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Nicotine dependence, also called tobacco dependence, is an addiction to tobacco products caused by the drug nicotine. Cigarette smoking is the most prevalent type of tobacco use; additional options include smokeless products (chew and snuff) and other smoke products (pipes, cigars, bidis, and hookah pipes).

Nicotine dependence entails a physiologic and psychological process. Physiologic dependence: Nicotine stimulates the neurotransmitter dopamine activating the reward pathway in the brain. Initially, the person is rewarded for using tobacco with pleasure or a perceived relief from stress. However, the pleasurable effects diminish with continued use, but smoking continues to avoid nicotine withdrawal. Psychological addiction: In the absence of a physical reward for smoking, persons experience cravings with certain activities, stimuli, or times throughout the day. Unlike the physical component to addiction, the psychological component persists indefinitely. Therefore, there is always a chance of relapsing. Physiologic and psychological withdrawal processes manifest as a variety of symptoms lasting 2 to 4 weeks. Nicotine withdrawal symptoms may include irritability, insomnia, hunger, fatigue, dizziness, difficulty concentrating, depressed mood, and chest tightness. While nicotine replacement therapy (NRT) may diminish or alleviate nicotine withdrawal, symptoms may persist to some degree.


The best smoking cessation treatment is prevention through public health education and abstinence. However, the availability of prescription and over-the-counter medications offers an array of options for those attempting to quit tobacco. Additionally, cognitive behavioral therapy and increased provider contact increases the chance of quitting tobacco products. Health care providers should utilize the five A’s each time they come in contact with a person who smokes (Table 62-1).

TABLE 62-1The Five A’s of Smoking Cessation

NRT has proven successful for tobacco cessation. NRT is available in multiple dosage forms and delivery devices, allowing for various cessation strategies. A compilation of NRT products, doses, and special considerations is provided in Table 62-2. NRT may be combined with each other and/or bupropion to increase long-term abstinence rates. Common symptoms of nicotine toxicity include nausea, vomiting, abdominal pain, hypertension, and tachycardia.

TABLE 62-2Nicotine Replacement Productsa

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