Pharmacology, Toxicology and Addiction MedicineTier 1Disease (DEADMAN)

Substance use disorder, including relapse prevention and acute withdrawal from - nicotine

Description

Nicotine dependence - compulsive use, tolerance, withdrawal on cessation
Delivery format increasingly includes e-cigarettes/vaping, now a major driver of new adolescent nicotine dependence
Withdrawal: irritability, anxiety, low mood, craving, increased appetite, insomnia - peaks 24-72h, largely resolves by 2-4 weeks

Epidemiology

Adult smoking rates continue to decline in Australia; adolescent vaping prevalence has risen sharply, now a public health priority
Nicotine vaping products require a prescription in Australia (therapeutic use pathway)

Aetiopathogenesis

Nicotine -> nicotinic acetylcholine receptor (alpha4beta2) agonism -> mesolimbic dopamine release -> reward/reinforcement
Chronic exposure -> receptor upregulation -> tolerance -> withdrawal on cessation (dopaminergic and noradrenergic rebound)

Diagnosis

Clinical - DSM-5-TR criteria; Fagerstrom Test for Nicotine Dependence quantifies severity and guides pharmacotherapy intensity
Time to first cigarette/vape after waking - single best predictor of dependence severity

Management

1. Combination pharmacotherapy - first-line

Combination NRT (patch + fast-acting oral form - gum/lozenge/spray) more effective than either alone
Varenicline - partial nicotinic agonist, effective for both smoking and vaping cessation (vaping indication is off-label but evidence-supported); most effective single agent
Bupropion - alternative, contraindicated in seizure disorder/eating disorder history

2. Vaping cessation specifically

Off-label use of NRT/varenicline - limited but growing evidence base in adults; less evidence in adolescents
Behavioural support essential given younger, less nicotine-dependence-literate population

3. Behavioural support

Brief advice + Quitline/structured counselling substantially improves quit rates when combined with pharmacotherapy
Set a quit date, relapse-prevention planning

Associations

Tobacco-specific: COPD, lung and multiple other cancers, cardiovascular disease
Vaping-specific: EVALI (e-cigarette/vaping-associated lung injury - rare, associated with THC/vitamin E acetate-containing products), unknown long-term respiratory/cardiovascular effects
Adolescent nicotine exposure -> altered neurodevelopment, higher conversion to combustible tobacco use

Natural history & complications

Most successful quit attempts require multiple attempts over years
Relapse commonest in first 2 weeks - matches peak withdrawal severity
Combination pharmacotherapy + behavioural support roughly doubles long-term quit rates vs unassisted attempts

6 more sections, plus exam facts

Premium unlocks every note across every specialty, and the full exam fact library behind it.

Get premium access