Nicotine is a highly addictive substance that not only perpetuates tobacco use, the leading cause of preventable morbidity and mortality in the United States, but also has its own adverse effects. Nicotine addiction is a chronic and relapsing disease and the prevalence of nicotine addiction is higher than that of alcohol and other drug addiction. The use of nicotine-containing products not only is associated with developing nicotine addiction, but also with using and becoming addicted to alcohol and other drugs. Despite the decline in recent years in the use of cigarettes, the use of alternative, non-cigarette nicotine products has been rising dramatically. While the overall harm of these products appears to be considerably lower than the harms associated with cigarette use, all nicotine-containing products carry the risk of addiction and other adverse health effects and, therefore, are a threat to the public health.

1. Understanding And Addressing
Nicotine Addiction
A Science-Based Approach to Policy and Practice
October 2015

2. Nicotine is Not Harmless
• Increase in blood pressure, respiration, and heart rate
• Adversely affects nervous, cardiovascular, respiratory,
and reproductive systems
• May contribute to cancerous tumor development
• Can be lethal if orally ingested
• Associated with poor reproductive health outcomes
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3. Nicotine is Not Harmless
• Early exposure can produce lasting effects on brain and
lung development
• Early exposure is associated with cognitive, emotional,
and behavioral deficits
• Perpetuates the use of harmful tobacco products
• Increases the risk of nicotine addiction and alcohol and
other drug use and addiction
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4. Nicotine Addiction Among
Cigarette Smokers
Overall, 37% of individuals aged 12 and older who reported
smoking cigarettes in the past 30 days had nicotine addiction
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5. Nicotine Addiction Linked to
Other Substance Use Disorders
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6. How Do People Become
Addicted to Nicotine?
• The mechanism is similar to how the other addictive
substances (e.g., stimulants) and highly rewarding
behaviors (e.g., gambling) produce addiction
• After entering the bloodstream, nicotine reaches the brain
within seconds and triggers a cascade of biochemical
reactions that are interpreted by the brain as rewarding
• Nicotine also acts on the adrenal glands, triggering the
release of natural stimulants including adrenaline
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7. How Do People Become
Addicted to Nicotine?
• Brain cells (neurons) stimulated by nicotine release
chemicals, such as dopamine, that produce feelings of
pleasure and that maintain or perpetuate those feelings
• Reactions along the brain pathways affected by nicotine
lead to changes in mood, increase concentration, and
decrease appetite
• After continued use, the body adjusts to the presence of
nicotine and increasing amounts are needed to produce the
same rewarding effects (i.e., tolerance) and to stave off the
negative effects of its absence (i.e., withdrawal)
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8. How Do People Become
Addicted to Nicotine?
• Withdrawal symptoms--such as anxiety, depression, and cognitive
deficits--can occur within minutes of the last dose of nicotine,
increasing the risk of repeated use to avoid discomfort
• As tolerance develops, nicotine ingestion must occur more frequently
and at shorter intervals to alleviate withdrawal symptoms
• Even when not ingesting nicotine, someone addicted to nicotine can
experience craving and withdrawal symptoms merely by being exposed
to cues that are mentally linked with nicotine use, such as specific
times of day, cigarette packaging and lighters, or social situations
where nicotine use tends to occur
• People are particularly susceptible to these triggering cues when they
are experiencing stressful life events
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9. Symptoms of Nicotine Addiction
A problematic pattern of use leading to clinically significant impairment/distress,
manifested by at least 2 of the following occurring within a 12-month period:
1. Tobacco taken in larger amounts or over a longer period than intended
2. Persistent desire or unsuccessful efforts to cut down or control use
3. A great deal of time spent in activities necessary to obtain or use
4. Craving, or a strong desire or urge to use
5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, home
6. Continued use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of tobacco
7. Important activities given up or reduced because of use
8. Recurrent use in physically hazardous situations
9. Continued use despite knowledge of having a persistent or recurrent physical or
psychological problem likely caused or exacerbated by tobacco
10. Tolerance
11. Withdrawal
Severity: Mild (2-3 symptoms), Moderate (4-5 symptoms), Severe (6 or more symptoms)
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10. Factors That Increase the Risk of
Nicotine Use and Addiction
Genetics and Physiology
• Genetics play a greater role than environmental factors in
predicting nicotine addiction, e.g., by determining how the
body metabolizes or processes nicotine
• Biological factors related to how the brain produces and
reacts to dopamine are associated with the risk of developing
nicotine addiction
• Certain personality traits that have a strong genetic basis,
such as risk-taking, sensation seeking, and cognitive
difficulties, can increase the risk of nicotine use and addiction
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11. Factors That Increase the Risk of
Nicotine Addiction
The Environment
• Prenatal exposure to nicotine
• Parents’ or peers’ nicotine product use
• Childhood trauma
• Use of products containing menthol
– Menthol is associated with an increased risk of smoking initiation, greater smoking
frequency, and nicotine addiction, and with decreased smoking cessation
– Menthol reduces the rate of nicotine metabolism (increasing exposure to nicotine) and
increases the reinforcing value of nicotine and the risk of addiction
– Menthol nicotine products disproportionately appeal to young people, blacks, and
women--groups historically singled out by the tobacco industry for targeted marketing
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12. Groups at Increased Risk
• Young people relative to adults
• Early initiators of nicotine use relative to later initiators
• People who use multiple nicotine products relative to a
single nicotine product, especially if cigarettes are one of
the products used
• People with mental illness or psychiatric symptoms
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13. Prevention
• The main way to prevent nicotine addiction is to prevent people
from using products that contain nicotine
• Because most people who are addicted to nicotine began using
nicotine products in adolescence or early adulthood, prevention
strategies that are implemented early tend to work best
• Effective approaches are comprehensive and involve:
– Public education and awareness
– Research-based policies/regulations that curb access and availability
– Early detection of risk
– Health-based interventions that promote cessation
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14. Effective Policies and Regulations
• The 2009 Family Smoking Prevention and Tobacco
Control Act gave the Food and Drug Administration
(FDA) the authority to regulate the manufacture,
distribution, and marketing of certain tobacco products
• In 2016, the authority of the FDA was extended to all
nicotine-containing products
• The FDA can prohibit the sale of cigarettes with
“characterizing flavors” (except menthol); require bigger
and more graphic warning labels on product packages
and advertisements; prohibit “reduced harm” claims; and
require FDA approval for new tobacco products
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15. Effective Policies and Regulations
• Taxes - Raising taxes on tobacco products increases their
cost, which has been associated with less smoking and more
smoking cessation, especially among youth
• Smoking Bans - Clean indoor/outdoor air laws
• Restrictions on Advertising – Extensive for cigarettes, limited
for non-cigarette nicotine products
• Warning Labels – Required on product packages and
advertisements
• Restricting Youth Access – Minimum legal purchase/sale age
for tobacco products
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16. Interventions and Treatment
• Brief interventions
• Smoking cessation quitlines
• Pharmaceutical therapies
– Nicotine replacement therapy (nicotine patches, gum, nasal
spray, inhalers, lozenges, and sub-lingual tablets)
– Bupropion (a prescription antidepressant medication)
– Varenicline (reduces rewarding effects of smoking as well
as craving and withdrawal symptoms)
• Psychosocial/behavioral therapies
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17. Recommendations for Policymakers
Strengthen tobacco control regulations and policies and apply them to
all nicotine products:
• Prohibit the marketing of nicotine products in any way that targets or appeals to youth
• Restrict youth access to all nicotine-containing products
• Include appropriate health warnings on all nicotine-containing products
• Improve packaging to prevent accidental nicotine poisonings, especially by youth
• Protect non-users from exposure to secondhand or passive smoke or aerosol
• Increase pricing (through higher taxes) to help minimize youth initiation and use
• Ensure the transparency and consistency of ingredients, dosing, and functioning of products
• Reduce the addiction potential of nicotine-containing products
• Invest in quality research to fill gaps in knowledge
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18. Recommendations for Policymakers
Actions for state and local governments:
• Increase funding for comprehensive, evidence-based prevention and cessation programming
• Enforce tobacco tax and point-of-sale laws, control retail outlet density and location, and
promote responsible sale and distribution of nicotine products
• Increase enforcement of laws restricting the sale of nicotine products to minors
• Enact strong and comprehensive indoor and outdoor clean air laws that prohibit the use of all
nicotine products anywhere the use of cigarettes is prohibited
• Enact zoning laws that restrict the density of nicotine product retail outlets
• Raise the minimum legal purchasing age to 21 for all nicotine-containing products
• Increase taxes on all nicotine products to help prevent youth initiation and reduce use
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19. Recommendations for Practice
• Identify nicotine use through routine screening for all forms of
nicotine product use
• Provide or connecting those who use nicotine products with
evidence-based interventions
• Incorporate screening and interventions into routine health care
practice and educational health initiatives
• Ensure a health- rather than a punitive-based intervention approach
• All addiction treatment programs, as well as criminal justice and
social service settings, should be required to address addiction
comprehensively--banning nicotine product use and specifically
including treatment for nicotine addiction in their services
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20. Conclusion
Nicotine is a highly addictive substance that not only perpetuates tobacco
use, the leading cause of preventable morbidity and mortality in the United
States, but also has its own adverse effects.
Public health and policy efforts have been remarkably successful in
reducing rates of cigarette smoking in the U.S. over the past few decades.
However, we must not allow the growing use of non-cigarette nicotine
products to undo decades of hard-won progress in reducing the health and
financial costs of nicotine product use.
A rational and science-based approach to the regulation of these products
is required.
Adequate attention must also be paid to preventing the use of all addictive
substances, including nicotine, and providing effective treatments that
reduce or eliminate harm to those with addiction.
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21. www.centeronaddiction.org