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Why is Nicotine So Hard to Quit?

Nicotine is addictive. Addiction is not a myth. Dependence is real.

Nicotine, a stimulant found in tobacco plants, is one of the most heavily used drugs in the world. 

Depending on the dose of nicotine and an individual's nervous system, it can also act as a sedative.

Nicotine acts on both the brain and the nervous system. From tobacco smoke, nicotine enters the bloodstream through the lungs, and from there, chemicals in the smoke are absorbed and carried rapidly to different parts of the body. It doesn’t help that cigarettes have additives which enhance the absorption or intake of nicotine. 

In order to keep getting the initial energy burst, repeat doses are “needed” because nicotine metabolises quickly and gets excreted.

Historically the FDA in the USA took until 1994 to officially recognise nicotine as a drug that produced dependency.

Smoking, in the beginning stages generally stems from curiosity rather than a want for nicotine, and it appears to provide an image, a shared social activity and something to do when bored. These factors motivate smoking until dependence takes over.

Nicotine addiction is what compels people to continue smoking long after they want to stop. That edgy feeling when nicotine in the blood “needs” replenishing stems from physical dependence which is characterised by withdrawal induced cravings that intrude upon thoughts, creating an urge to smoke, so intense and urgent it seems it can't be ignored. Sometimes it becomes so distracting that a person is unable to function normally.

Addiction affects the frontal cortex of the brain and hijacks impulse control and judgment. The brain's reward system gets altered in such a way that the memory of previous rewards triggers cravings for both the nicotine and the rewarding experiences, in spite of negative consequences. 

And therein lies the problem. Continued use, despite negative consequences is the main definition of any addiction. With smoking, people find themselves wanting, craving, then “needing” to do it even in the face of negative health consequences.

In a recent trip to hospital, I was alarmed at the number of patients I saw recovering post operatively in a surgical ward who “needed” to sneak out of the hospital grounds to the nearest bus stop to smoke, which is no easy feat in a wheelchair, in pain, with low energy and drips or drain bags attached to them. Nurses are super busy and it’s not their job to be security guards. 

One patient, despite having kidney disease and being on dialysis and knowing that quitting may be the one most important thing she could do to slow the progression of both kidney and heart failure, did not stop her from sneaking out to smoke, and sneaking in takeaways, potato chips and salty crackers to snack on, despite being on a low sodium hospital meal plan. Addiction is both brutal and sad. Those of us who work with smokers have to be understanding and empathic of peoples reasons and barriers and among other things, help them understand the nature of nicotine.

Since 2013 in NZ, doctors, anaesthetists and surgeons have been advising their patients to stop smoking as early as possible, ideally 6-8 weeks before surgery in order to reduce life threatening complications. They do a stellar job, and in every stage of medical intervention, patients get asked a lot whether they smoke. But as University senior research fellow Brent Caldwell says "Smoking is not a lifestyle choice. It's a compulsion that overwhelms free will, so it's important to make sure people are given support."

How soon one reaches for a cigarette in the morning is a good indication of how strong their addiction is. It’s why we ask certain questions in assessments, to evaluate nicotine dependence and to better understand client needs.

According to the Fagerström Test, if someone has their first cigarette of the day within 5 minutes of waking up, their addiction is pretty strong. If it’s within 30 minutes, it’s moderate, and if it’s within 60 minutes or later, it’s somewhat lower. 

Cigarette smoking is the primary source of nicotine. If a typical smoker takes 10 or more puffs on each cigarette, and they smoke about one pack (25 cigarettes) a day, they’re getting at least 250 "hits" every day. That’s a lot of “teaching” the brain to keep using nicotine. And repeated use increases the risk of addiction.  

Cigarettes deliver nicotine to the brain, really quickly, which in turn releases feel good chemicals and creates a strong association, so that a cigarette and what you do when you having one, equals pleasure. 

Because the body is able to build up a high tolerance to nicotine, people then need to smoke more cigarettes to get that same buzz. 

Nicotine basically hijacks the dopamine reward system and fires off happiness rockets which only last for about 2 hours. Then another hit is “needed.” So smoking is really just an illusionary, short term reward that doesn’t actually provide positive experiences or benefits. Instead, cigarettes cause a lot of harm because of all the combustible chemicals they provide. 

One of the biggest differences with smoking, and what makes it so problematic, is that there’s an opportunity really, to smoke all day long if someone wants to, because it’s not illegal and it doesn’t impair functioning like alcohol and drugs do. Cigarettes are also pretty easy to access and the social consequences are fairly small. And, because someone could possibly smoke all day, every day, the amount of times their habit is reinforced is completely tangled up with almost everything they do. Waking up. Drinking coffee. Eating. Socialising. Drinking alcohol. Driving. Watching television. Taking a break. Talking on the phone. Even preparing to go to bed. These become triggers.

There used to be even more public places that provided opportunities. Before 1990 people could sit at a desk in their place of work and smoke all day if they wanted! And, before 2004 smokers used to light up in bars, cafes, restaurants, casinos or clubs. NZ was one of the first countries in the world to go smokefree in hospitality venues to make them healthier places to work.

Even seeing another person smoke or smelling a cigarette can trigger the psychological desire to smoke. 

Not only that, the powerful nature of addiction is that a smoker can just think about smoking and their dopamine will light up at the thought of doing it in the future. And when they do smoke, because their behaviour and habits are so entangled with all those activities I mentioned before, when they do finally quit, they basically have to re-learn how to get through a new day doing most of what they did before, in a new way. That’s why getting behavioural support is so important. 

It’s important to remember that it isn’t the nicotine that’s killing people.

It’s been estimated that there are over 4000 chemical constituents in tobacco smoke. (British Columbia Ministry of Health,1998) And 95 of those chemicals include 45 known or suspected carcinogens, according to the International Agency for Research on Cancer. Cancer (carcinogens) and toxins come from burning the tobacco itself. Not the nicotine. The tar in a cigarette is what leads to a high risk of emphysema, lung cancer and bronchial disorders. The carbon monoxide in the smoke is what increases the chance of cardiovascular disease.
 
The tangle that smokers have to unravel when they quit smoking has to deal with 4 layers. 

  • The addictive need.
  • The social need.
  • The emotional need.
  • And, the simple hand to mouth habit.

Mentally, when we are faced with giving up a habit, it calls for a major change in behaviour. While withdrawal itself is related to the pharmacological effects of nicotine, the severity of withdrawal symptoms can also be affected by the social and emotional experiences. For some people, the feel, smell and sight of a cigarette and the ritual of getting it, unwrapping it, handling it, lighting it and smoking it are all associated with pleasure.

So if you’re wanting to quit, along with behavioural help, nicotine use is seen as a harm reduction approach. The idea is to allow yourself the nicotine while you gradually taper off it and work on changing the social and psychological reasons that caused you to smoke. 

Physically, to relieve any withdrawal symptoms, it helps to gradually lessen the amount of nicotine one absorbs during the quitting process.

It’s also important to remember that in fact, smokers are already addicted to nicotine; therefore the use of a ‘cleaner’ form of nicotine delivery doesn’t represent any additional risk of addiction. Any delivery system which provides nicotine intake should only be for smokers wishing to quit, and never be recommended or used by nonsmokers. 

I’m hopeful that having information about nicotine will give you some understanding of what’s ahead and why quitting isn’t just a matter of willpower. I’m hoping that you’ll reach out and register for support to get through it.

QuitNow.NZ provides online telehealth counselling, an encouraging and resourceful website, and access to an expert moderated online community. 

For more information on getting free professional help to quit smoking visit here www.quitnow.nz/register/



 

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