reducing your smoking.⁴ But of course, everyone is different, and you have to find the technique that works the best for you.

Tips to help you quit smoking:²

• Keep your hands busy like finding something to fidget with
• Throw away any cigarette packets, ashtrays, lighters or reminders of smoking
• Spend time away from those who smoke
• Choose a date you will stop on, and stick to it
• Try relaxation techniques
• Stay active
• Small slips can happen, but don’t let them affect your motivation
• Reward yourself for your achievements 

You can do it!