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updated November 23, 2010

Nicotine dependence

Filed under: Addiction
Nicotine dependence is an addiction to tobacco products caused by the drug nicotine. Nicotine dependence — also referred to as tobacco dependence — means you can't stop using the substance, even though it's causing you harm. While it's the nicotine in tobacco that causes nicotine dependence, the toxic effects come mainly from other substances in tobacco. Smokers have much higher rates of heart disease, stroke and cancer than do nonsmokers.

Nicotine produces physical and mood-altering effects in your brain that are temporarily pleasing. These effects make you want to use tobacco and lead to dependence. At the same time, stopping tobacco use causes withdrawal symptoms, including irritability and anxiety.

Many effective treatments for nicotine dependence are available to help you manage withdrawal and stop smoking for good. Ask your doctor for help.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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In some people, using any amount of tobacco can quickly lead to nicotine dependence. Signs that you may be addicted include:

  • You can't stop smoking. You've made one or more serious, but unsuccessful, attempts to stop.
  • You experience withdrawal symptoms when you try to stop. Your attempts at stopping have caused physical and mood-related signs and symptoms, such as strong cravings, anxiety, irritability, restlessness, difficulty concentrating, depressed mood, frustration or anger, increased hunger, insomnia, and constipation or diarrhea.
  • You keep smoking despite health problems. Even though you've developed problems with your lungs or your heart, you haven't stopped or can't stop.
  • You give up social or recreational activities in order to smoke. You may stop going to smoke-free restaurants or stop socializing with certain family members or friends because you can't smoke in these locations or situations.

When to see a doctor
You're not alone if you've tried to stop smoking, but haven't been able to stop for good. Most smokers make many attempts to stop smoking before they have stable, long-term success.

You're more likely to stop for good if you follow a treatment plan that addresses both the physical and the behavioral aspects of nicotine dependence. Using medications and working with a stop-smoking counselor will significantly boost your chances of success.

Ask your doctor to help you create a treatment plan that works for you.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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Nicotine is the chemical in tobacco that keeps you smoking. Nicotine is very addictive. It increases the release of brain chemicals called neurotransmitters, which help regulate mood and behavior. One of these neurotransmitters is dopamine, which makes you feel good. Getting that dopamine boost is part of the addiction process.

Nicotine dependence, also referred to as tobacco dependence, involves behavioral as well as physical factors. Behaviors and cues that you may associate with smoking include:

  • Certain times of the day, such as with morning coffee or during breaks at work
  • After a meal
  • Drinking alcohol
  • Certain places or friends
  • Talking on the phone
  • Stressful situations or when you're feeling down
  • The smell of a burning cigarette
  • Driving your car

To overcome your dependence on tobacco, you need to deal with the behaviors and routines that you associate with smoking.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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Anyone who smokes or uses other forms of tobacco is at risk of becoming dependent on tobacco and nicotine. Most people begin smoking during childhood or adolescence. The younger you begin smoking, the greater the chance that you'll become a heavy smoker as an adult.

Children who grow up with parents who smoke are more likely to become smokers. Children with friends who smoke also are more likely to try cigarettes.

Other factors that influence nicotine dependence include:

  • Genetics. The genes you inherit play a role in some aspects of nicotine dependence. For example, the likelihood that you will start smoking and keep smoking may be partly inherited. Some people experiment with smoking and don't experience pleasure, so they never become smokers. Other people develop dependence very quickly. Some "social smokers" can smoke just once in a while, and yet another group of smokers can stop smoking with no withdrawal symptoms. These differences can be explained by genetic factors that influence how receptors on the surface of your brain's nerve cells respond to nicotine.
  • Depression, other mental illness and substance abuse. People who have depression, schizophrenia and other forms of mental illness are more likely to be smokers. Smoking may be a form of self-medication for these disorders. People who abuse alcohol and illegal drugs also are more likely to be smokers.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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When you inhale tobacco smoke, you take in numerous chemicals that reach most of your body's vital organs. Tobacco smoke contains more than 60 known cancer-causing chemicals and more than 4,000 other harmful substances.

Smoking harms almost every organ of your body. More than half the people who keep smoking will die because of it. The negative health effects include:

  • Lung cancer and other lung diseases. Smoking causes nearly 9 out of 10 lung cancer cases, as well as other lung diseases, such as emphysema and chronic bronchitis. Smoking also makes asthma worse.
  • Heart and circulatory system problems. Smoking increases your risk of dying of cardiovascular disease, including heart attack and stroke. Even smoking just one to four cigarettes daily increases your risk of heart disease. If you have cardiovascular illness or heart failure, smoking worsens your condition. However, stopping smoking reduces your risk of having a heart attack by 50 percent in the first year.
  • Other cancers. Smoking is a major cause of cancers of the esophagus, larynx, throat (pharynx) and mouth and is also related to cancers of the bladder, pancreas, kidney and cervix, and some leukemias.
  • Physical appearance. The chemicals in tobacco smoke can change the structure of your skin, causing premature aging and wrinkles. Smoking also yellows your teeth, fingers and fingernails.
  • Infertility and impotence. Smoking increases the risk of infertility in women and the chance of impotence in men.
  • Pregnancy and newborn complications. Mothers who smoke while pregnant face a higher risk of miscarriage, preterm delivery, decreased birth weight and sudden infant death syndrome (SIDS) in their newborn. Low birth weight babies are more likely to die around the time of birth (perinatal period) or have learning and physical problems later in life.
  • Cold, flu and other illnesses. Smokers are more prone to respiratory infections, such as colds, flu and bronchitis.
  • Diabetes. Smoking increases insulin resistance, which can set the stage for the development of type 2 diabetes. If you have diabetes, smoking can speed the progress of complications, such as kidney disease and eye problems.
  • Weakened senses. Smoking deadens your senses of taste and smell, so food isn't as appetizing.
  • Risks to your family. Spouses and partners of smokers have a higher risk of lung cancer and heart disease, compared with people who don't live with a smoker. If you smoke, your children will be more prone to sudden infant death syndrome, asthma, ear infections and colds.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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You're likely to start by seeing your primary care doctor or a general practitioner.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready, and what to expect from your doctor:

  • Consider your smoking triggers. List the circumstances when you're most likely to reach for a cigarette. In what situations has smoking become a ritual? Are there any situations when you're less likely to smoke?
  • Write down any physical symptoms you've had that may be related to smoking, and for how long.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, as well as any vitamins or supplements, that you're taking.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important in case time runs out. For nicotine dependence, some basic questions to ask your doctor include:

  • Do you think smoking could be causing or worsening my other health problems?
  • Is there still time for my health to benefit from quitting smoking?
  • What treatment options seem most likely to help in my case?
  • What should I do to start getting ready?
  • Can you refer me to a specialist who can help me stop smoking?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Some questions your doctor may ask include:

  • How many cigarettes do you smoke each day?
  • Do you feel like you need to smoke more than you used to to get the same effects?
  • Do you have any symptoms or health problems that you suspect are related to smoking?
  • Do you smoke around others?
  • Do you have any lifestyle limitations related to smoking, such as difficulty playing sports or trying other physical activities?
  • Has smoking caused any problems at work or in your relationships?
  • Do you have any physical health problems such as heart disease or diabetes?
  • Do you have any mental health problems, such as depression or anxiety?
  • Have you tried to stop smoking? If so, what worked? What didn't work?
  • What are your biggest obstacles to stopping smoking?
  • What motivates you to stop smoking?
  • Will your loved ones support your effort to stop smoking?
  • Have any of your close friends and family also expressed concern about your drinking?

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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There are no physical tests to determine the exact degree to which you're dependent on nicotine. Your doctor may ask you questions or have you complete a questionnaire to get a sense of how dependant you are on nicotine. The more cigarettes you smoke each day and the sooner you smoke after awakening, the more dependent you are.

In diagnosing nicotine dependence, your doctor likely will consider criteria detailed in a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to help them diagnose conditions and by insurance companies to reimburse for treatment.

DSM criteria for nicotine dependence include three or more of the following at any time in the same 12-month period:

  • You've developed nicotine tolerance. The effect of nicotine is most intense the first time you use it. Common side effects, such as nausea and dizziness, will lessen the  more and longer you smoke.
  • You experience withdrawal symptoms when you stop using tobacco.
  • You often take tobacco in larger amounts or over a longer period than intended.
  • You spend a lot of time obtaining or maintaining your supply of tobacco.
  • You've made persistent or unsuccessful efforts to cut down or control your tobacco use.
  • You have limited or given up importanft social, occupational or recreational activities because of tobacco use.
  • You continue to use tobacco despite knowing you have medical problems that are likely related to tobacco dependence.

Knowing your degree of dependence will help your doctor determine the best medication plan for you.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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Like most smokers, you've probably made at least one recent, serious attempt to stop. You may be feeling discouraged about trying again. But it's rare to succeed on your first attempt to stop smoking — especially if you try to do it without help. You're much more likely to succeed if you use treatments that have been proved effective. Medications and counseling both work. Combining these approaches makes it even more likely to work.

Although it may be tough to break your tobacco dependence, the benefits are well worth the effort. Smoking is the single most preventable cause of death in the U.S.

Your health will benefit almost immediately if you stop smoking. Just 20 minutes after your last cigarette, your heart rate goes down. Twelve hours later, levels of carbon monoxide, a toxic gas, in your blood return to normal. Your lung function improves and your circulation starts to get better within three months. After a year, your risk of having a heart attack drops by half. And after five to 15 years, your stroke risk will be the same as that of a nonsmoker.

Many medications, including nicotine replacement therapy and non-nicotine medications, have been approved as safe and effective in treating tobacco dependence. Any of these medications, combined with behavioral changes, can increase your chances of quitting.

Using more than one medication may help you get better results than if you use a single medication. You'll get better results by combining a longer acting medication — such as the nicotine patch or the drug bupropion (Zyban, Wellbutrin) or varenicline (Chantix) — with a short-acting nicotine replacement product, such as nicotine gum, lozenge, nasal spray or inhaler.

If you've tried a medication on your own but haven't been able to stop smoking, talk to your health care provider. He or she can help you move in the right direction by adjusting the dose of your medication, recommending a different medication or using a combination of medications.

Most people who want to stop smoking can benefit from a medication. But if you're pregnant or breast-feeding, you smoke fewer than 10 cigarettes a day or you're under age 18, talk to your doctor before taking any over-the-counter nicotine replacement products.

Nicotine replacement therapy
Nicotine replacement therapy gives you nicotine without the other harmful chemicals in tobacco smoke. Many people mistakenly believe that nicotine causes cancer, but that's not the case. Nicotine replacement medications, including patches, gum, lozenges, nasal spray and inhaler, can help relieve difficult withdrawal symptoms and cravings. The best time to start using nicotine replacement is on the day you set to stop smoking.

Most nicotine replacement products are available over-the-counter:

  • Nicotine patch (NicoDerm CQ, Habitrol, others). The patch delivers nicotine through your skin and into your bloodstream. You wear a new patch each day. The treatment period usually lasts for eight weeks or longer. Don't be in a hurry to stop using the patch, especially if you've stopped smoking or dramatically reduced your smoking. If you haven't been able to stop smoking completely after the two weeks or so of treatment, ask your doctor for help in adjusting the dose of the patch or adding another medication.
  • Nicotine gum (Nicorette, others). This gum delivers nicotine to your blood through the lining of your mouth. It's available in a 2-milligram (mg) dose for regular smokers and a 4-mg dose for heavy smokers. You can use up to 20 pieces a day as needed. Nicotine gum is often recommended to curb cravings. To use the gum correctly, chew it a few times until you feel a mild tingling or peppery taste, then park the gum between your cheek and gumline for several minutes. This "chewing and parking" allows nicotine to be gradually absorbed in your bloodstream. Avoid drinking carbonated or acidic drinks, such as coffee or juice, before or while using nicotine gum or lozenges.
  • Nicotine lozenge (Commit, Nicorette mini lozenge). This is a tablet that dissolves in your mouth and, like nicotine gum, delivers nicotine through the lining of your mouth. The lozenges are available in 2- and 4-mg doses, for regular or heavier smokers. To use the lozenge, place it in your mouth between your gumline and cheek or under your tongue and allow it to dissolve. You'll start with one lozenge every one to two hours and gradually increase the time between treatments.

These nicotine replacement products are available by prescription:

  • Nicotine nasal spray (Nicotrol NS). The nicotine in this product, sprayed directly into each nostril, is absorbed through your nasal membranes into your blood vessels. The nasal spray delivers nicotine a bit quicker than gum, lozenges or the patch, but not as rapidly as smoking a cigarette. It's usually prescribed for three-month periods for up to six months. Side effects may include nasal irritation.
  • Nicotine inhaler (Nicotrol). This device is shaped something like a cigarette holder. You puff on it, and it delivers nicotine vapor in your mouth. You absorb the nicotine through the lining in your mouth, where it then enters your bloodstream. Common side effects are mouth or throat irritation and occasional coughing.

Non-nicotine medications
Medications that don't contain nicotine include:

  • Bupropion. The antidepressant drug bupropion (Zyban, Wellbutrin) increases levels of dopamine and norepinephrine, brain chemicals that are also boosted by nicotine. Bupropion may be prescribed along with a nicotine patch. Bupropion has the advantage of helping to minimize weight gain after you quit smoking. Side effects may include sleep disturbance and dry mouth. If you have a history of seizures or serious head trauma, such as a skull fracture, you shouldn't take this drug.
  • Varenicline (Chantix). This medication acts on the brain's nicotine receptors, decreasing withdrawal symptoms and reducing the feelings of pleasure you get from smoking. Potential side effects include nausea, headache, insomnia and vivid dreams. Rarely, varenicline has been associated with serious psychiatric symptoms, such as depressed mood, agitation and suicidal thoughts.
  • Nortriptyline (Pamelor). This tricyclic antidepressant has been shown to help smokers stop. It acts by increasing the levels of the brain neurotransmitter norepinephrine. It is used as a second line medication to treat tobacco dependence. Side effects may include dry mouth.
  • Clonidine (Catapres). This drug is approved for use in treating high blood pressure, but may be used as a second line medication for tobacco dependence if other medications haven't helped. Its usefulness is limited because of side effects such as drowsiness and sedation.

Counseling, support groups and smoking cessation programs
Combining medications with behavioral counseling provides the best chance for long-term success in quitting tobacco use. Medications help you cope with withdrawal symptoms, while behavioral treatments help you develop the skills you need to stay away from tobacco over the long run. The more time you spend with a counselor, the better your treatment results will be.

Several types of counseling and support can help with stopping smoking:

  • Telephone counseling. No matter where you live, you can take advantage of telephone counseling to help you give up tobacco. Every state in the U.S. has a telephone quit line, and some have more than one. To get help finding the one in your state that's the best fit for you, call 800-QUIT-NOW (800-784-8669).
  • Individual or group counseling program. Your doctor may recommend local support groups or a treatment program where counseling is provided by a tobacco treatment specialist. Counseling helps you learn techniques for preparing to stop smoking and provides support for you during the process. Many hospitals, health care plans, health care providers and employers offer treatment programs or have tobacco treatment specialists who are certified to provide treatment for tobacco dependence. Nicotine Anonymous groups are available in many locations to provide support for smokers trying to quit.
  • Internet-based programs. Several websites offer support and strategies for people who are trying to stop smoking. is free and provides information and techniques as well as blogs, community forums, ask the expert and many other features. Text messaging services, including personalized reminders about a quit-smoking plan, also may prove helpful.

Remember, it's common to lapse, and sometimes relapse. But your goal is no smoking at all — even light or occasional smoking is dangerous. You can learn from past experiences and what may have led to a lapse or relapse. Armed with that knowledge — you'll be stronger during your next attempt.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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When you stop smoking, you'll likely experience some unpleasant or stressful symptoms of nicotine withdrawal. Medications will markedly reduce the difficulty of withdrawal. Even so, it's important to have a plan for managing withdrawal symptoms.

Withdrawal symptoms are usually the most intense during the first week after you stop smoking. They may continue for several weeks, with declining intensity. Although most nicotine withdrawal symptoms pass within a month, you may occasionally experience a strong urge or craving to smoke months after stopping. Triggers or cues that were associated with your smoking can provoke these urges or cravings.

Here are some things you can do to manage withdrawal symptoms:

  • Exercise regularly. Regular physical activity has been found to reduce withdrawal symptoms and help people stop smoking. Exercise also helps offset potential weight gain often associated with stopping.
  • Wait out cravings. Cravings or urges usually last less than five minutes. Wash the dishes, go for a walk or have a healthy snack, such as carrots, an apple or sunflower seeds. Pursue something that keeps your hands busy, and before you know it, the urge will have passed.
  • Identify rationalizations. If you find yourself thinking, "I'll just smoke one to get through this tough time" or "Just one won't hurt," recognize it as a message that can derail your plan. Review your reasons for quitting, and replace that thought with something positive to support your stopping.
  • Talk to a support person if you're feeling anxious or depressed or need encouragement to get through a difficult craving.
  • Avoid high-risk situations. Know your triggers, and stay away from people, places and situations that tempt you to smoke.
  • Be realistic about the energy and time it takes to stop smoking. Adjust your schedule to a lighter workload. Take time to do something fun or simply relax.
  • Eat regular meals, including plenty of fruits and vegetables, and drink more water.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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How can you stay motivated? Start by thinking about the mixed feelings you may have about smoking. Then make a list of your reasons for stopping smoking.

Stopping smoking is a positive change for many reasons. Think of short-term benefits, such as breathing easier, saving money and having better smelling clothes. Long-term benefits include a lower risk of disease, increased chances for a longer life and a healthier environment for your family. Use these reasons to build your motivation. Look at your list often, especially when you feel your motivation is lagging.

To stay smoke-free over the long haul, consider these tips:

  • Identify your major smoking triggers and challenges. This will help you solve problems and have a plan to deal with high-risk situations.
  • Seek support. Social support is key to achieving a stable and solid, smoke-free life. Ask your family, friends and co-workers for support and encouragement. Don't expect them to guess what you need. Be direct, and let them know what specifically helps you most.
  • Practice positive self-talk. Think of one or two phrases to use repeatedly for encouragement, such as "I am grateful to be smoke-free."
  • Set smoke-free boundaries. If there's another smoker in your household, set boundaries by making your home and car smoke-free. Ask smoking co-workers not to offer you a smoke or invite your outside for a smoke break.
  • Regularly review the benefits you're getting from quitting. Look at your list again. Add up how much money you've saved. Ask your family members for their observations.
  • Avoid alcohol. Drinking is a high-risk situation. Avoid drinking situations until you are confident you can remain smoke-free.
  • Reward yourself. Buy a magazine, go to the park, meet a friend for lunch, take a class.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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The best way to prevent tobacco dependence is to not smoke in the first place. The best way to prevent your children from smoking is to not smoke yourself. If you're a parent who smokes, the younger your children are when you quit, the less likely they are to become smokers themselves. Even if you don't smoke, here are some things you might try as a parent:

  • Promote smoke-free environments. Support legislation to make all workplaces smoke-free. Encourage smoke-free public places, including restaurants or other places where your teen may work.
  • Support legislation to increase taxes on tobacco products. Higher prices discourage teens from starting to smoke. Higher prices on tobacco products, coupled with smoke-free workplace laws, are the most effective public health policies to reduce smoking in adults and prevent young people from ever starting.
  • Talk with your teenagers. Ask whether their friends smoke. Most teenagers smoke their first cigarette with a friend who already smokes.
  • Learn what your children think about smoking. Ask them to read this article so that you can discuss it together.
  • Help your children explore personal feelings. Use nonjudgmental questions and rehearse with them how they could handle tough situations regarding peer pressure and smoking.
  • Note the social repercussions. Remind your teenager that smoking gives you bad breath and makes your hair and clothes smell.
  • Work with your schools. Become active in community stop-smoking programs.

©1998-2013 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.
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