Giving up smoking

Nicotine, dependence and cravings

Nicotine is a stimulant drug – from the lungs it reaches the brain in about seven seconds. Most people assume that when they smoke they become addicted to nicotine, but there is now some scientific evidence that suggests nicotine is not as addictive as we used to believe. Researchers now think there is something about the act or habit of smoking that people get addicted to and that nicotine is the ‘vehicle’ that creates that addiction. Nicotine, therefore, is not the ‘primary’ addiction. However, there is evidence that nicotine replacement therapy works for some people, as it can help reduce the urge to smoke.

Professor Aveyard explains why some people become addicted to smoking.

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And can you talk to me a little bit about what it is that people are actually addicted to when it comes to smoking?

Yes. Well there’s probably a number of processes involved, but we’re pretty certain that the main driver of sort of addiction if you like, is this nicotine that’s released. And nicotine by itself, is probably not that addictive. So nicotine gum or things that you can buy in the shop, nobody seems to start using nicotine gum and carry on using it if they have never used cigarettes. It’s only when it’s been, they’ve smoked, getting the nicotine from cigarettes that it’s a problem.

And what nicotine does, it’s not actually a fantastic drug. So from an experience of the user’s point of view, people don’t always get a huge pleasure from it. But it takes over a part of the brain that is used as our reward system and that brain does some automatic learning which tells the brain to notice what they were doing just a few seconds earlier. Now it only takes a few seconds from inhaling the smoke into your lungs. It is then absorbed into your blood stream and immediately goes straight to the heart and then is pumped up the arteries that run into your head. So within a few seconds of smoking the nicotine is hitting that reward system in your head. And that is creating this acquired drive as we say. This feeling what you experience as a person who smokes is a feeling of needing to smoke.

And then certain changes take place. After a while of smoking your brain adapts to the level of nicotine and when you go without nicotine you begin to feel certain unpleasant symptoms like feeling grumpy is one of things that people notice. Some people feel down in the dumps when they haven’t smoked or anxious and agitated.

So people feel these symptoms and that can also help drive smoking because what they notice is that when they have another cigarette, they feel okay again.

And one of the things that leads to it actually is a feeling that smoking is stress relieving, because one of the symptoms of stress, well they are feeling agitated, feeling irritable, feeling sometimes a bit down in the dumps. And all of those feelings are suddenly relieved by smoking. But it’s the smoking that caused those symptoms in the first place.

People we talked with thought trying to stop smoking had caused them a wide range of responses including getting ‘snappy’ and irritable, feeling physically unwell, being unable to concentrate or sleep, experiencing a tightening in their chest or stomach, having the “shivers” and feeling depressed or hungry. A couple of people even felt that stopping smoking suddenly precipitated a panic attack. However some people who stopped smoking suddenly had no problems or only felt as if they had a ‘cold’ for a few days.

Judith thinks it’s a fallacy that nicotine is a relaxant. She used to plan carefully when to have her cigarettes but now realises she mainly smoked out of boredom or habit.

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Age at interview: 36

Sex: Female

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And I didn’t need all those cigarettes. It was, it was because you were given, partly because you were given the time to go and have them, it’s weird, when you actually look at cigarettes and why you’re smoking. There’s so much down to boredom and there’s so much down to habit. And actually very little of it is down to the addiction, because we always make sure we have our cigarette before we get desperate potentially. So we never, I mean obviously there are some instances, like when you’re going on flights and things you do get to the point where you’re craving a cigarette, a natural craving, not that smoking’s ever natural, but that allowing the nicotine to drop so far that you physically need that top up.

But there’s so much in life that we never let that get to the point of, we’re always there worrying about it. It’s a fallacy that it’s a relaxant, because the only reason it relaxes you, is because you’ve got to the point where you’re really needing it, either psychologically or as a chemical reaction. And it’s only through being free of it that I realise I’m so chilled out these days and that was part of my mental health was anxiety and not having to constantly second guess when I was going to get my cigarette. Who I was going to visit, because could I smoke in their house, could I not smoke in their house? Were they four flights up? Was it an intimate dinner part or gathering where it was going to be really obvious if I suddenly got up and walked out to have a cigarette it just, it takes over your life. It used to make me late for things. Because I’d think well I had one five minutes ago, but I could probably just squeeze one in before I leave. And of course I could squeeze one in before I left, time wise I did. I crow bared it in, so that I could have that extra one. But again it didn’t do any more for me, having a second one.

Sarah tried to quit smoking whilst dealing with an eating disorder. She had a panic attack and then worried how she would cope without cigarettes.

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Age at interview: 33

Sex: Female

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And I think that as I became well, whilst I was making changes to my life, that as, smoking was the one thing that I kind of kept as a constant. And I think that’s why I found quitting smoking particularly hard because it has a number of other sort of potential things that it could, and I fear the thing like putting on weight. Well particularly that one. But also the breaking of a habit which I find really quite difficult and I, I guess I’ve always, it’s always concerned me that that would bring about symptoms of my anorexia if I, you know, too big a change too much, too, too fast.

So yes, I did manage to, I tried hypnotherapy. And I never forget, I went along and I had this hypnotherapy session. I must have been 27 at the time, and I was still reasonably unwell. I wasn’t it, I wasn’t using a lot, I was quite well, but I wasn’t a hundred per cent. And I went along and whilst I didn’t want, my mind didn’t want a cigarette any more, physically my body needed nicotine and I had a complete panic attack and I remember parents who were sat there, there all wanted me to really quit up smoking, quit smoking. And I remember my Dad saying, “Okay now, I’m worried. Now I’m worried. Where are the cigarettes. Let’s give her a cigarette.” [Laughs]. Because it was all too much and I think that that you know, again just re-enforced my concerns really, that I was just going to have panic attacks. It was going to increase my anxiety.

Rukmini didn’t find it hard to give up smoking. She had no withdrawal symptoms.

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Age at interview: 35

Sex: Female

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I don’t think it was hard giving up, because I don’t think in the first place I was ready quit, in the sense, in which medicine understands addiction. I don’t think. I think I did was more a social thing and it was more, almost it was a political thing, because I wanted to assert myself in public spaces and say that I could do what men could do. It was more that then.

I didn’t really miss it, but I would have said that I wasn’t tempted. I was tempted to pick a cigarette up and smoke. And it wasn’t hard, like, I didn’t find it really difficult, or I didn’t have any kind of withdrawal symptoms, but if I smelt somebody smoking, I had a whiff of smoke, I’d say, Hm. That would be nice. But I don’t, I didn’t really like it. I didn’t go crazy. I missed that. I did drink a lot of tea and I think that was my way of coping. But I don’t think it really bothered me much. You know, I was fine.

Miles had a non-smoking girlfriend and knew he had to stop smoking, but he still had the ‘odd one’.

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Age at interview: 48

Sex: Male

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What was sort of awful about them? What was it that you….?

I think from memory it was something within the body that sort of craves it. It was almost like someone’s speaking, your body’s almost speaking to you about cigarettes almost I think from memory. Because I knew I had to be tough. I knew I had to be, you know, to sort of overcome it. Because it was in with [wife’s name], and I think if I’d gone back to cigarettes, I think I might have got the cold shoulder. I don’t know whether she would have or not, but… I think that, just the risk of that would have been too much. So…

I mean of course, you know, because she was in [name of town] and I was in [name of town] or I only intended to see her at weekends, but I think I was apart from the odd time of having the odd one, I think I was more or less I was pretty good. Because I knew by this stage that I had to kick the habit. I knew that the, this wasn’t addiction. It was a physical addiction to some extent, you know, a habitual addiction as well.

Some people found it hard when they couldn’t smoke for some hours, for example in a meeting, in daytime during Ramadan or on a flight. Some got into a ‘mild panic’ when they ran out of cigarettes.

Munir wondered how much he really needed a cigarette, since he could go for 18 hours without smoking during Ramadan.

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Age at interview: 54

Sex: Male

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Yes, during the month of Ramadan as soon as we open fast, obviously a bit of food, and next thing you know, you’re outside having a smoke, you know, you go away from the kitchen and start smoking and the first cigarette after opening Ramadan, after you fast, you used, used to give me, you know, my head used to spin. But then, the next cigarette used to be okay, and ten minutes later you used to light up another cigarette, I used to smoke another one and I just used to make up for it. You know, the time you’ve given up smoking all day, you’ve not smoked all day, and that’s seemed to work very well, come to think of it, but all day, you’re don’t smoke because you’re fasting, and then as soon as the fast opens, you have a bit of something to eat and then you’re smoking, like a chain smoker, after every few minutes, you know, and then you know, you have the willpower to not to smoke during day for ten, twelve and this year, there were 18 hour you know, fast. And people manage to not smoke during those eighteen hours. But amazingly as soon as the fast opens, you start smoking again. I mean surely the logic says that if you can give up, if you cannot, if you can stay without a cigarette for 18 hours I’m sure you can stay without a cigarette for 24 hours, but it’s not mentally, you’re itching to smoke, you know, so…

Keith thought he had been addicted to nicotine but thought it “curious” that during long days at work he forgot about smoking. Sue had realised she was not addicted when her GP pointed out that “If you’re only having one in the morning... why don’t you just pack it up?” He said, “That’s ridiculous. You’re not addicted.” Sue says that he was the first person who actually told her that the desire for cigarettes was in her head.

Professor Aveyard talks about how behavioural prompts (cues) affect when and where people like to smoke and how changing your routines can help you to give up smoking.

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Can you tell me a little bit about what sort of the role of behavioural prompts in that sense?

Yes, well the bit of the brain that does this sort of learning that says oh well you know, nicotine, let’s go with that, let’s keep smoking these cigarettes, is the bit of the brain that is involved in this conditioned response learning. It’s the bit of the brain when a lot of people have heard of Pavlov’s Dogs, and what Pavlov did, was every time he fed his dogs, he rang a bell, and he noticed my dog does this when I give him his food or before he gets his food he’s dribbling. Right well, Pavlov noticed that after a while, he could just ring the bell and the dogs would dribble. And the dogs had come to associate the bell with the reward which was the food. Now that’s what happens when a smoking learns to smoke. They learn to smoke in characteristic spaces so they’re not thinking about smoking. They go to a place where they normally smoke, outside a building nowadays, quite often people will smoke in their cars or they’ll get up in the morning and they’ll go downstairs and put the kettle on and they’ll reach for a cigarette and they won’t really be thinking about smoking, it’s just this kind of automatic learning that has gone on, and it’s that kind of learning that makes it so hard, when you are trying to stop smoking, because you go through all your familiar routines and you are doing the things that you normally do and low and behold you’re suddenly faced by the need to smoke a cigarette. And that’s what the problem is. So it’s why sometimes changing your routines can be so helpful to people, when they are trying to stop smoking because they’re avoiding these in the jargon we say cues to smoke, but the situations and places and sometimes mood states, when you normally have smoked previously.

John remembered a long train journey to Scotland that stopped once and all the smokers got off to smoke. He says “And even then I was starting to think this is a bit daft. Because you know, you’ve managed an hour and a half, you can manage another hour and a half. But you just felt it was you, you were a smoker, therefore that’s what you had to do. The whys didn’t make much sense”. Andy felt that it was “pathetic” he was “enslaved to a little white stick” and Peter said that it had become “associated with many other things that were... positive and enjoyable”.

Sometimes the fear of craving for a cigarette was worse than the craving itself: Roger said that he would prepare for times when tobacconists would be closed over Christmas holidays by buying in many packets of tobacco. Judith would smoke several cigarettes in quick succession if she knew she would not be able to smoke later, but wondered how much she needed them.

Even when Cassie was in hospital with a collapsed lung, she got her friend to push her outside for a cigarette.

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Age at interview: 22

Sex: Female

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I remember being in hospital, my lung had collapsed. I was Intensive Care for five days. I was in a really bad way. And, as soon as my friends got there, the first thing I got them to do was put me in a wheelchair and take me outside to smoke. And I was choking and coughing up stuff and I was still puffing away, which is terrible. It just shows you how strong the addiction and the need to have it is. You know, I put my life on the line. I was in Intensive Care, I couldn’t breathe, it could happen again. Just the cigarette could trigger it, because at that time it was a trigger. And I was willing to risk it for a cigarette. So you know, the grip is really, really tight. And I think, you know, psychologically it really had gets hold of you.

How would you say sort of psychologically it’s got hold of you? What are the signs?

Signs? What are the signs? Just the need to smoke. I get very irritable if I don’t have a cigarette and I get, you know, I would, as much as it embarrasses me to say this, I would do anything to have a cigarette if I really wanted one. I’ve been through the bin to pick up my cigarette ends to see if there’s a bit left on there. I’ve been through the outside bin. You know, I’d go, I don’t know if I’d go as far as to ask a stranger, because I think that is, I don’t think it’s worse than the bin, but you know, I just find that very invading of from someone else. But you know, I get very angry when other people ask me for my cigarettes, because I think buy your own they’re mine. You know. So I think maybe that’s the psychological thing, the need to keep hold of them so that I can carry on smoking, and I think, if I had like £5 left and that’ all I had till the next month or until next year, I would spend it on cigarettes rather than anything else. And if someone gave me the choice between food and cigarettes, may be not now, but before, I would have chosen cigarettes. Which is quite drastic.

Sue found it strange that the smoking ban meant that smoking was always on her mind because she had to plan cigarette breaks throughout the day.

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Age at interview: 57

Sex: Female

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The funniest thing is when you can smoke anywhere I think in a way it’s less ritualistic. You know, you’ve got your first one, your last one of the day, but if, if you can light up and smoke wherever you are, there’s, there’s kind of less pressure on you to smoke now. Whereas if you have to go out of the building to smoke, you begin to think, oh I haven’t had a cigarette for 40 minutes. Oh I wonder if, now if I stopped doing what I’m doing now, I can take a 5 minute break or a ten minute break. If I can a ten minute break I can smoke two.

So you’re, you’re planning all the time, you’re sort of, planning your day around your cigarette breaks and I think in a way it’s less productive, because it’s on your mind all the time. Is like if you’re on a diet and you think about food all the time, whereas if you’re not on a diet you don’t think about food at all. And it, it’s hard to give you a, a sort of what my smoking day was like from the days when you smoke anywhere, because it just wherever you fancied a cigarette. It was far more planned in the years since it became more difficult to smoke.

Because meeting breaks would have to be timetabled as well. You could no longer go into a meeting for a whole day and say, well we’ll just kind of finish when we finish. It would be well we need a break at eleven and another one at half twelve for lunch and then one at two and then one at four. And I do, one of my friends who smokes is, is a director of a company and she insists on building in cigarette breaks to meetings. Insists, otherwise she wouldn’t make it through the meeting.

Many people had thought hard about their desire to smoke when they were considering giving up smoking; some were convinced that they had been addicted to nicotine while others felt it was more a social habit, or a combination of the two. Some people felt they must have a physical addiction to nicotine because when they tried ’light’ cigarettes they would just smoke twice as many.

People spoke about the ‘illogical’ nature of their desire for cigarettes, and how it was so powerful that despite the obvious risks of smoking they still continued. Haseen thought that he could resist almost all other temptations but still found it very difficult not to smoke. Sarah talked about the ‘function’ of her smoking, in that it gave her some sort of support with her eating disorder. Others talked about the role smoking had in reducing or controlling stress. Caroline said that even though she adored her children and they wanted her to quit, she still felt she had to smoke.

Abdul was a chain smoker – he started to hate smoking and felt that he had to “demonise” smoking in order to quit.

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Age at interview: 37

Sex: Male

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When I talked about giving up smoking, I said, “I’ve had to demonise it.” Which, and I knew at the time when I was trying to stop it, and I knew at the time when I was still smoking and hating it. I knew what I was doing. I was demonising it. I hated it. And I had nothing positive to say about it at that stage, you know, before I gave up that is, you know, leading in… I mean for years now I’ve been wanting to give up, you know, three, four years or whatever. And I was a chain smoker and it wasn’t good, you know, and you know, just in my mind hating it. You know, understanding what it was doing. And getting fed up about using it as an excuse for being rubbish at badminton effectively, and not very good. And recognising that I had to hate it in order to give it up. And that I had to treat it like a person. Or I tried to treat like an entity. You know, that somehow it wasn’t me, but it was this thing. You know, I suppose someone might have been possessed or something, I didn’t want it any more, you know. And that’s may be what it’s like thinking about it, being like possessed you know, in some kind of way, demonising it and saying, “Look I want I want to get rid of this. I’ve got to somehow exorcise and get rid of it.” You know, and almost taking you out of yourself, and then you seeing it over there and not you any more where you are. And that’s basically what’s happened I think, because I see smoking as other thing now, rather than this thing that was sitting where I’m sitting. And that’s how I understand it, you know, so, yes.

Raf felt on edge without a cigarette and had a constant urge to smoke. This may be why he smoked for so long.

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Age at interview: 40

Sex: Male

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So did you notice the difference in taste between all those different cigarettes?

Not, not really. I mean they all, to me they felt the same. Apart from Silk Cut because they have little holes in the filter and it were just a case of the thought of them helping me stop smoking, was the reason why I actually started smoking them, but, whereas I’d smoke one cigarette, with Silk Cut I’d end up smoking two, one straight after the other, just to get that same kind of fix.

And then eventually I just changed brands again, and it went back to how it was prior to going onto Silk Cut.

So what was the fix like that you wanted out of cigarettes?

It was just, I don’t know really how to explain it, but it was just, it was like an urge but, with some urges, after a little while the urge goes away, but with this it was just constantly there, until I didn’t actually light a cigarette and smoking it, I didn’t feel no different. But once I’d actually had a smoke I’d be a lot more calm, and I’d be able to concentrate better. And basically I think that’s just what kept me smoking.

It was like well not like, it actually it was addiction, but I mean I don’t know because, I’ve never done drugs or anything, so I wouldn’t know what that kind of addiction would be, but to me, I mean this was like the next best thing, and until I’d have a cigarette, I would be, I wouldn’t really be myself, I’d always be slightly jumpy, on edge, that kind of thing.

Gareth is puzzled that he and his siblings have all stopped smoking but have all started again.

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Age at interview: 58

Sex: Male

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But it’s strange really, because, you know, I mean I’ve got brothers and sisters. My sister has just stopped. My brother, well they’ve all, you know, I think, I don’t know if there’s similar behaviours here, because, because we’re brothers and sisters, there are four of us. We’ve all been smokers, some of them still are. But we very rarely smoke together, because we don’t spend, we’re not, well we’re close, but we don’t see each other often. But you know, the fact that one has stopped, well actually they’ve all stopped at different times, but restarted. So it makes you think well bloody hell, why? Why can’t we just stop once for the rest of your life?

I don’t know. I think you can’t really explain, you can’t explain everything. But it would be nice to know, you know, why that is the case. It would be interesting yes.

Sometimes I wonder, because you know, because I’m managed… The thing is on one hand I know it’s an addiction. And your body just screams for it as soon as you have a puff, and you know, the receptors just open up and say take me. I often wonder well how can I just stop like that and have no desire, no feeling the need to have a cigarette. Doesn’t that rule out an addiction? [Laughs]. No, you know, because that’s how I stop. I, it’s weird. I don’t quite get that one. So I don’t know my receptors may be just half open.

Some people thought only in retrospect they felt they had been addicted to nicotine. People spoke about having ingrained habits such as a ‘hand to mouth’ action; constantly thinking about smoking; collecting smoking paraphernalia such as tobacco tins, papers, ashtrays and lighters. Carol described herself as having an “addictive personality”, and talked about swapping “one addiction for another” in the sense that she now puts food in her mouth rather than cigarettes.

Tom’s desire to smoke seemed to be prompted by certain situations, such as coming out of the cinema.

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I had, I still had the occasional craving for it, a long, a long time after I stopped, because I’d been smoking for the best part of 15 years. So there was a lot of, a lot of connections, a lot of things that you do. This was a weird thing - it wasn’t so much like a physical dependency at times, it was more like a kind of, almost like there was a psychological link between doing particular things. So like I’d always, because I always had a cigarette after I’d had a meal, that was when I wanted one, even after I’d given up, or weird ones like, I, for quite a long time after, I really wanted a cigarette when I came out of a cinema, because I’d always done it, and getting off a ‘plane, and all these things, I used to look forward a cigarette. Oh yes, this is great, but I quite fancy having a fag when this is done.

And it was also as if I had to kind of, I had to do each of those things, and not have a cigarette afterwards, before I knew I could do it without wanting one. So that took quite a long time. Because I don’t think I went anywhere on a ‘plane for quite a while after I’d had my last cigarette, and I was really surprised when we landed that kind of "cor, I really want a cigarette." So yeah. That’s kind of about it, what brought it all about.

Although some people could manage to smoke less, cutting down or smoking light cigarettes were often not regarded as ways to decrease addiction to smoking.

Also see ‘Effects of not smoking’ and ‘Cutting down’ unsuccessful attempts and trying again’.

Last reviewed August 2018.