Nicotine Addiction

Quick Overview

• Description: physical and psychological dependence on nicotine
• Symptoms: intense craving for nicotine, loss of control, continued use despite harmful consequences, withdrawal symptoms (e.g., restlessness and irritability)
• Causes: conditioning of the reward centre in the brain, stress, and possibly genetically influenced responses to nicotine
• Diagnosis: criteria include strong desire, high consumption, difficulty abstaining from nicotine, and quick reversion to smoking after waking
• Treatment: motivational interviewing, behavioural therapy support, nicotine substitution therapy
• Prognosis: high relapse risk without professional support; high motivation is crucial for success

Nicotine Addiction: Description

For decades, advertising has presented smokers as attractive, free, and cosmopolitan. Despite extensive efforts at education, this image still persists in many minds today. In reality, most tobacco users are simply addicted to nicotine.

The chemical in the tobacco plant affects both the body and the mind of smokers. Cigarettes can have a calming effect or be stimulating. The risk of smoking becoming addictive is significant.

Consuming tobacco is no longer a choice but driven by an internal compulsion. At that point, smoking can no longer be regarded as a recreational activity. When people try to reduce or quit, they experience a battle with themselves.

Even their best intentions often fail because the craving is too strong. This inner conflict causes stress. The act of reaching for a cigarette becomes almost automatic, aimed at reducing this pressure. Addiction is a vicious circle that can usually only be broken with external support.

Passive Smoking and Nicotine

Not only smokers themselves are harmed by the smoke. People who breathe in secondhand smoke can also sustain damage.

This is especially critical when pregnant women smoke, increasing the risk of preterm birth. Newborns often have lower birth weights and are at higher risk of sudden infant death syndrome (SIDS).

Nicotine also passes into the infant’s system through breast milk. The more a mother smokes, the higher the concentration in her milk.

If a mother smokes during pregnancy, the baby is also nicotine-dependent. Once she stops breastfeeding or does not breastfeed at all, the child undergoes an involuntary withdrawal from nicotine because they stop absorbing the chemical through blood and milk. These children are at greater risk of smoking themselves later in life.

Children exposed to secondhand smoke also suffer more frequently from respiratory illnesses, pneumonia, skin conditions (e.g., eczema), allergies, and middle ear infections.

Nicotine Addiction: How Many People Are Affected?

Approximately 20% of adults in Germany smoke — about 20 million people. Around 23% of men and 17% of women take up smoking. Compared to previous decades, the smoking rate in Germany has significantly decreased.

Among adolescents aged 12 to 17, the number of smokers has also fallen: in 2001, it was 28%. By 2023, it had dropped to nearly 7%.

Similarly, the trend among 18 to 25-year-olds shows a decline from 45% in 2001 to just 26% in 2023.

Nevertheless, nicotine addiction remains widespread. Smokers reduce their lifespan by approximately ten years due to tobacco use. About 130,000 people in Germany die each year from smoking-related illnesses.

Most of the tobacco consumed in this country is in cigarettes, either with or without filters, pre-packaged or rolled and stoppered manually. Cigarillos, cigars, pipes, chew and sniff tobacco, and water pipes are less common.

Nicotine and Toxic Smoke

The raw material of tobacco is dried leaves of the tobacco plant. The plant only becomes consumable — as smoke, chewing, or snuff — after industrial processing.

Tobacco smoke contains over 4,000 chemicals. The most significant active substance is nicotine. Depending on the origin of the plants and how the tobacco is prepared, smokers, snuff users, or chewers absorb varying amounts of this toxic chemical.

Besides nicotine, numerous other chemicals and heavy metals are present in tobacco smoke, such as cyanide, benzene, formaldehyde, hydrazine, vinyl chloride, lead, cadmium, nickel, chromium, aluminium, and carbon monoxide. More than 40 of these substances are proven carcinogens.

According to the classification of mental disorders in ICD-10 (International Classification of Diseases) from the WHO, a diagnosis of nicotine dependence requires that, over a period of one month or recurrently within a year, at least three of the following criteria are met:

1. A strong desire (craving) or compulsion to consume tobacco.
2. Limited control over the start, end, and amount of consumption.
3. The appearance of physical withdrawal symptoms when consumption is reduced or stopped. These withdrawal symptoms can be alleviated by nicotine intake.
4. Tolerance development: the amount of nicotine must be increased to achieve the same effect.
5. Abandonment or neglect of other interests due to substance use.
6. Persistent tobacco use despite clear harmful consequences.

As the body becomes accustomed to nicotine, affected individuals initially need to consume more to experience the same effect.

Typical withdrawal symptoms include increased irritability and restlessness. Many smokers believe they are reducing inner unrest with nicotine, but in reality, it provides only short-term relief—and in the long run, the unrest intensifies. Additional withdrawal symptoms can include reduced concentration, feelings of hunger, sleep disturbances, and anxiety.

Smoking: Health consequences

While nicotine is responsible for the addictive effect, the other chemicals in tobacco smoke primarily harm health. The health impacts of smoking affect the whole body, and in many cases, tobacco use is the cause of premature death.

Smokers’ airways are exposed to a massive load of chemicals. Long-term damages from nicotine dependence range from chronic bronchitis to lung cancer. Moreover, smoking promotes arteriosclerosis (hardening of the arteries), which can lead to serious circulation issues.

Smoking raises blood pressure and increases the risk of cardiovascular diseases. Severe long-term consequences include coronary heart disease (CHD), heart attacks, and peripheral arterial disease (“runner’s leg”). Other effects include type 2 diabetes, skin, and dental damage.

Furthermore, smoking significantly increases the risk of developing various cancers, especially lung, laryngeal, oesophageal, and oral cavity cancers. These are mainly the areas that come into direct contact with tobacco smoke.

Nicotine consumption is also linked to the development of other malignant tumours, such as pancreatic, kidney, gastric cancers, and leukaemia.

Causes and risk factors of nicotine dependence

Nicotine addiction develops through a combination of psychological and biological factors. Nicotine creates both physical and psychological dependence.

Nicotine as a learned behaviour

Most affected individuals start smoking in childhood or adolescence, driven by curiosity or peer pressure. Many also use cigarettes to mask insecurity.

The first cigarette does not produce a pleasant feeling. In fact, the body reacts to the initial dose of nicotine as it would to a poisoning: with dizziness, increased saliva, rapid heartbeat, headaches, nausea, vomiting, diarrhoea, and even loss of consciousness.

However, many young people feel “cool” when smoking and tolerate the unpleasant taste and side effects. The positive social feeling from smoking together reinforces the behaviour.

In adulthood, communal smoking often serves a social purpose as well. Breaks at work and after meals become associated with relaxation and enjoyment linked to smoking.

Once the link between certain situations and smoking is learned, reaching for a cigarette after meals or while socialising becomes almost automatic. This process is known in medical terms as conditioning.

Biological factors of nicotine addiction

Nicotine addiction arises when our natural reward system in the brain is manipulated. This system is vital for survival; it rewards behaviours like eating when hungry by releasing dopamine, which makes us feel good.

Consumption of nicotine leads to increased dopamine release. The act of smoking then is rewarded similarly to eating, drinking, or sex. Early in addiction, this craving for the ‘high’ it produces promotes dependence.

Regular smokers over-stimulate this system, and the amount of nicotine previously enough for a positive effect becomes insufficient. Development of tolerance and withdrawal symptoms characterize the physical dependence. The body demands increasingly higher doses.

Through neurotransmitter release, nicotine also impacts mental state—producing a psychotropic effect. It can improve alertness, support memory, and increase stress resilience.

Simultaneously, nicotine lowers irritability, reduces arousal, and diminishes appetite. Depending on the individual’s mood, nicotine can be calming (e.g., during stress) or stimulating (e.g., when tired). A person is psychologically dependent when they feel they “must have” a cigarette and constantly think about it.

If both physical and psychological dependence are present, it becomes very difficult for individuals to control their consumption. Withdrawal symptoms occur as nicotine levels fall, often determining when the next cigarette will be smoked.

Nicotine Dependence: Investigations and Diagnosis

If there is suspicion of tobacco addiction, you can initially consult your general practitioner or GP. They will ask questions about your tobacco use to diagnose nicotine dependence. The Fagerström Test is a widely accepted method to assess the severity of the addiction. It includes questions such as:

• How many cigarettes do you smoke per day?
• Do you find it difficult not to smoke in places where smoking is prohibited?
• How soon after waking do you smoke your first cigarette?

The doctor will also examine your overall health to determine whether any health damage has already occurred as a result of your tobacco use. If necessary, these issues will be treated.

In cases of severe nicotine dependence, a therapeutic treatment is recommended. If the individual is motivated, less intensive measures may also be effective. Your doctor or GP will inform you about the various options available for smoking cessation.

Nicotine Dependence: Treatment

Various options are available for treating nicotine dependence, ranging from nicotine patches to psychotherapy. The coverage of costs varies across countries and is usually regulated by law. Many treatments are not fully covered or reimbursed. It is advisable to contact your health insurance provider to verify which costs may be covered for cessation and treatment.

Nicotine Dependence: Motivational and Brief Interventions

A brief intervention for nicotine dependence is usually carried out in doctor’s surgeries or addiction counselling centres. First, your smoking behaviour is recorded, and then your motivation to quit is explored.

The smoker is supported through short, motivational conversations aimed at encouraging the planned cessation of nicotine. Telephone advice and self-help groups also provide effective assistance in fighting nicotine dependence.

Nicotine Dependence: Therapeutic Treatment

The most proven approaches to smoking cessation include behaviour therapy in group or individual settings. During behavioural therapy, the behaviour of the affected person is analysed, and alternative behaviours are developed.

The therapist will ask, for example, which situations and feelings tend to trigger the urge to smoke. Commonly, this is linked to stress, which the smoker hopes to reduce with cigarettes.

In therapy, smokers are supported in finding other ways to cope with stress. Relaxation techniques and strengthening social networks play an important role. These strategies help individuals learn alternative behaviours — a process called counterconditioning for smoking cessation.

Nicotine Dependence: Nicotine Replacement Therapy

Another option for quitting smoking involves nicotine patches, gum, inhalers, or sprays. These products supply the body with a controlled amount of nicotine.

The nicotine patch releases nicotine continuously. Depending on previous consumption, treatment usually begins with a high dose of nicotine, which is then gradually reduced. The patches maintain a steady nicotine level in the body to lessen withdrawal symptoms.

Nasal nicotine sprays imitate the effect of a cigarette most closely but pose a higher risk of addiction and a lower success rate for quitting.

Physical dependence on nicotine typically resolves after about two weeks. However, psychological dependence remains and requires further treatment to prevent relapse.

How long the intense craving (known as craving) persists varies greatly. In many cases, nicotine replacement therapy is an effective method to support long-term abstinence from tobacco.

Nicotine Dependence: Other Measures

People beginning to quit smoking should create a daily schedule or plan to manage their day. Engaging in distracting activities can be helpful.

Exercise, in particular, can facilitate abstinence since it improves fitness and makes breathing feel easier. Additionally, physical activity stimulates the release of mood-enhancing neurotransmitters in the brain, producing a feeling of happiness.

Friends and family can also play a key role. The social environment should be informed of the intention to quit to provide support. For example, relatives should not offer cigarettes, as this could lead to a discouraging relapse.

Psychotherapy can support all these measures. For example, a structured daily routine with enough distractions can be designed in therapy. Individuals also learn how to say “no” if offered a cigarette.

Nicotine Dependence: Course and Prognosis

The earlier someone starts smoking, the higher the risk of becoming dependent and suffering long-term damage. Adolescents who begin smoking early often also consume alcohol and drugs.

Therefore, it is crucial to protect children and teenagers from nicotine. Adults can set a positive example and influence younger generations positively.

A key prerequisite for successful smoking cessation is motivation. After a prolonged period of abstinence, the risk of relapse decreases. However, even after years, complete safety cannot be assumed; certain scents or situations may trigger memories of the pleasurable feeling associated with smoking.

Deciding to quit nicotine must therefore be reaffirmed constantly. It requires effort and a high degree of personal motivation.

In the UAE

In the UAE, where smoking prevalence remains significant despite ongoing tobacco control efforts, understanding nicotine addiction is vital for public health. The combination of cultural acceptance, social customs, and increasing availability of diverse tobacco products – including smoking shisha and emerging alternatives—underscores the importance of comprehensive education and accessible cessation programmes. Schools, workplaces, and healthcare providers play a critical role in raising awareness, offering support, and implementing strategies tailored to the UAE’s unique social context.

Given the health risks associated with nicotine dependence—ranging from respiratory and cardiovascular diseases to various cancers – prioritising prevention, early intervention, and sustained support for quitting smoking is essential. Leveraging a multi-sectoral approach that includes policy enforcement, community engagement, and personalised treatment options will better address the challenge of nicotine dependence, ultimately reducing its long-term impact on individuals and society in the UAE.