Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN
Written By: Phillippe Greenough
Article Updated: 01/25/2021
Number of References: 25 Sources
Nicotine is a prevalent drug and is used primarily through smoking cigarettes or vaping. Even though the harm that cigarette smoking can cause is common knowledge, the addictive power of nicotine is such that people continue to smoke, even though they know it is killing them. Nicotine withdrawal can last for around a week or two, and symptoms may include insomnia, headache, irritability, and anxiety. In this article, we will examine how nicotine works in the brain, the symptoms of nicotine withdrawal, the timeline involved, and some effective detox treatments.
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Nicotine withdrawal symptoms are mostly psychological, although there are physical symptoms as well. The symptoms of nicotine withdrawal usually begin fairly soon after the last time someone used the drug. The half-life of nicotine is fairly short at between 1 to 3 hours. Because of this, symptoms will begin within 6 hours of the last use. Below, we will take a look at the symptom progression of nicotine withdrawal over the first 4 weeks of abstinence. The symptoms are quite intense in the first few days after the last nicotine use, and the physical symptoms usually resolve within days. The psychological symptoms are usually the most intense and longest-lasting out of these and may remain at a high level for several weeks. There are medications and behavioral therapies that may help treat the symptoms of nicotine withdrawal, but the only way for these symptoms to permanently resolve is through continued abstinence from nicotine.
A general overview of the nicotine withdrawal timeline may look something like this:
Within hours of the last drug use, the symptoms of nicotine withdrawal will begin to appear. The first symptoms to emerge are usually anxiety, restlessness, and cravings. These will increase over the first day and will usually be joined by increased appetite and irritability. Insomnia may emerge during the first night and thinking may become disorganized or clouded. The second day may be marked by headaches and constipation and irritability may increase. These symptoms will worsen over the second day and, oftentimes, into the third day since the last nicotine use. The symptoms will usually peak during the third day before starting a slow resolution that will take place over the following weeks.
Some nicotine withdrawal symptoms that can be expected during the first week include:
The second week usually starts off much better than the first, as most of the physical symptoms are well on their way to resolution. The psychological symptoms, however, are usually still at a fairly high level. Anxiety, depression, fatigue, and strong cravings should still be expected, although they are usually improved compared to the first week. Bowel movements may still be somewhat infrequent, but this usually improves as the week progresses. Insomnia may still be present, although it should see some improvement. Once sleep becomes more regular, it is often characterized by vivid dreams or nightmares, and these may persist for the rest of the week, at least.
Some common symptoms during the second week of nicotine withdrawal can include:
The beginning of the third week often sees the total resolution of physical symptoms of nicotine withdrawal. The psychological symptoms, while often still present, should be much improved by this time. Anxiety, depression, and minor fatigue may be expected, although cravings can still be quite intense. Restlessness and difficulty concentrating may be present as well, but they are usually on their way towards resolution. By four weeks after the last nicotine use, most of the symptoms should either be completely resolved or show substantial improvement. While cravings may be present, they usually come and go and may not necessarily be constant, however, strong cravings may be triggered by specific things, such as second-hand smoke. Depression and anxiety are frequently still present but are usually much improved. Even though the worst of the nicotine withdrawal symptoms may be passed, there is still work to do. Relapse is still a very real risk, and continued care and support are often needed to prevent a return to nicotine addiction.
Some symptoms that may persist through the third or fourth week of nicotine addiction can include:
While the acute phase of nicotine withdrawal may last several days or a week, the post-acute withdrawal symptoms may last much, much longer. These are often much less intense than the acute symptoms, but their persistence can be very challenging.
The post-acute symptoms of nicotine withdrawal include:
These symptoms may persist for many months and are often the reason someone will return to nicotine use. The long duration of these symptoms seems to wear people down, with strong and sometimes constant cravings driving someone back to nicotine use. These symptoms also may benefit from medications or behavioral therapy, but the only permanent solution is to stay away from nicotine use.
Nicotine is an extremely addictive drug that produces both neurological stimulation and relaxation when used. The way nicotine produces these effects is quite complex and involves many brain regions and while it primarily affects one neurotransmitter, it can produce downstream effects in several different neurotransmitters. Firstly, when smoking a cigarette, nicotine is absorbed into the blood through the lungs and quickly diffuses into the brain. Once in the brain, it binds strongly with specific neurotransmitter receptors known as nicotinic acetylcholine receptors (NARs) that normally respond to the neurotransmitter acetylcholine. The potency with which nicotine binds to these receptors produces very strong direct and indirect effects including a release of dopamine, serotonin, norepinephrine, glutamate, GABA, acetylcholine, and endorphins. This lively downstream effect of neurotransmitter release is responsible for the “buzz” or high produced by nicotine use.
As far as the addictive potential of nicotine use, the neurotransmitter dopamine is mostly responsible. This is an excitatory neurotransmitter that produces feelings of reward and pleasure. Dopamine is released in many brain regions and its specific effect depends on where in the brain it is released. The immediate effects of nicotine use are produced by dopamine in the locus coeruleus and nucleus accumbens, among other areas. In certain regions of the brain, such as the nucleus accumbens, increased dopamine signaling is a known contributor to addictive behaviors as we will explore more in-depth a little later. A complementary effect of cigarette smoking, although not due to nicotine itself, is that chronic smoking will lead to reduced levels of the enzymes monoamine oxidase A and B. These enzymes break down certain neurotransmitters such as dopamine and norepinephrine after they have been released. With reduced levels of these enzymes, there is more available dopamine in the brain and this could lead to an accelerated addiction process.
Through chronic use of nicotine, the brain will begin to adapt to the increased levels of the neurotransmitters that are released through using the drug. This initially takes the form of downregulation, which is the process of the brain reducing the sensitivity of the overstimulated neurotransmitter receptors in an attempt to maintain balance. This initially produces tolerance and continued use will result in a physiological dependence. A further process known as neurological remodeling will begin after downregulation has started, and this process is much slower to perform and, subsequently, to reverse once someone stops smoking. Remodeling is the act of structural changes occurring in the brain to prioritize and encourage nicotine use, and the nucleus accumbens is a major player in this regard. Long-term nicotine use can also, paradoxically, lead to the upregulation of nicotinic acetylcholine receptors, which increases the brain’s sensitivity to nicotine. This can increase the desire for nicotine as well as the psychological effects of nicotine use. In the short term, once downregulation has begun, someone will begin to experience nicotine withdrawal symptoms when they go too long without using the drug.
As we have mentioned throughout the article, medications and therapy can provide massive benefits to someone’s subjective experience of nicotine withdrawal symptoms and their objective chances of a successful recovery and long-term abstinence from nicotine use. While nicotine replacement therapy can be useful in helping someone quit smoking, there are still risks associated with nicotine use, regardless of the route it is used. The safest option is to quit using nicotine entirely. There are multiple effective medications that can reduce the symptoms of nicotine withdrawal and behavioral therapies can help reduce cravings. Quitting nicotine use can seem like an impossible challenge at times, but with help, it can be done. Don’t wait, recovery can start today.
There are several other drugs that can produce uncomfortable or even dangerous withdrawal symptoms. We have more in-depth withdrawal guides for drugs such as:
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