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Withdrawal

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Introduction

Stopping smoking is different for everyone. Some smokers find it easy to quit, others don't. However, there are some signs and symptoms that many people have in common when they quit.1,2

What are withdrawal symptoms?

Withdrawal symptoms are a collection of changes in your mood, behaviour, and body.2,3 They usually appear when you stop smoking and are relieved or reversed by starting smoking again.2

Most symptoms occur because you are no longer getting nicotine, the addictive drug in tobacco.1,3 Nicotine in other forms, such as nicotine patches, gum, lozenges and inhaler, reduces the strength of withdrawal symptoms.3

Major symptoms of withdrawal are1,3:

  • Urges to smoke
  • Depressed mood
  • Difficulty sleeping or sleep disturbances
  • Irritability, frustration or anger
  • Anxiety
  • Difficulty concentrating
  • Restlessness
  • Decreased heart rate
  • Increased appetite (hunger) or weight gain
  • Decreased adrenaline and cortisol (brain chemicals)

It's common for people to develop a few of these symptoms when they quit.1,2 Most people only have mild symptoms, but a minority of smokers have more severe symptoms.2,4 Some people also report positive effects from stopping smoking, such as feeling more satisfied.4

Withdrawal symptoms usually appear within the first 24 hours and peak in the first week.5 On average, most symptoms fade and are gone after one month.1,5,6 However, some people have rises and falls in symptoms over several weeks.6,7 Six months after quitting, people usually feel the same as or better than when they were smoking.5

An increase in appetite may last for six months or more.1,5 Most people do gain some weight when they stop smoking, which mostly occurs in the first one or two years after they quit.8 However, research with women shows that in the long term, the average weight of ex-smokers is similar to people who have never smoked.8

Cravings

Cravings (the urge or desire to smoke) can be due to nicotine withdrawal.3 However, they can also be triggered by things that you've learned to link with smoking.9,10,11

Triggers, can be quite varied.10,11 For example, they can be linked to places where you normally smoked, people who you usually smoked with, and being near other people smoking. Similarly, habits or routines such as smoking after meals, drinking coffee or alcohol, or talking on the telephone may bring on cravings.

A lot of people feel the urge to smoke when they feel angry, bored, tense or happy; or when they want to relax. Often, it's a combination of place, activity and emotions that create a strong urge to smoke; for example, being home alone, when doing something routine, or when something stressful is happening.10

Some people have occasional urges to smoke long after other withdrawal symptoms have gone.2 If this happens to you, try not to be disheartened. Even though you've decided that you want to be a non-smoker, there may be times when you still have a desire to smoke. Remind yourself why you want to quit, think how far you've come and what you've gained. As you become used to doing other things instead of smoking in situations which trigger cravings, these urges to smoke tend not to happen as often and be less strong.2,11

Other signs or symptoms when stopping smoking

Some people have reported other symptoms, which may also be due to stopping smoking.

  • Coughing12
  • Other cold symptoms such as sneezing, headache, earache, sore throat, deafness or feeling off-colour12
  • Mouth ulcers12
  • Bowel disturbance, constipation13
  • Drowsiness or fatigue2,5

Reports of coughing after stopping smoking are common.12 However, other cold symptoms, mouth ulcers and bowel symptoms appear to affect small numbers of people only.12,13

Other consequences of stopping smoking

Medicines

Chemicals in cigarettes change the way some medications work.1,14 In some cases, the dose of your medication may have to be changed by your doctor. See your doctor before quitting if you are taking any medication.

Mental illness

Stopping smoking can affect some medications prescribed for mental illnesses, and can sometimes worsen existing mental illness for several months.1,15,16 Although uncommon, stopping smoking can bring on an episode of depression, anxiety or other mental illness in people who have had such illnesses before or who are vulnerable to them.1,15 So, if you have suffered from depression, anxiety or other mental illness, ask your doctor's advice before quitting.

Caffeine

Tea, coffee, chocolate and some soft drinks contain caffeine. Without nicotine from cigarettes, your body retains much more of this stimulant, making you feel restless, irritable, anxious and sleepless.5 Do not drink more cups of coffee or other drinks containing caffeine to distract yourself from cravings for cigarettes.

Eating disorders

People who have eating disorders may be more likely to have an increased appetite and weight gain after they stop smoking.17 If you suspect you have an eating disorder, visit your doctor or dietician.

Menstrual cycle

Women may have worse withdrawal symptoms just before and during their period.18 Nicotine patches appear to help reduce craving for nicotine, period pain and water retention.18

Coping with withdrawal symptoms

Nicotine replacement products - the gum, patches, lozenges, inhaler and tablet - help reduce nicotine withdrawal symptoms.19 They are sold at pharmacies without prescription.

The drug containing bupropion, sold under the brand name Zyban, reduces some nicotine withdrawal symptoms.20 This drug is a non-nicotine pill, and must be prescribed by a doctor, as it is not suitable for all people.

If you are concerned about weight gain, talk to a doctor or dietician, and make a sensible eating plan. Allow yourself some treats, as keeping to a strict diet may reduce your chances of quitting.21 Weight gain may be delayed while using nicotine gum or bupropion.8,15

Doing exercise you enjoy can help lower stress, reduce cravings and withdrawal symptoms and help keep your weight down.21

Try doing activities which give you pleasure and a sense of well being, such as reading, getting involved in new or favourite hobbies, or spending more time with friends and family. Perhaps relax by having a massage or spa, doing deep breathing exercises, listening to music, or taking yoga classes.

Try to resist smoking "just one" cigarette. People who smoke occasionally after quitting report having worse withdrawal symptoms.6 ‘Slip-ups' commonly lead to going back to regular smoking.22

Remember the good things that are happening to your body as well. Now that you have stopped smoking, your body can start to heal and reverse the damage from cigarettes.5

It's important to keep encouraging yourself to stick to your decision to quit. Make a list of the good things about being a non-smoker. Give yourself a pat on the back for your daily successes, and reward yourself occasionally with the money you have saved.

Doing something about managing other sources of stress in your life may help you cope better with withdrawal. Other things which make you tense or frustrated can make your withdrawal symptoms seem worse than they actually are.23 Try the exercise "Doing something about stress" in the booklet "Quit because you can" available by calling Quit on 13 7848.

Here is one way to confront your cravings and overcome the urge to smoke.

Remember the 4Ds:

  • Delay acting on the urge to open a pack and light a cigarette. After a few minutes, the urge to smoke weakens.
  • Deep breathe. Take a long, slow breath, and let it out slowly. Repeat three times.
  • Do something else. Take your mind off smoking by taking action: put on some music, keep your hands busy, go for a walk or ring a friend.
  • Drink water. Sip it slowly, and hold it in your mouth to savour the taste.

You need to understand why you smoke in order to plan how to cope without cigarettes when you quit. You may need to change your behaviour or avoid situations that trigger urges to smoke for a little while. Those who are most successful at resisting the urge to smoke use a range of coping strategies to help them. For more information, advice and support, call the Quitline 13 7848.

References

  1. American Psychiatric Association. Practice guidelines for the treatment of patients with nicotine dependence. American Journal of Psychiatry, 153:10, October 1996 Supplement.
  2. US Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction. A report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health, 1988.
  3. Royal College of Physicians of London. Nicotine addiction in Britain: a report of the Tobacco Advisory Group of The Royal College of Physicians. London: Royal College of Physicians of London, 2000.
  4. Gilbert HM, Warburton DM. Individual variation in psychological and psychomotor symptoms following smoking cessation: the implications for treatment. Psychol Health. 2003; 18(5): 613-624.
  5. US Department of Health and Human Services. The health benefits of smoking cessation. A report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No (CDC) 90-8416, 1990.
  6. Piasecki TM, Jorenby DE, Smith SS, Fiore MC, Baker TB. Smoking withdrawal dynamics: I. Abstinence distress in lapsers and abstainers. J Abnorm Psychol. 2003;112(1):3-13.
  7. Piasecki TM, Fiore MC, Baker TB. Profiles in discouragement: two studies of variability in the time course of smoking withdrawal symptoms. J Abnorm Psychol. 1998; 107(2): 238-51.
  8. US Department of Health and Human Services. Women and Smoking. A Report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001.
  9. Jarvis MJ. Why people smoke. BMJ. 2004;328(7434):277-9.
  10. Stoffelmayr B, Wadland WC, Pan W. An examination of the process of relapse prevention therapy designed to aid smoking cessation. Addict Behav. 2003 Sep;28(7):1351-8.
  11. Doherty K, Kinnunen T, Militello FS, Garvey AJ. Urges to smoke during the first month of abstinence: relationship to relapse and predictors. Psychopharmacology (Berl). 1995;119(2):171-8.
  12. Ussher M, West R, Steptoe A, McEwen A. Increase in common cold symptoms and mouth ulcers following smoking cessation. Tobacco Control 2003;12(1):86-8.
  13. Hajek P, Gillison F, McRobbie H. Stopping smoking can cause constipation. Addiction 2003; 98(11): 1563-7.
  14. Gowan J, Roller L. Prescription problems. The Australian Journal of Pharmacy 1999; 80: 1058-64.
  15. Fiore MC et al. Treating tobacco use and dependence: Clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service, 2000.
  16. Zwar N, Richmond R, Borland R, Stillman S, Cunningham M, Litt J. Smoking Cessation Guidelines for Australian General Practice. Practice handbook. Canberra: Commonwealth Department of Health and Ageing, 2004.
  17. Pomerleau CS, Marks JL, Pomerleau OF. Who gets what symptom? Effects of psychiatric cofactors and nicotine dependence on patterns of smoking withdrawal symptomatology. Nicotine Tob Res. 2000;2(3):275-80.
  18. Allen SS, Hatsukami D, Christianson D, Brown S. Effects of transdermal nicotine on craving, withdrawal and premenstrual symptomatology in short-term smoking abstinence during different phases of the menstrual cycle. Nicotine Tob Res. 2000;2(3):231-41.
  19. Silagy C, Lancaster T, Stead LF, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation (Cochrane Review). In: The Cochrane Library, Issue 4, 2001. Oxford: Update Software.
  20. Shiffman S, Johnston JA, Khayrallah M et al. The effect of bupropion on nicotine craving and withdrawal. Psychopharmacology 2000; 148: 33-40.
  21. Ussher MH, West R, Taylor AH, McEwen A. Exercise interventions for smoking cessation. Cochrane Database Syst Rev. 2000;(3):CD002295.
  22. Borland, R. Understanding relapse in smoking cessation - when and where it happens. In Relapse and Other Realities: An update on smoking cessation rates in Australia. Report commissioned by SmithKline Beecham Consumer Healthcare, May 2000.
  23. Gilbert HM, Warburton DM. Attribution and the effects of expectancy: how beliefs can influence the experiences of smoking cessation. Addict Behav. 2003;28(7):1359-69.