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3 Psychological effects of nicotine and smoking in man

3.1 The effects of nicotine and smoking on mood and cognition
3.2 The nicotine withdrawal syndrome
3.3 Psychological dependence on nicotine and smoking
References

3.1 The effects of nicotine and smoking on mood and cognition

Demonstration of nicotine addiction and evidence of putative underlying neurobiological mechanisms in animals do not establish conclusively that nicotine has psychological effects in man. Furthermore, much of the evidence on the psychological effects of nicotine in man is derived from studies of smokers, and the question therefore arises as to how much any psychological effect of smoking is in fact attributable to nicotine. Evidence relating to this question is reviewed in this chapter.
Smokers' perceptions of the psychological effects of smoking

From early on in their smoking career, smokers perceive that smoking provides certain psychological benefits. 'Feeling calmer' is typically the most commonly reported subjective effect of smoking, with 64% of adolescent female daily smokers reporting feeling calmer while smoking compared with 38% of non-daily smokers.1 An earlier study2 of over 5,000 adolescent boys found that 68% of those who smoked agreed that smoking helped them feel more at ease, and 79% agreed that smoking can help people when they feel nervous or embarrassed. There was also some evidence suggesting that these percentages increase with age.

Studies in adults have found similar results. In one study of 600 adult smokers,3 53% agreed strongly and 38% agreed mildly with the statement 'smoking can help people relax', whilst only 2% disagreed strongly. Another typical study4 asked a representative sample of over 500 British smokers how likely they thought that they would be able to do various things (eg relax, concentrate or feel confident with other people) if they:

carried on smoking
cut down their smoking by half, or
stopped smoking altogether.

The response most strongly determined by smoking status was the ability to relax: 77% felt they would be able to relax if they continued smoking and only 8% said they would not, whereas only 40% felt they would be able to relax if they quit, and 38% felt they would be unlikely to be able to relax if they stopped smoking. Other factors were perceived to be less likely to be affected by smoking status: for example, 65% felt they would be able to concentrate if they continued smoking, whilst 56% felt they would be able to concentrate if they quit. Even in studies which failed to find a 'sedative' factor in the questionnaire structure, the questionnaire items which appeared to relate most strongly to negative affect reduction received very high agreement ratings. For example, in the study by Russell et al,5 73% of a sample of smokers and 91% of a smokers' clinic sample stated that they smoked more when they were worried. This can be compared with only 34% and 57% of the same two samples who felt that smoking helps to keep them going when they are tired, and only 13% and 11% who felt more attractive to the opposite sex when smoking.

Although these studies have identified several reasons given by smokers as to why they smoke, they have not been designed to compare the relative importance of different smoking motives. However, the effect for which smokers most consistently say they smoke is the alleviation of an unpleasant mood state in which they feel tense, irritable and miserable. Adult smokers report this reason for smoking more frequently than saying that smoking helps them to think and concentrate.5 Interestingly, however, many of the studies described above found that non-smokers also perceived smoking as having a mood regulating effect. Indeed, studies of beliefs about smoking in children have found that children who have never smoked already perceived smoking as having beneficial effects on mood. For example, in the 1994 survey by the Office of Population, Censuses and Surveys of almost 3,000 11-15 year olds in England,6 58% of never-smokers agreed with the statement, 'smoking helps people relax if they feel nervous'. Of those who were already weekly smokers, 89% agreed with this statement. However, only 25% of never-smokers and 32% of regular smokers agreed with the statement that 'smokers stay slimmer than non-smokers'. This suggests that some beliefs about smoking may be learned by methods other than personal experience, and raises the question of whether smoking or nicotine really does produce a positive effect on mood and/or cognitive performance.

Laboratory studies of the effect of nicotine and smoking on mood

Since smokers frequently state that they feel more inclined to smoke when they feel tense, embarrassed, depressed, angry or bored, and readily agree with statements to the effect that smoking can help reduce these unpleasant emotions, it would be expected to be fairly straightforward to design and conduct a laboratory study showing that smoking a cigarette (or receiving nicotine some other way) improves the smoker's mood relative to some control procedure.

However, numerous laboratory studies have failed to detect any mood enhancing effects of smoking or nicotine. In one fairly typical study,7 16 overnight-deprived smokers smoked five medium-nicotine cigarettes or five nicotine-free cigarettes, each separated by 30 minutes. The subjects' mood was assessed by a Feeling State Questionnaire (0-10 ratings of strength of 19 subjective states including tension, happiness, relaxation and worry), completed before the first and last cigarettes and after the second and last cigarettes. The only one of these 19 mood items which showed a significant improvement on nicotine cigarettes compared with nicotine-free cigarettes was drowsiness which was reduced to a greater degree by the nicotine cigarettes. This study found that the first cigarette of the day produced a mild stimulant effect, and that this effect was maintained by subsequent cigarettes. However, no effects on dysphoric mood were detected.

A review of the area of smoking and affect regulation8 concluded that 'nicotine reduces anxiety and negative affect in chronic smokers'. Eight studies were cited which failed to find beneficial effects of nicotine on mood, but it was suggested that in these studies either the smokers of high-nicotine cigarettes received too much nicotine, or that the mood enhancing effects occur only when the smoker is exposed to mild to moderate anticipatory anxiety. This might explain why studies with no stressor7 and studies involving brief periods of high stress9 do not generally find a calming effect of smoking.

On the other hand, the few laboratory studies which found improvements in mood following smoking nicotine cigarettes have generally studied nicotine-deprived smokers. It therefore remains possible that any effects are attributable to withdrawal relief rather than to mood enhancement per se.10 Similarly, many of the studies requiring participants to smoke a cigarette have not included adequate control conditions, with participants also smoking a denicotinised cigarette in a double-blind manner. Any effects detected with the weaker designs could easily be attributable to the expectations or demand characteristics of the experimental situation.

Some studies have administered controlled doses of nicotine in a placebo-controlled, double-blind fashion to smokers and non-smokers using routes other than inhalation. One study11 found that subcutaneous injections of nicotine produced no mood enhancement in either 24-hour deprived smokers or never-smokers, with the mood of the latter worsening on the higher nicotine dose (0.6 mg). These results are consistent with those of others12,13 who have found that nicotine administered to non-smokers via a nasal spray produced dose-dependent increases in ratings of feeling 'jittery', with no beneficial effects on mood. Similarly, it has been found that intravenous nicotine increased anxiety relative to placebo in non-smoking patients with Alzheimer's disease, and that a moderate dose increased ratings of tension, depression and confusion over those reported with a lower dose (no placebo was given in this study) in healthy non-smoking volunteers.14 It is possible that the worsening of mood at high nicotine doses in these studies is due to mild overdosing, but the complete absence of any beneficial effects at lower doses, either before or after a stressor,11 shows that there is no primary mood enhancing effect of nicotine. It seems most likely that the belief that smoking improves mood develops from the repeated experience of mood worsening during periods of abstinence (via nicotine withdrawal), rather than from a consistent effect of smoking improving mood above baseline (never-smoker) levels.

Laboratory studies of nicotine and smoking effects on cognitive performance

The effects of nicotine and smoking on human performance were comprehensively reviewed by Heishman et al.15 They concluded that in non-abstinent smokers and non-smokers, only finger tapping speed and similar motor responses were reliably enhanced by nicotine, and that there were no reliable improvements on tasks with a greater cognitive loading. On the other hand, nicotine was found to have more widespread performance enhancing effects in abstinent smokers. This was interpreted as evidence that nicotine can reverse withdrawal-induced deficits in several areas of performance.

Since that review, however, a number of studies have provided further evidence suggestive of absolute improvements in cognitive performance in humans following nicotine absorption. Low doses of subcutaneous nicotine in non-smokers were found to produce faster reaction times in attentional tasks.16,17 Similarly, low doses of nicotine improved recognition memory in non-smokers,13 and smoking a cigarette produced similar improvements in rapid information processing whether the smokers were deprived of nicotine for one or 12 hours.18 Heishman updated his earlier review in the light of some of these more recent studies and concluded that this new evidence indicates that nicotine produces true enhancement of certain aspects of attention and cognition.19 Further evidence of improvements in aviation simulator flight performance20 and attention tasks21 in non-smokers following placebo-controlled nicotine administration lends further support to this conclusion, which is also consistent with the evidence from studies in rats.22,23 However, the magnitude of this effect of nicotine is small, comparable to the effects obtained by consuming caffeinated beverages.24-26

Other evidence on the psychological effects of nicotine and its withdrawal

Consistent with the laboratory studies, there is good evidence that when smokers attempt to abstain for short periods outside the laboratory environment, their mood and cognitive performance temporarily worsens.27,28 That this nicotine withdrawal syndrome can produce significant mental impairment is supported by a recent study29 which found consistently higher numbers of non-fatal accidents at work reported in the UK on national No Smoking Day than on normal working days over a 10-year period.

There is also clear evidence that smokers tend to be less mentally healthy than never- or ex-smokers, rather than being happier or calmer people.30 Indeed, within countries such as the UK and the US, tobacco use is much more prevalent amongst people with serious mental disorders such as schizophrenia30 or among those incarcerated in prisons.31 This in itself should not be interpreted as strong evidence that smoking causes stress or poor mental health, since it is possible that these individuals use tobacco primarily in an attempt to reduce their stress.32 However, other evidence is consistent with the idea that being a smoker may increase stress and that, in the longer term, quitting actually decreases stress.

When the mood of smokers is measured before and after quitting, their mood typically worsens during the first few days of abstinence, and then returns to previous levels within about four weeks. In studies which have continued to measure these quitters' mood over a longer period, the general finding is that it continues to improve above the level when they were smoking.33 Similarly, it has been found that smokers who manage to quit for six months report a steady reduction in stress from the first month of abstinence, such that six months after quitting their stress levels are lower than when they smoked.34

Additional evidence that smoking may actually increase stress comes from studies of the daily pattern of stress change in smokers. Parrott et al have conducted a number of studies35,36 which demonstrated that smokers' stress levels during a normal smoking day increase rapidly between cigarettes, the net effect being large fluctuations in mood and greater total stress than occurs in non-smokers.

Conclusions

It is evident that smokers perceive that smoking helps alleviate negative mood states, but the available evidence suggests that the only negative mood state so alleviated is that resulting directly from the nicotine dependence itself. Thus, the nicotine in tobacco relieves nicotine withdrawal symptoms, but does not have mood enhancing properties in non-addicted individuals. If anything, the experience of being addicted to tobacco appears to add to, rather than relieve, stress in the everyday lives of smokers.

Paradoxically, although relatively few smokers report that they smoke primarily to help them think and concentrate, the evidence suggests that nicotine can improve certain aspects of cognitive performance, even in non-addicted individuals. The magnitude of this effect is however small.

3.2 The nicotine withdrawal syndrome

A drug withdrawal syndrome is a collection of signs and symptoms caused by abstinence from use of a drug to which there has been physiological adaptation. The symptoms should be temporary because, after a period of sustained abstinence, the body should revert to a normal, drug-free state.37

Abstinence from cigarette smoking is associated with a characteristic set of signs and symptoms which may be labelled the 'cigarette withdrawal syndrome'. Determining whether this syndrome is due specifically to nicotine, as opposed to the loss of other aspects of smoking, requires a demonstration that it is prevented by ingestion of nicotine from another source (eg nicotine chewing gum) or that the syndrome occurs as a result of abstinence from other forms of nicotine intake. Such a demonstration is undermined by the fact that alternative nicotine delivery systems generally result in lower levels of nicotine intake than smoking and also provide nicotine much more slowly. Therefore, even when a particular element of the cigarette withdrawal syndrome is not reliably alleviated by, for example, nicotine gum, it may still represent a nicotine withdrawal state.37 However, there is strong evidence that nicotine replacement reduces the severity of the cigarette withdrawal syndrome in general, and specific elements in particular.38-40

The major changes in mood, physical symptoms and physiological variables that have been reliably shown to follow abstinence from smoking are listed in Table 3.1. The most prominent are symptoms of anxiety, restlessness, poor concentration and irritability or aggression, their relative frequency varying between different smoking populations. The duration of these responses after withdrawal, measured in terms of the time for which they have been shown to be significantly different from pre-abstinence levels, is predominantly four weeks or less, though some effects, such as the increase in appetite, are more protracted. Table 3.1 also identifies those characteristics for which there is consistent evidence of alleviation by nicotine replacement. Studies carried out into how far these responses cohere into a single syndrome suggest that, whilst mood changes tend to go together, increased appetite does not correlate well with other symptoms.44 Tate et al45 have also reported that the presentation of withdrawal symptoms within smokers appears to be relatively consistent over separate, closely spaced abstinence periods, with the possible exception of increased appetite.

Table 3.1. Major signs and symptoms of cigarette withdrawal.

				Incidence

Symptom	Duration²⁷	Reduced by NRT	Predicts relapse⁴¹	Self-quitters²⁷ (%)	Clinic patients⁴² (%)

Irritability/aggression	<4 weeks	Yes	No	38	80
Depression	<4 weeks	Yes	Yes	31	60⁴³
Anxiety	<2 weeks	Yes	No	49	87
Restlessness	<2 weeks	Yes	No	46	71
Poor concentration	<1 week	Yes	No	43	73
Increased appetite	>10 weeks	Yes	No	53	67
Urges to smoke	>2 weeks	Yes	Yes	37	62
Night-time awakenings	<1 week	nk	No	39	24
Decreased heart rate	>10 weeks	Yes	nk	61	79
Decreased adrenaline	<2 weeks³⁹	nk	nk	nk	nk
Decreased cortisol	nk	nk	nk	nk	nk
nk = not known; NRT = nicotine replacement therapy.

There has been some debate as to whether cravings or urges to smoke are also part of this withdrawal syndrome. A powerful case can be made for their inclusion since there is now good evidence that these cravings are reduced by nicotine replacement38 and are correlated with other elements of the withdrawal syndrome.46 In fact, there is also evidence that urges to smoke are probably the single most important element of the withdrawal syndrome, in that they are most clearly predictive of subsequent relapse to smoking.47-49

There has also been debate about whether increased anxiety should be included as a withdrawal symptom. Recent research50 suggests that it should not because it has been found that anxiety levels actually fall rather than rise among totally abstaining smokers (as opposed to those who might have had minor lapses). Some studies have reported an initial elevation in anxiety after stopping smoking, but this is short-lived and followed by a drop to below the levels while smoking.41 It has been argued that the increase in anxiety observed in some studies on cessation of smoking is a psychological response to the attempt to stop, which is made worse when that attempt is not being wholly successful.50 This is an issue that requires clarification.
The overall conclusion that withdrawal from cigarettes results in symptoms and signs that are reversed by nicotine strongly implicates nicotine dependence as at least one major component of dependence on smoking. The concept of the withdrawal symptoms also has important implications for our understanding of the psychological basis for continued smoking.

3.3 Psychological dependence on nicotine and smoking

The development of dependence is an important component of the psychological effects of any drug, and there is abundant evidence that nicotine dependence develops in cigarette smokers. Some of this is derived from observational studies of the trends and patterns of nicotine consumption by smokers, whilst other evidence comes from studies of measures of dependence within smokers. In some of these studies there is an explicit theoretical rationale for the link between the measurement used and the core concept of compulsive use, whereas in others the link is based on unstated assumptions. The evidence is illustrated as follows.

Consumption of nicotine by smokers

Average consumption of cigarettes by male and female smokers in Britain is currently 16 and 14 cigarettes per day respectively, a figure which has changed little over the past 20 years.51 The amount of nicotine ingested from each cigarette varies considerably between individuals, but has been estimated at approximately 1.0-1.5 mg.52,53 These estimates, and also estimates derived from measurements of plasma cotinine concentrations,54 suggest a daily intake of nicotine in smokers of approximately 16-24 mg per day in men and 14-21 mg per day in women. In the absence of constraints by restrictions such as workplace smoking bans, most smokers smoke regularly throughout the day and 34% have their first cigarette within 15 minutes of waking.51 Daily cigarette consumption has been shown in several studies to be consistent over periods of months.55-57 The fact that smoking patterns are so consistent and stable, both in the general population of smokers over time and within individual smokers, implies some degree of dependence on cigarettes.

Markers and measures of dependence in smokers

Daily cigarette consumption. A frequently used marker of dependence is daily cigarette consumption, on the assumption that the more cigarettes smoked per day the harder people should find it to stop. This might reflect several mechanisms, in that a high level of nicotine intake could:

lead to more pronounced neuro-adaptation
reflect a greater constitutional need for nicotine, or
reflect a more highly learned and deeply ingrained habit.

Whatever the mechanism, there is clear evidence that those who smoke more cigarettes per day are less likely to be able to stop.55,58,59

Biochemical markers of nicotine intake. Biochemical markers have also been used as indices of dependence. The most widely used is the concentration of the nicotine metabolite, cotinine, in saliva. This has the advantages, first, of being easily obtained and reflecting nicotine intake over a period of days because of its relatively long half-life,57 and secondly, that cotinine more accurately reflects nicotine intake than daily cigarette consumption. Above about 10 cigarettes per day, the correlation between daily cigarette consumption and nicotine intake is weak,57 probably because of the important influence of puffing and inhalation patterns. In fact, it is possible in principle to obtain as much nicotine from five cigarettes per day as most smokers achieve with 30 per day (see Chapter 6). The level of cotinine in saliva has been shown to predict success of attempts to stop smoking.60
Questionnaire methods of measuring dependence on nicotine. Questionnaire methods have also been used extensively to measure nicotine dependence. Probably the most widely used is the Fagerström Test for Nicotine Dependence (FTND) (see Table 3.2),61 a shortened version of the Fagerström Tolerance Questionnaire (FTQ).62 The measure combines an index of consumption (cigarettes per day) with difficulty tolerating reduced nicotine levels:

time to first cigarette of the day
smoking even when ill
smoking more in the morning
difficulty not smoking in no smoking areas
which cigarette would hate to give up.

Table 3.2. The Fagerström test for nicotine dependence.

Question	Answer	Score

How soon after you wake up do you smoke your first cigarette	Within 5 minutes	3
	6-30 minutes	2
	31-60 minutes	1
	>60 minutes	0
Do you find it difficult to refrain from smoking in places where it is forbidden?	Yes	1
	No	0
Which cigarette would you hate to give up most?	The first one in the morning	1
Which cigarette would you hate to give up most?	Others	0
How many cigarettes per day do you smoke?	<=10	0
	11-20	1
	21-30	2
	>=31	3
Do you smoke more frequently during the first hours after waking than during the rest of the day?	Yes	1
	No	0
Do you smoke if you are so ill that you are in bed most of the day?	Yes	1
	No	0

Note: scores are totalled to yield a single value.

A two-item test, the Heaviness of Smoking Index (HSI), which measures the number of cigarettes per day and the time to the first cigarette of the day, has also been examined.63 The extent to which the FTND measures a single construct has been called into question, as has the theoretical underpinning of the questionnaire.55,64 A threshold of 7 on the FTQ and 6 on the FTND is generally used to divide smokers into high and low dependence categories. Because the FTQ, FTND and HSI have been shown in many studies to predict failure of attempts to stop smoking,65,66 they are held to provide evidence of dependence. However, in terms of quantifying this, it is not clear how far these measures are any improvement over simply measuring the number of cigarettes smoked per day.55

Another questionnaire measure of dependence is the dependence subscale of the Smoking Motivation Questionnaire41 which focuses on subjective feelings of dependence and cravings during abstinence. This scale has been shown to predict the severity of urges to smoke during quit attempts.41 Subjective dependence, measured in terms of perceived difficulty maintaining abstinence, has also been shown to predict failure of quit attempts.65 In Britain, 32% of smokers report that they would find it 'very difficult' to go without smoking for a whole day.51

Other measures of dependence have been derived from the American Psychiatric Association's diagnostic criteria for substance dependence, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III,67 and DSM-IV,68 and from the World Health Organization's International Classification of Diseases (ICD)-10 criteria69 (see Chapter 4 for details):

Hughes et al70 reported that 90% of a general population sample of 1,006 middle-aged male smokers fulfilled DSM-III criteria for dependence, while 36% had an FTQ score of 7 or more. However, concordance between the two measures was low.
Nelson and Wittchen71 used the Composite International Diagnostic Interview (CIDI) (a questionnaire based on DSM-IV) to assess dependence in a sample of 3,021 smokers in Germany aged 14-24 years. They defined 52% of smokers as dependent, most frequently on the grounds of failure of attempts to control or cease use.
Kandel et al72 used items derived from DSM-IV criteria to study drug dependence in a sample of 87,915 adults, and concluded that nicotine was more highly addictive than alcohol, cocaine or marijuana.
Kawakami et al73 examined lifetime prevalence of dependence in male ever-smokers aged 35 or over in Japan using the CIDI to measure dependence according to ICD-10, DSM-IIIR and DSM-IV criteria. Estimates of lifetime prevalence of dependence by these criteria were 42%, 26% and 32%, respectively. They also measured dependence using the FTQ, and found that 19% had a FTQ score of 7 or more. The ICD-10 diagnosis was significantly associated with failure to stop smoking.
Kawakami et al74 have recently developed a new 10-item questionnaire, the Tobacco Dependence Screener, for assessing tobacco dependence according to ICD-10, DSM-IIIR and DSM-IV criteria. This instrument has been shown to have a higher coherence (intercorrelations among items) than the FTQ, to be associated with cigarette consumption, and to predict failure to stop smoking.

Conclusions

There is considerable evidence from questionnaire studies that certain smoking characteristics can predict failure in an attempt to give up smoking, and thus to identify in broad terms dependence or addiction to smoking. Markers of nicotine consumption indicate that smokers maintain a relatively consistent nicotine intake, and that failure to maintain that intake results in symptoms of nicotine withdrawal. Studies of mood effects indicate that the major psychological motivation to smoke is the avoidance of negative mood states caused by withdrawal of nicotine. It is therefore evident that nicotine plays a fundamental role in smoking behaviour.

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Contents

Contributors, Foreword and Key Points
1 Tobacco smoking in Britain: an overview
2 Physical and pharmacological effects of nicotine
3 Psychological effects of nicotine and smoking in man
4 Is nicotine a drug of addiction?
5 The natural history of smoking: the smoker's career
6 Regulation of nicotine intake for smokers, and implications for health
7 The management of nicotine addiction
8 Regulatory approaches to tobacco products in Britain
9 Summary and recommendations

This page last updated on May 8, 2001