EDGE Best Practice Series: Nicotine and Mental Health

/ 6 minute read

EDGE Best Practice Series: Nicotine and Mental Health

Mental health has been given an increasingly large share of the medical spotlight in recent years. There are now more networks of support and guidance available to those suffering from a myriad of conditions than ever before.

Our collective understanding of mental health disorders and how to treat them has increased massively in the 21st Century, and we now know far more about the relationships between our lifestyle choices and our mental wellbeing.

Nicotine and smoking often go hand-in-hand, and the two have undeniable links to mental health. Despite the common belief that smoking helps you to relax, relieve stress and settle anxiety, experts including the NHS have proven the contrary. In fact, smoking is understood to increase tension and anxiety, with smokers also being more likely to develop depression than non-smokers.

Are Nicotine and Mental Health Linked?

There is a clear link between smoking and mental health, with those suffering from a long-term condition smoking far more than those without. (See figure 1).

chart linking smoking rates with mental conditions

Can Nicotine Affect Stress?

It’s a mean trick nicotine can play on our minds – the craving for a cigarette makes us feel stressed irritable and anxious. These feelings are then temporarily relieved when we smoke, giving us the impression that smoking has improved our mood and reduced our stress levels.

In reality, the need to relieve this stress would largely not exist if we did not have an addiction to nicotine in the first place – a self-fulfilling prophecy. Worse still, while smoking reduces the withdrawal symptoms, it cannot actually reduce anxiety or deal with the root cause of the issue - It’s a sticking plaster on a gunshot wound

Can Nicotine Affect Depression?

Adults suffering from depression are twice as likely to smoke as those without. Because the withdrawal symptoms of nicotine addiction are synonymous with depression, it is still not completely understood whether smoking leads to depression or vice-versa, the relationship is complex.

Those with depression often have lower levels of dopamine in their system. Smoking is an easy way for these people to experience a temporary boost of dopamine by consuming nicotine.

While this may seem positive at first, over time the act of smoking encourages the brain’s natural dopamine trigger to switch-off, decreasing an already low supply even more and ultimately exacerbating the feeling of depression.

Those with depression may be hit particularly hard by withdrawal during a quit attempt. If you smoked before experiencing depression, and after abstaining from nicotine for two weeks or more do not feel your mood has improved, then the cause of the depression may lie elsewhere and you should consult your GP for advice.

Those suffering with depression while quitting nicotine are advised to follow the below advice to help them on their journey:

Exercise: Being physically active can help. Start small and build up over time. This can be hard to do when you’re depressed. But your efforts will pay off.

Structure your day: Make a plan to stay busy. Get out of the house if you can.

Be with other people: Many people who are depressed are cut off from other people. Being in touch or talking with others every day can help your mood.

Reward yourself: Do things you enjoy. Even small things add up and help you feel better.

Can Nicotine Affect Anxiety?

One of the most prevalent mental health issues faced by modern society is anxiety. While we all experience it in some form throughout our daily lives, particularly extreme circumstances and those who are susceptible to it can experience far more intense bouts that can cripple them and prevent them leading a normal life.

Because of smoking’s perceived ability to boost mood, many anxiety sufferers take up the habit in an effort to manage their emotions. The unfortunate reality is that doing so can not only trigger anxiety, but intensify it.

The feeling of relief experienced in these cases is not actually because of any effect on your anxiety, but simply because smoking reduces the withdrawal symptoms of nicotine addiction – the impact is temporary and ultimately does not resolve the original reason you were anxious in the first place, meaning the feelings will almost always return. When combined with the anxiety triggered by nicotine withdrawal alone, you may end up facing twice as much nervousness, fear and panic.

Practicing the below relaxation techniques can help to manage anxiety without the dependence on nicotine, but you should always consult your GP for proper advice tailored to your needs.

Breathe: Take a few slow, deep breaths—in through your nose, out through your mouth.

Locate Your Stress: Explore where stress affects your body. Finding ways to reduce physical tension will also help your mental stress.

Visualize: Think of a place where you feel safe, comfortable, and relaxed. Picture it as clearly as you can, including imagining what you would feel, hear, and maybe even smell if you were in that relaxing place. A warm bath, a massage, or stretching can help.

Focus: Life can sometimes be overwhelming. try to focus on what is happening now, not what you might have to deal with in the future.

Care: Make an extra effort to take care of yourself. This includes basic things like eating a balanced diet, drinking lots of water, and getting enough sleep.

Do Good: Doing something nice for others can make your day better too. Being caring toward others helps reduce your own stress.

Decaffeinate: Caffeine can help you stay awake, but it also can make you feel tense, jittery, and stressed. Cutting back or even doing away with caffeine can help reduce your feelings of stress.

Accept: Doing something nice for others can make your day better too. Being caring toward others helps reduce your own stress.

Nicotine and Schizophrenia

People with Schizophrenia are three times more likely to smoke than other people and tend to have a much more intense habit. It is believed this relationship stems from the belief among sufferers that smoking helps them manage their symptoms and even side-effects of medication. Interestingly, sufferers were found to extract more nicotine per cigarette than other smokers, leading experts to believe there is a relationship between the habit and the condition.

Further research is ongoing, however recent and historic studies have shown that smoking actually increases a person’s risk of developing a mental health disorder including schizophrenia, but the exact links are not fully understood.

While it may play a role in the condition’s development, there are also studies that have demonstrated improvements in patients following the administration of nicotine. With the addictive substance actually normalising some of the cognitive and sensory deficits caused by the condition.

The improvement seen in these cases is believed to be linked to nicotine’s ability to trigger dopamine production in the areas of the brain most affected by schizophrenia. The receptors in the brain which nicotine binds to are involved in the processes impaired by schizophrenia: thinking ability, reward, movement and pain relief.

Patients were actually found to have fewer and poorly functioning examples of these receptors in their bodies, suggesting a strong link between the role of nicotine and potential medication for the condition. Using nicotine was shown to improve eye tracking, sound filtering and adaptation to strong sensory inputs. Enhancements in learning ability, memory and attention span were also noted in sufferers who smoked.

Because of this evidence, experts are now looking to nicotine as a guide to develop a medication that works in a similar way to remedy the issues caused by schizophrenia, without the unintended addiction. If such a thing can be achieved, then there is a positive future for patients who rely on smoking to reduce their symptoms.

Can Smoking Impact My Medication?

While many people smoke without a second thought, doing so can actually impact the effectiveness of a range of medications. If you are already prescribed something and have taken up smoking, it is entirely possible that your dose may need to be adjusted to accommodate the impact on its performance. The impact occurs because smoking triggers the production of an enzyme that breaks down the medication before it can act.

It should be noted that it is the collective compounds delivered when smoking that interfere with certain types of medication, not actually the nicotine itself. While most interactions with medication are not clinically significant, users of the below examples should take note if you have started smoking after beginning a prescription. You should always consult your GP before making any decision about your medication.

Drug name

Action to take when stopping smoking

Aminophylline, Theophylline

The dose of theophylline may need to be reduced by about one quarter to one third one week after withdrawal. However, it may take several weeks for enzyme induction to dissipate. Monitor theophylline concentration periodically. Advise the person to seek help if they develop signs of theophylline toxicity such as palpitations or nausea.


Be alert for increased adverse effects of chlorpromazine (for example, dizziness, sedation, extra-pyramidal symptoms). If adverse effects occur, reduce the dose as necessary.


Monitor serum drug levels before stopping smoking and one week after stopping smoking. On stopping smoking, reduce dose gradually over a week until around 75% of original dose reached. Repeat plasma level one week after stopping smoking. Further dose reductions may be required.


When given to people who smoke, increase the daily dose in 50mg increments at 2-week intervals, up to a maximum dose of 300mg. If the person stops smoking the dose should be immediately reduced to the initial starting dose.


Be alert for signs of opioid toxicity and reduce the methadone dose accordingly.


Be alert for increased adverse effects of olanzapine (for example, dizziness, sedation, hypotension). If adverse effects occur, reduce the dose as necessary.


Dose reductions may be necessary if the person stops smoking, as riociguat exposure is reduced by 50-60% in people who smoke.


If a person taking warfarin stops smoking, their INR might increase so monitor the INR more closely. Advise people to tell the healthcare professional managing their anticoagulant control that they are stopping smoking.


If you want to learn more about nicotine addiction and the effects it can have on your body, check our the EDGE Best Practice Series: Understanding Nicotine Addiction. If you want to start your journey towards a nicotine free lifestyle, we'd love to help - the first step is understanding what tools will best serve you on this journey; get started here.

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