3.2.1 Physical and Psychological Dependence

Differentiate pharmacological dependence from moral framing in patient education

Physical dependence on nicotine involves downregulation of dopamine receptor sensitivity and upregulation of nicotinic acetylcholine receptors (nAChRs).¹ Patients in the preparation stage benefit from understanding that withdrawal discomfort reflects neuroadaptation reversing itself - a temporary recalibration, not permanent damage. This framing supports both NRT consideration and realistic expectation-setting for the early quit period.

Use the pleasure-decline-craving model to explain tolerance and dependence to patients

The three-phase addiction cycle - positive reinforcement (pleasure), neuroadaptation (tolerance), and negative reinforcement (craving/withdrawal avoidance) - maps directly onto DSM-5 criteria for substance use disorders.¹ Presenting this model during the preparation stage helps patients understand why willpower alone is insufficient: they are not simply resisting a desire, they are counteracting a neurological deficit state. This framing supports NRT consideration and realistic expectation-setting.²

Leverage habit loop disruption as a behavioural intervention target

Habit substitution leverages the cue-routine-reward architecture described by Duhigg and grounded in the basal ganglia research of Graybiel (2008).¹ For nicotine dependence, the clinical strategy involves: (1) identifying high-frequency cues via a smoking diary, (2) designing specific alternative routines for each cue, and (3) practicing them before quit day so the new pathway has some strength before the old one is challenged. Vague implementation intentions ('I will resist') are significantly less effective than specific ones ('When I finish lunch, I will walk to the water cooler instead of going outside').²