Smoking & Struggling: Nicotine Dependence & Co-Morbid Psychiatric Illnesses

Addressing the Addiction

The 2021 National Survey on Drug Use and Health found that among individuals aged 12 and older in the United States, approximately 22.0% report using tobacco or nicotine vaping products in the last 30 days. Further, the 2022 Future Monitoring Survey found that among young people, approximately 8.7% of 8th graders, 15.1% of 10th graders, and 24.8% of 12th graders report using any form of nicotine in the past 30 days.[1] 

While the smoking rates among adults without chronic conditions are significantly reduced over years, the rates remain high among adults with psychiatric disorders.[2] Nicotine dependence especially affects individuals with underlying mental illnesses or cognitive impairments, at a rate of approximately 41% - twice the rate of which the CDC reports for the general population. Many nicotine-dependent individuals have comorbid psychiatric disorders, such as attention-deficit hyperactivity disorder (ADHD), anxiety disorders, and depression.[3]

Nicotine Dependence & Comorbid Psychiatric Disorders 

Smoking is the leading and most preventable cause of death in the United States, which is disproportionately affecting those with psychiatric disorders. By determining the prevalence of nicotine dependence and comorbid psychiatric disorders, smoking cessation efforts can be more focused upon those affected individuals.[4]

Miller (2005) conducted a representative sample study of U.S. adults, to investigate the connection between nicotine dependence and psychiatric disorders. A face-to-face interview conducted according to the DSM-IV interview schedule assessed the dependence on nicotine and the presence of a wide range of psychiatric disorders based on DSM-IV criteria. One of the criteria was whether they used nicotine to alleviate withdrawal symptoms of nicotine. This could be assessed based on four factors:[5]

1. Using nicotine upon waking

2. Using nicotine despite being restricted from its use (e.g., banned in certain locations, activities, events)

3. Using nicotine to avoid withdrawal symptoms

4. Waking up in the middle of the night to use nicotine

The study concluded that a significant correlation exists between individuals with a nicotine dependence and certain Axis I (e.g., alcohol and drug use disorders, major depression, dysthymia, mania, hypomania, panic disorder with and without agoraphobia, social phobia, specific phobia, and generalized anxiety disorder) and Axis II disorders (e.g., avoidant, dependent, obsessive-compulsive, histrionic, paranoid, schizoid, and antisocial PDs).[6] There was an especially strong association to disorders involving alcohol and other drug use, as well as mood disorders such as major depression, specific phobia, antisocial, and paranoid personality disorders.[7] 

Nicotine smoking has also been found that put individuals at an increased risk for suicide, biopolar disorder, and a dose-response relationship has been found between smoking and schizophrenia. In a two-sample Mendelian randomization study conducted by Yuan et. al (2020), the odds ratios of smoking initiation was higher for all seven psychiatric disorders included in the study than for no psychiatric disorder at all. The disorders and odds ratios include 1.96 for suicide attempts, 1.69 for post-traumatic stress disorder, 1.54 for schizophrenia, 1.41 for bipolar disorder, 1.38 for major depressive disorder, 1.20 for insomnia, and 1.17 for anxiety.[8]

The symptoms of ADHD are notably similar to withdrawal symptoms of nicotine. For example, such symptoms include deficits in sustained attention, response inhibition, and working memory. Pomerleau et. al (1995) found in their study that individuals with ADHD are at more risk for smoking due to the similarities in these symptoms, and the quit ratio for smokers with ADHD was 29%, while the quit ratio for smokers with no mental illness was a significantly higher percent of 48.5%. Other studies have also reached similar results, with Lambert and Hartsough (1998) finding tobacco dependence to be 40% in individuals with ADHD, compared to 19% for individuals without ADHD.[9] 

The reason why nicotine dependence affects patients with psychiatric disorders disproportionately higher is because people may attempt to self-medicate to alleviate symptoms of their mental disorders with nicotine. For some, nicotine abstinence may actually worsen symptoms of mental disorders.[10] Moreover, about 20 years ago, major tobacco US manufacturers recognized that a large proportion of their customer population was individuals with underlying psychiatric disorders. Knowing this, they began to craft advertisements and marketing of their nicotine products to target consumers with different psychological needs, such as using nicotine to manage mood, anxiety, stress, anger, social dependence, and insecurity.[11] 

Why is Quitting So Hard? 

Smoking cessation for individuals with psychiatric disorders is significantly more difficult than for healthy individuals for a variety of reasons. For one, smoking increases metabolism against antipsychotic medications. For example, smokers with schizophrenia would then have a lower ratio of serum concentration to dose of antipsychotics. Genetic differences influence which individuals will develop a nicotine addiction upon initial use of the drug. In particular, individuals with a fast metabolism may experience quicker nicotine withdrawal symptoms after being exposed to it, increasing the risk of nicotine dependency. The cessation process also involves addressing the fundamental deficit in cognitive processing that nicotine temporarily resolves. For example, in patients with schizophrenia, this deficit may be the psychotic symptoms.[12] 

Some individuals with a mental health illness may believe that the initial worsened feelings of anxiety and depression, withdrawal symptoms, upon cessation indicate that quitting nicotine will worsen their mental health. However, multiple researchers, such as Wu et. al (2023), have shown that long-term cessation of smoking among people with and without psychiatric disorders improved mental health outcomes. The incorrect psychological perception that smoking relieves stress prevents many people from trying to stop smoking. This distress is simply the cause of nicotine withdrawal, which would eventually end in long-term cessation.[13]

Smokers with a mental illness are also significantly more likely to develop nicotine withdrawal syndrome, where the symptoms of withdrawal are more severe and distressful. This heavy burden of withdrawal also makes it more difficult for a psychiatrically ill patient to quit. This makes nicotine withdrawal an important target for intervention for smokers with a mental illness.[14]

Starting the Journey to Stop Smoking 

Patients with a psychiatric illness and comorbid nicotine dependence are dying 25 years younger than the general population, from smoking-related illnesses such as heart and lung disease.[15] Understanding why these patients smoke, becoming dependent on nicotine, and what we can do to encourage smoking cessation would help prevent these premature mortalities.

Psychosocial support and medication are two types of treatment that have been published by the United States Public Health Service Guidelines in 2000 for general medical patients. However, these treatment types may not be completely suitable or applicable to psychiatric patients as well. Psychosocial support involves cognitive-behavior therapy (CBT) strategies to target identifying smoking cues, breaking the link between smoking and these cues, and learning alternative coping mechanisms. A formal program with other people trying to quit smoking may also contribute to the social aspect of support. Medications for nicotine replacement include bupropion, nortriptyline, clonidine, and varenicline. Identifying what a patient has already tried during their attempts to quit nicotine, as well as their mental and physical reactions to it, can help to determine what the next method of quitting can entail.[16]

If one is trying to quit, it is important to recognize that the cessation process will require constant effort. Overcoming withdrawal symptoms (e.g., feelings of irritability, anger, and depression) can be done by staying active, connected with people, and busy. Anxiety and depression levels are significantly reduced within the first few months of cessation, which means these withdrawal symptoms will decrease automatically, as well.[17] The Centers for Disease Control and Prevention (CDC) (2022) explains withdrawal symptoms that one may experience, and ways to manage them, including:[18] 

• Urges/Cravings

• Medications to quit 

• Avoiding triggers and cues to smoke (people one smokes with, places one smokes, activities one frequently does while smoking)

• Remind oneself why one is quitting

• Irritability/Anger

• Deep breaths

• Meditation

• Therapy

• Restlessness

• Physical activity

• Reducing caffeine intake

• Difficulty Concentrating

• Limiting activities with strong concentration for a short period of time

• Recognizing that this is an effect of nicotine withdrawal

• Trouble Sleeping

• Reducing caffeine, especially near bedtime

• Taking off nicotine patches at least an hour before sleeping

• Reducing electronic device usage

• Adding physical activity during the daytime

• Building a sleep schedule

• Excessive Hunger/Weight Gain

• Snacking smart

• Physical activity

• Mindfulness/focusing on eating while eating

• Anxiety or Depression Symptoms

• Physical activity

• Scheduling and organization

• Social interactions

• Rewarding yourself

• Speaking to a healthcare provider

If one is experiencing nicotine dependence and comorbid psychiatric illnesses, or having severe difficulty with quitting nicotine due to withdrawal symptoms, it is important to reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) or healthcare provider for guidance and support. 

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 U.S. Department of Health and Human Services. (2023, January 23). What is the scope of tobacco, nicotine, and e-cigarette use in the United States?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-scope-tobacco-use-its-cost-to-society  

2 U.S. Department of Health and Human Services. (2023b, February 24). Do people with mental illness and substance use disorders use tobacco more often?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/do-people-mental-illness-substance-use-disorders-use-tobacco-more-often 

3 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). Nicotine Addiction and Psychiatric Disorders. International review of neurobiology, 124, 171–208. https://doi.org/10.1016/bs.irn.2015.08.004 

4 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). Nicotine Dependence and Psychiatric Disorders in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(11):1107–1115. doi:10.1001/archpsyc.61.11.1107 

5 Ibid. 

6 Ibid. 

7 Ibid. 

8 Yuan, S., Yao, H. & Larsson, S.C. (2020). Associations of cigarette smoking with psychiatric disorders: evidence from a two-sample Mendelian randomization study. Sci Rep 10, 13807 https://doi.org/10.1038/s41598-020-70458-4 

9 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). 

10 Ibid. 

11 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). 

12 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). Smoking cessation in patients with psychiatric disorders. Primary care companion to the Journal of clinical psychiatry, 10(1), 52–58. https://doi.org/10.4088/pcc.v10n0109 

13 Wu A.D., Gao M., Aveyard P., Taylor G. (2023). Smoking Cessation and Changes in Anxiety and Depression in Adults With and Without Psychiatric Disorders. JAMA Network Open. 6(5):e2316111. doi:10.1001/jamanetworkopen.2023.16111

14 Smith, P. H., Homish, G. G., Giovino, G. A., & Kozlowski, L. T. (2014). Cigarette smoking and mental illness: a study of nicotine withdrawal. American journal of public health, 104(2), e127–e133. https://doi.org/10.2105/AJPH.2013.301502 

15 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). 

16 Centers for Disease Control and Prevention. (2023, February 10). People with mental health conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/groups/people-with-mental-health-conditions.html   

17 Ibid.

18 Centers for Disease Control and Prevention. (2022, December 12). 7 common withdrawal symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/7-common-withdrawal-symptoms/index.html 

Exploring the Mechanisms, Popularity & Health Implications of Vaping

How Does Vaping Work?

Vaping imitates the act of smoking by utilizing battery-powered devices that produce an aerosol resembling water vapor. However, this aerosol contains not only nicotine but also flavorings and over 30 additional chemicals. When inhaled, the aerosol enters the lungs, allowing the nicotine and chemicals to enter the bloodstream. A single vape pod contains the same amount of addictive nicotine as 20 cigarettes. Vaping conditions the brain to anticipate higher nicotine levels, leading to a stronger desire to vape.[1]

Initially, vape devices resembled traditional cigarettes, but more recent models have taken on different forms, such as resembling a USB flash drive or a compact pod. Vaping devices vary in their appearances, yet they share fundamental components, including a battery, sensor and atomizer/flavor cartridge.[2]

Targeted Age Group

As numbers for cigarette smoking have been on the decline for the past year, the popularity of vapes, a type of e-cigarette, has exploded in the United States, especially in younger generations. Johns Hopkins Medicine conveyed that over two million middle and high school students admitted to the use of vapes in 2022, with 80% of them using flavored e-cigarettes.[3] The Texas Health and Human Services notes that the teenage brain is particularly vulnerable to the impact of nicotine, making it more challenging to quit vaping and raising the likelihood of teens transitioning to smoking tobacco cigarettes due to nicotine addiction.[4]

Vaping devices have gained immense popularity among teenagers, becoming the most prevalent form of nicotine used among youth in the United States. A 2020 report from the National Institute on Drug Abuse indicates that many teens are unaware that vaping cartridges contain nicotine and mistakenly believe they only contain flavoring.[5] The widespread availability of these devices, captivating advertisements, a wide range of e-liquid flavors, and the perception that they are safer than traditional cigarettes contribute to their appeal among this age group. Moreover, their concealable nature, lacking the distinct odor of tobacco cigarettes, and their ability to be disguised as flash drives make them easier for teens to hide from teachers and parents.[6]

Why do People Vape?

The idea that vaping is less harmful than smoking has made it especially popular to young audiences, who do not see negative repercussions from the devices and often do not even know they contain nicotine.[7] According to the CDC, some vaping devices advertise themselves as not even containing any nicotine despite being found to have it.[8] The popularity of vaping makes it extremely accessible to young people, and teenagers are especially susceptible to the idea of doing something because those around them choose to participate. The CDC adds that one of the most common reasons provided for beginning to vape by middle and high school students in the United States was that they had a friend who used vapes. Further, most participants added they continued to vape due to feelings of stress, depression and anxiety.[9]

Negative Health Effects

While there is a belief that vaping is significantly better for health than smoking cigarettes, this is not necessarily true. Vaping can be linked to a number of lung injuries and even deaths as a large number of harmful chemicals have been identified in these devices. Nicotine, found in both traditional cigarettes and e-cigarettes, serves as the main active component and possesses a strong addictive nature. It generates a desire for smoking and can lead to withdrawal symptoms if the craving is ignored. Johns Hopkins Medicine notes that nicotine is considered a toxic substance, capable of elevating blood pressure, triggering a surge in adrenaline levels, accelerating heart rate, and augmenting the risk of experiencing a heart attack.[10]

effects on the brain

Additionally, the use of nicotine during adolescence can pose risks to the developing brain, which continues to mature until approximately the age of 25. Nicotine consumption during this stage can potentially harm the regions of the brain responsible for attention, learning, mood regulation and impulse control.[11] In the process of forming memories or acquiring new skills, the brain establishes stronger connections (synapses) between its cells, and the adolescent brain constructs synapses at a faster rate compared to adult brains. However, nicotine alters the normal formation of these synapses. Furthermore, the use of nicotine during adolescence may also heighten the likelihood of future addiction to other substances.[12]

easing Anxiety?

The CDC found that when asked why they vape, one of the most common responses youth will provide is that it, “helps ease their feelings of stress, anxiety or depression”. However, continuous use of an e-cigarette can actually exacerbate these feelings.[13] Nicotine-containing e-cigarettes exert an impact on various major systems within the body. For instance, vaping stimulates increased dopamine activity in the brain's reward pathway, elevates heart rate and blood pressure, and potentially disrupts the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. These physiological changes, in turn, have psychological implications for addiction, cognition, mood and anxiety.[14]

The use of nicotine salts in e-cigarettes enhances the efficiency of nicotine delivery, potentially increasing their addictive nature. Vaping may also result in short-term enhancements in cognitive performance, as nicotine has the ability to improve memory and attention. Users of e-cigarettes often report mood-enhancing and anxiety-reducing effects, although Tattan-Birch & Shahab (2020) note these may be actually attributed to the relief of withdrawal symptoms.[15] Symptoms of nicotine withdrawal encompass irritability, restlessness, feelings of anxiety or depression, sleep difficulties, impaired concentration, and intense cravings for nicotine. In an attempt to alleviate these symptoms, individuals may continue using tobacco products and associate their feelings of relief with the act of vaping rather than withdrawal. Teenagers may resort to vaping as a means to cope with stress or anxiety, inadvertently perpetuating a cycle of nicotine dependency.[16]

If you or someone you know is struggling with anxiety and/or nicotine addiction, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support. Click here to see our interview on the role of social anxiety in addiction as well as how Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) can be effective methods at overcoming substance abuse.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Texas Health and Human Services. (2023). What is Vaping? Texas Department of State Health Services. https://www.dshs.texas.gov/vaping/what-is-vaping#:~:text=Vaping%20simulates%20smoking.,cross%20over%20into%20the%20bloodstream.

2 Ibid.

3 Blaha, M. J. (2022). 5 Vaping Facts You Need to Know. Johns Hopkins Medicine.  https://www.hopkinsmedicine.org/health/wellness-and-prevention/5-truths-you-need-to-know-about-vaping

4 Texas Health and Human Services

5 NIDA. 2020, January 8. Vaping Devices (Electronic Cigarettes) DrugFacts. Retrieved from https://nida.nih.gov/publications/drugfacts/vaping-devices-electronic-cigarettes

6 Ibid.

7 Johns Hopkins Medicine

8 Centers for Disease Control and Prevention. (2022). Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults. CDC. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

9 Ibid.

10 Johns Hopkins Medicine

11 CDC

12 Ibid.

13 Ibid.

14 Tattan-Birch, H., & Shahab, L. (2020). The Psychobiology of Nicotine Vaping. In Psychobiological Issues in Substance Use and Misuse (1st Edition). Routledge. 

15 Ibid.

16 CDC