June 2013

• What does the term addiction mean?

• Is nicotine addictive?
• Properties of nicotine
• Difficulty in quitting
• Nicotine withdrawal symptoms
• Genetic influence
• Nicotine and harm reduction
• Tobacco industry recognition of the importance
of nicotine
Nicotine and addiction

What does the Addiction is defined by the World Health Organization as “repeated use of a
psychoactive substance or substances, to the extent that the user is:
term addiction
mean? • periodically or chronically intoxicated,
• shows a compulsion to take the preferred substance(s),
• has great difficulty in voluntarily ceasing or modifying substance use,
• exhibits determination to obtain psychoactive substances by almost any
means, and
• tolerance is prominent and a withdrawal syndrome frequently occurs
when substance use is interrupted.” 1

The Royal College of Physicians lists the following criteria for addiction:

• a strong desire to take the drug

• substance is taken in larger amounts or longer than intended
• difficulty in controlling use
• a great deal of time is spent in obtaining, using or recovering from the
effects of the substance
• a higher priority is given to drug use than to other activities and
obligations
• continued use despite harmful consequences
• tolerance
• withdrawal. 2

Is nicotine Tobacco addiction (like all drug addictions) is a complex combination of

pharmacology, learned behaviour, genetics, and social and environmental
addictive? factors (including tobacco product design and marketing). 3

The US Surgeon General acknowledges that “there is no established

consensus on criteria for diagnosing nicotine addiction” but asserts that a
number of symptoms can be cited as indicators of addiction. These include

• drug use that is highly controlled or compulsive with psychoactive effects,

• stereotypical patterns of use
• continued use despite harmful effects, and
• relapse following abstinence accompanied by recurrent cravings. 4

1 ASH Fact Sheet: Nicotine and Addiction Planned review date – June 2015
 The Surgeon General concludes that “nicotine is the key chemical
compound that causes and sustains the powerful addicting effects of
commercial tobacco products.” 4 This report follows a landmark review
published in 1988 which had also concluded that cigarettes and other forms
of tobacco are addictive and nicotine is the drug in tobacco that causes
addiction. 5

A report by the Royal College of Physicians on nicotine addiction agrees that

nicotine fulfils criteria for defining an addictive substance. The report states
that:

“it is reasonable to conclude that nicotine delivered through tobacco smoke

should be regarded as an addictive drug, and tobacco use as the means of
self-administration” and concludes that: “Cigarettes are highly efficient
nicotine delivery devices and are as addictive as drugs such as heroin or
cocaine.” 2

There is some evidence to suggest that smokers can become addicted to

nicotine very quickly. A study from the United States found that adolescent
smokers displayed symptoms of nicotine withdrawal within the first few
weeks of commencing smoking. 6

Properties of Nicotine induces pleasure and reduces stress and anxiety. Smokers use it to
modulate levels of arousal and to control mood. 7 Paradoxically, while
nicotine nicotine is a stimulant drug, effects of both stimulation and relaxation may be
felt. The mental and physical state of the smoker, and the situation in which
smoking occurs, can influence the way in which a particular cigarette will
affect psychological perceptions. 8 The addictive effect of nicotine is linked to
its capacity to trigger the release of dopamine - a chemical in the brain that is
associated with feelings of pleasure. 7

However, research has suggested that in the long term, nicotine depresses
the ability of the brain to experience pleasure. 9 Thus, smokers need greater
amounts of the drug to achieve the same levels of satisfaction. Smoking is
therefore a form of self-medication: further smoking alleviates the withdrawal
symptoms which set in soon after the effects of nicotine wear off.

Difficulty in Possibly one of the strongest indicators of the effect of nicotine is the
discrepancy between the desire to quit and quitting success rates. Surveys
quitting consistently show that the majority of smokers (around two-thirds) want to
stop smoking 10 yet the successful quit rate remains very low.

The 2008/09 “Smoking-related Behaviour and Attitudes” survey found that

26% of smokers had attempted to quit in the previous year and as many as
21% of smokers had made three attempts in the previous year alone. 11
However, only eight per cent of smokers succeeded in quitting for two or
more years. Similarly, figures from the United States show that each year
only 3 per cent of smokers succeed in quitting. Most smokers take several
attempts to quit before they finally succeed. 12 13

The power of addiction is further demonstrated by the fact that some

smokers are unable to stop smoking even after undergoing surgery for
smoking-related illnesses. A 1995 study found that around forty per cent of
those who had a laryngectomy resumed smoking soon after surgery, while
about 50 per cent of lung cancer patients resumed smoking after undergoing
surgery. 14 Among smokers who have had a heart attack, as many as 70%
2 ASH Fact Sheet: Nicotine and Addiction Planned review date – June 2015
 take up smoking again within a year. 15 More recent studies confirm the
difficulties faced by smokers in quitting even following the diagnosis of a life
threatening illness. 16 17

Other There are a number of markers which can measure dependence on a

substance. A key factor is the degree of compulsion to take the drug
measures of experienced by the user. Most smokers smoke on a daily basis. In Britain,
dependence the average self-reported consumption of cigarettes is 13 per day. 18 Other
indicators of dependence include the time from waking to first cigarette. In
2010, among smokers of all ages, 14 per cent reported lighting up within five
minutes of waking. Heavy smokers are much more likely than light smokers
to smoke immediately on waking: 32% of those smoking more than 20
cigarettes a day light up within five minutes of waking, compared to just 4%
of those smoking fewer than 10 a day.18

The A widely used tool for measuring nicotine addiction is the Fagerstrom test for
nicotine dependence 19
Fagerström
Test for The questionnaire determines the degree of dependence by measuring the
Nicotine extent of nicotine exposure, impaired control over use and urgency for use.
A key question about time from waking to first cigarette is used as a strong
Dependence predictor of relapse following a quit attempt.

Nicotine Another marker for addiction is the occurrence of withdrawal symptoms

following cessation of drug use. For smokers, typical physical symptoms
withdrawal following cessation or reduction of nicotine intake include craving for nicotine,
symptoms irritability, anxiety, difficulty concentrating, restlessness, sleep disturbances,
decreased heart rate, and increased appetite or weight gain. 20 These
symptoms can be alleviated by using Nicotine Replacement Therapy
products, such as patches, gum, nasal spray and lozenges or other
medication such as varenicline (Champix) or bupropion (Zyban).

For further information about using nicotine as an aid to stopping smoking

see ASH Fact Sheet: Benefits and aids to quitting.

Genetic Research suggests that certain smokers may be predisposed to nicotine

addiction through the effects of a gene responsible for metabolising nicotine.
influence Scientists have found that non-smokers are twice as likely to carry a mutation
in a gene that helps to rid the body of nicotine. 21 Researchers in the United
States found that smokers who carried a genetic variant were more likely
than non-carriers to be heavy smokers, more heavily dependent on nicotine,
and less likely to quit smoking. Carrying the variant did not make a person
more likely to be a smoker, but smokers who carried the variant were more
likely to be addicted to nicotine. 22 In addition, smokers who carry mutations
in the gene CYP2A6 are likely to smoke less because nicotine is not rapidly
removed from the brain and bloodstream. 23 By contrast, smokers with the
efficient version of the gene will tend to smoke more heavily to compensate
for nicotine being removed more rapidly.

Nicotine and Although nicotine is the addictive component of tobacco products it is the
toxins and carcinogens in tobacco smoke that cause most of the harm from
harm reduction using tobacco. 24 Pure or ‘clean’ nicotine extracted from tobacco can be used
to help people overcome their addiction as demonstrated through the use of
nicotine replacement therapies (NRT). For more information on ways to stop
smoking see the ASH fact sheet: Stopping smoking - the benefits and aids to

3 ASH Fact Sheet: Nicotine and Addiction Planned review date – June 2015
 quitting NRT can also be used to help smokers cut down the number of
cigarettes smoked or as an aid to temporary abstinence, that is, when a
smoker is required to go without smoking for a long period of time, for
example, on a long flight or during a stay in hospital. 25 The National Institute
for health and Care Excellence (NICE ) has now published guidance on
tobacco harm reduction. 26 While recognising that quitting smoking is always
the best option for smokers, the NICE guidance supports the use of licensed
nicotine containing products to help smokers not currently able to quit to cut
down and as a substitute for smoking, where necessary indefinitely. The
Medicines and Healthcare products Regulatory Agency (MHRA) has also
announced that non-tobacco nicotine products (for example electronic
cigarettes) will be regulated as medicines. 27 For further information see ASH
policy on Regulating nicotine products

Tobacco Tobacco industry documents dating from the 1960s have shown that tobacco
companies recognised that the main reason that people continue smoking is
industry nicotine addiction. A lawyer acting for Brown & Williamson said: “Nicotine is
recognition of addictive. We are, then, in the business of selling nicotine, an addictive
the importance drug.” 28 Publicly, however, tobacco companies denied that nicotine was
addictive, because such an admission would have undermined their stance
of nicotine that smoking is a matter of personal choice. As the US Tobacco Institute put
it in 1980: “We can’t defend continued smoking as ‘free choice’ if the person
was ‘addicted’. 29 The industry was also quick to realise that selling an
addictive product is good for business: as a British American Tobacco memo
said in 1979: “We also think that consideration should be given to the
hypothesis that the high profits additionally associated with the tobacco
industry are directly related to the fact that the customer is dependent on the
product.” 30 In March 1997, Liggett Group, the smallest of the five major US
tobacco companies, became the first to admit that smoking is addictive as
part of a deal to settle legal claims against the company. 31 Subsequently the
tobacco companies tried to cast doubt over the meaning of addiction by
comparing smoking with other common pursuits such as shopping or eating
chocolate. 32

For further examples of the tobacco industry’s position on addiction see

chapter 2 of ‘Tobacco Explained’. Other examples can be found in “Trust Us,
We’re the Tobacco Industry”

References
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4 ASH Fact Sheet: Nicotine and Addiction Planned review date – June 2015
8
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9
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