Available online at:
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J Camosun Psyc Res. (2023). Vol. 5(1), pp. 16-26.
Submitted Fall 2022; accepted June 2023.

How Does Nicotine Withdrawal Manifest Itself?
Authors: Marina H. Dempsey*
Supervising Instructor: Michael Pollock, Psyc 245 (“Drugs & Behavior”)
Department of Psychology, Camosun College, 3100 Foul Bay Road, Victoria, BC, Canada V8P 5J2
*Corresponding author email: marinahdemps@gmail.com

ABSTRACT
In this paper, I sought to understand how nicotine withdrawal symptoms manifest, both
psychologically and physiologically, with the goal of better understanding how these factors
contribute to the maintenance of nicotine addiction. Previous research has found nicotine
withdrawal to affect variables such as the intensity of nicotine cravings, emotional regulation,
and cognitive performance. In this current case study, I tested the strength of these relationships
by examining naturalistic daily changes in their variables longitudinally over a period of one
week. Nicotine intake was measured by calculating the total dosage (ml/mg) of nicotine
consumed each day, while self-report scales were used to assess craving intensity, emotional
regulation levels, and subjective cognitive functioning by a cognitive self-assessment. The
results of this study found significant correlations of nicotine amount with emotional regulation
and craving levels, but not with cognitive functioning levels. These findings suggest that nicotine
withdrawal manifests as intense cravings and difficulties with regulating emotions; however, no
relationship with cognitive function was established. A possible practical application of these
findings could be the use of craving and emotional regulation levels as indicators of relapse risk.
Future research should build upon this study by making some improvements to the design and
methodology, such as using a larger sample size to increase generalizability, use objective
measures such as physiological or neuroimaging techniques to provide more accurate and
reliable data, and extend the study duration, to examine the long-term effects of withdrawal on
the variables of interest.
1. Introduction
1.1 Research Problem
Nicotine withdrawal causes undesirable
symptoms that consequently reinforce the
continued use of the drug. Quitting nicotine
frequently results in deficits in cognitive
functioning, such as working memory,
concentration, and response time.
Furthermore, nicotine withdrawal can cause
difficulties with emotional regulation,

manifesting as emotional outbursts, anger,
and anxiety. In addition, cravings for
nicotine can begin immediately after quitting
and is frequently the most severe and
undesirable symptom of nicotine
withdrawal. I wish to know about the
physiological and psychological
consequences of nicotine withdrawal so that
I can help people better manage, cope with,
and recover from nicotine addiction.

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1.2 Literature Review
One factor previously found to predict
how nicotine withdrawal symptoms manifest
is the severity of cravings experienced
(Robinson et al., 2011). For example, in a
randomized controlled trial by Robinson et
al. (2011), researchers randomly assigned
treatment seeking smokers to either an
abstainer condition or a control (free-will
smoking) condition. All participants in both
conditions attended four laboratory sessions
and completed the Positive and Negative
Effect Scale (PANAS), the Center for
Epidemiologic Studies' Depression Scale
(CES-D), and the Wisconsin Smoking
Withdrawal Scale (WSWS) over the course
of 14 days, as well as a physiological
measurement (ECG). The PANAS is a 20item scale used to measure positive and
negative affect over the previous week. The
CES-D is a 20-item self-report measure used
to assess depression symptoms in
nonclinical populations. The WSWS is a 28item self-report used to evaluate nicotine
withdrawal symptoms across seven different
subscales: Anger, Anxiety, Sadness,
Concentration, Craving, Sleep, and Hunger,
on a 5-point Likert scale that ranges from 0
(strongly disagree) to 5 (strongly agree). The
study's multimodal findings suggest that
more dependent smokers experience more
negative affect, craving, and reactivity to
unpleasant emotional cues, regardless of
smoking abstinence status. The in-session
ratings (i.e., WSWS craving scores)
indicated that increased craving was
associated with a worsening of mood for
relapsers and controls, but not for abstainers.
Based on these results, the researchers
suggested that heavier and more dependent
smokers experience greater negative affect
(e.g., irritability, anxiety, etc.) and craving
symptoms at baseline, with convincing
evidence across multiple types of measures

(e.g., retrospective questionaries, in-session
ratings, physiological measurement).
In addition to cravings, another factor
previously found to predict symptoms of
nicotine withdrawal is levels of emotional
dysregulation (Rogers et al., 2019). For
example, in a randomized controlled trial by
Rogers et. al (2019), researchers randomly
assigned participants (n = 188) to an active
group or control group. The Difficulties with
Emotion Regulation Scale (DERS) was
administered to participants on quit day and
during the post-quit follow-up assessments
(1-, 2-, 4-, 12- weeks post-quit). The DERS
is a 36-item self-report measure that assesses
participants' ability to regulate negative
emotional states on a 5-point Likert scale
ranging from 1 (almost never) to 5 (almost
always). The researchers looked at how the
baseline DERS total score predicted
withdrawal symptoms over time.
Withdrawal symptoms were modelled using
data from the quit-day and post-quit
assessments, and data analysis revealed that
those with the highest baseline DERS scores
experienced the most withdrawal symptoms
during the quit week, followed by the
greatest increase and decrease in withdrawal
symptoms, when compared to those with
lower baseline DERS scores. Based on these
results, the researchers suggest that
individual differences in baseline levels of
emotion dysregulation were significantly
associated with quit day withdrawal
symptoms. Another possible mechanism
which nicotine symptoms manifest is
through changes in cognitive performance
(Wesnes et al., 2013).
In an experimental study conducted by
Wesnes et al. (2013), researchers assigned
thirty healthy males (n = 30) to either
receive a placebo drug or an experimental
drug to see how they affected cigarette
consumption and withdrawal symptoms
(i.e., changes in cognitive performance)
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during ad libitum (free-will) smoking versus
abstinence. Researchers proposed that after
24 hours of nicotine abstinence, withdrawal
would manifest cognitively, impairing the
quality of cognitive functions such as
attention and memory (short-term and longterm). The participants were administered
tests to measure attention, specifically, digit
vigilance reaction time and choice reaction
time. Digit vigilance reaction time (DVT) is
a simple task designed to assess vigilance
while performing rapid visual tracking and
accurate target stimuli selection. It
emphasises alertness and vigilance while
putting little emphasis on two other aspects
of attention: selectivity and capacity.
Respondents are instructed to locate and
cross out either sixes or nines that appear at
random within 59 rows of single digits on
two different pages. Choice Reaction Time
(CRT) assesses overall alertness as well as
motor speed. It is a two-choice reaction time
test, but with two possible stimuli and two
possible responses, stimulus and response
uncertainty are introduced. The patient is
required to respond to one stimulus but not
to another. Periods of abstinence showed a
statistically significant decline in
performance (p = .05) in measures of
attention, specifically digit vigilance
reaction time (p < .001) and choice reaction
time (p < .001). Based on these results, the
researchers suggest that nicotine withdrawal
manifests itself after 24 hours of abstinence
by impairing cognitive functions of attention
and long- term memory.
1.3 Hypotheses
Based on the above literature review, I
predicted the following hypotheses:
Hypothesis #1: If nicotine amounts
decrease then cravings will increase.

Hypothesis #2: If nicotine amounts
decrease then emotional regulation will
decrease.
Hypothesis #3: If nicotine amounts
decrease then cognitive performance will
decrease.
2. Methods
2.1 Participants
The first author, a twenty-two-year-old
cisgender woman, served as the sole
participant in this N = 1 case study. The
subject is a Camosun College undergraduate
student who completed the current study as
part of a PSYC 245 (Drugs and Behavior)
assignment and chose this topic because of
personal interest in the effects of nicotine
withdrawal. The subject was a regular
nicotine user, and the nicotine amounts
consumed over the course of this study were
within the participant's normal ranges.
2.2 Materials and Procedures
The subject performed a correlational
case study or N = 1 to test concurrently the
three hypotheses by examining naturalistic
daily changes in the variables longitudinally.
To do so, the subject kept a study journal
with them at all times over this study’s
three-week period in order to record selfobservations of the following three
variables: (1) nicotine amount, (2) craving
intensity (3) emotional regulation, (4)
cognitive functioning.
Nicotine Amount - To measure the
frequency and dosage of nicotine,
participants recorded in their study journal
three times a day (i.e., morning, afternoon,
evening) the amounts of nicotine consumed
during this study. From these records, the
amount of nicotine per unit (mg/PU) was
calculated by multiplying the amount of
nicotine per 1ml (mg/ml) by the smoking
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unit (15 e-vaporizer puffs = 1 cigarette). The
total amount of nicotine was taken by adding
the three scores up in each day of this study.
If the participant did not consume nicotine
on a given day, then the total amount of
nicotine for the subjects’ day was scored as
zero.
Craving Intensity - To measure the
intensity of cravings, I recorded in their
study journal three times a day (i.e.,
morning, afternoon, evening) the intensity of
nicotine cravings experienced on each day
during this study. Participants rated on a 0 to
5 scale the intensity of cravings felt at each
time of the day, and the average of the three
scores were used as the final score for each
day. The following response anchors were
used on this craving intensity scale: 0 = none
at all, 1 = slight, 2 = moderate, 3 =
considerable, 4 = extreme, 5 = unbearable.
Emotional Regulation - To measure
emotional regulation, each participant rated
on a scale how "in control" of their feelings
they were during each day of this study.
Participants recorded in their study journals
three times a day (i.e., morning, afternoon,
evening) their emotional regulation scores,
and the average of the three scores was used
as the final score for each day. The
following response anchors were used on
this emotional regulation scale: 0 = not at
all, 5 = moderately, 10 = a great deal.
Cognitive Functioning - To measure
cognitive functioning, the participant
answered nine questions about cognitive
functions (i.e., attention, memory) using a 0
– 4 scale. This self-assessment required
participants to total up the number of each
anchors scored (i.e., give 0 points for
statements rated as never, 2 points for
statements rated as sometimes, and 4 points
for statements rated as always) to obtain a
final score. Participants completed the
cognitive functioning scale twice a day (i.e.,
afternoon, evening) and took the average of

the two scores to use as the score for each
day. The following response anchors were
used on the cognitive functioning scale: 0 =
never, 1 = rarely, 2 = sometimes, 3 = often,
4 = always. The following anchors were
used to obtain the final score on the
cognitive functioning scale: 0 = normal
cognition, up to 12 = mild cognitive
impairments, 13 – 24 = moderate cognitive
impairments, 25 – 36 = severe cognitive
impairments (see Appendix A).
2.3 Statistical Analyses
To assess the strength and statistical
significance of associations between
variables predicted by the three hypotheses,
I performed Pearson r product moment
correlations of their predictor variable
(nicotine amount), with their outcome
variables (craving intensity, emotional
regulation, and cognitive functioning). For
testing Hypothesis #1, I correlated the total
nicotine amount consumed by the participant
each day with the participant’s average
craving intensity score each day. For testing
Hypothesis #2, I correlated the total nicotine
amount consumed each day with the
participant’s average emotional regulation
score each day. For testing Hypothesis #3, I
correlated the total nicotine amount
consumed each day with the participant’s
average cognitive functioning score on the
same day. A correlation coefficient was
considered statistically significant if the
probability of its random occurrence (p) was
< .05 (i.e., less than 5% of the time expected
by chance alone)..
3. Results
As shown in Table 1, results of the
correlational analyses indicated that both
emotional regulation and craving levels were
significantly and positively correlated with
nicotine amount. Emotional regulation levels
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were significantly correlated with nicotine
amount (r = .67, p = .001; see Figure 1).
Similarly, craving level was significantly
correlated with nicotine amount (r = - .56, p
= .01; see Figure 2). In contrast, no
statistically significant correlations were
found between cognitive functioning levels
and nicotine amount (r = -.30, p = .21; see
Figure 3. Based on a comparison of the
correlation coefficients, emotional
regulation showed the strongest correlation
with nicotine amount. The results found that
when people consumed more nicotine, they
experienced higher levels of both emotional
regulation and cravings for nicotine.
However, there was no significant
relationship between cognitive functioning
and nicotine consumption. The correlation
between emotional regulation and nicotine
intake was the strongest among the variables
used in this study.
4. Discussion
4.1 Summary of Results
Based on previous research, I
hypothesized that decreases in nicotine
amount would be followed by changes in
three variables: increase the level of craving
(Hypothesis #1), decrease in regulating
emotions (Hypothesis #2), and decrease in
cognitive functioning (Hypothesis #3). The
data obtained from this study supported the
predicted relationship of nicotine amount
with craving and emotional regulation
(Hypothesis #1 & #2) but not with cognitive
functioning (Hypothesis #3). Future research
should use an experimental design to
establish causal roles of nicotine amounts
upon emotional regulation and craving.

4.2 Relation of Results to Past Research
The ability of this correlational study to
predict craving levels based on nicotine
amount is in line with previous research.
Robinson et al. (2011) found that the amount
of nicotine ingested was associated with
increase and severity of cravings. While
Robinson et al. (2011) had treatment seeking
smokers use multimodal reports (i.e.,
retrospective questionnaires) to assess their
nicotine and craving levels, I longitudinally
assessed these variables in college students.
The similarity of both our conclusions
despite using different research designs
suggests a generalized relationship exists
between increased nicotine consumption and
higher craving levels.
My correlational study between
emotional regulation and nicotine amount
was able to suggest a relationship between
these variables, as past research did. Rogers
et al. (2019) found that levels of emotional
regulation were associated with nicotine
amounts by administering self- report
measures and collecting baseline emotional
regulation data. In my correlational study,
emotional regulation levels and nicotine
amounts were strongly associated. Despite
using different research designs, the
similarity of our conclusions suggests that
there is a generalized relationship between
increased nicotine consumption and levels of
emotional regulation.
The current correlational study failed to
confirm the relationship between cognitive
functioning levels and nicotine consumption
reported by previous research. Wesnes et al.
(2013) found that after 24 hours of
abstinence from nicotine, cognitive
functioning was significantly impaired.
Researchers measured cognitive functioning
(i.e., memory and attention) using choice
reaction time and digit vigilance reaction
time and after 24 hours of nicotine
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abstinence, impairments were observed in
attention and long-term memory. In contrast,
my correlational study used a self-report
questionnaire regarding cognitive
functioning levels. The methodology of my
current study differed from that of the
Wesnes et al. (2013) study in three major
ways that might account for the discrepant
results. First, the measures used to obtain
cognitive functioning levels could have
affected the findings. In the current study,
the correlational measures relied only upon
self-reports of cognitive functioning, which
are subjective. Future studies should test
whether the objectively verified aspects of
cognitive functioning outlined by Wesnes et
al. (2013), but not subjective selfassessments, predict cognitive functioning
levels. Second, the measures used to obtain
cognitive functioning scores in both studies
may lack convergent validity (i.e., the extent
that the scores on your measure are related
to scores on another measure that measure
the same construct). In the study by Wesnes
et al. (2013), cognitive functioning was
measured objectively, using an automated
program to administer the choice reaction
time test and the digit vigilance reaction
time test, whereas in the current
correlational study, I used a cognitive
functioning self-report questionnaire that
asked subjective questions such as “I have
difficulty remembering things that happen or
what people told me” (see Appendix 1).
Third, the sample sizes used in each study
could have affected the findings. Studies
with larger sample sizes are more likely to
obtain statistically significant results. In the
study by Wesnes et al. (2013), the sample
size was much larger (n = 30) than in the
current correlation study (n = 1). A larger
sample size is more likely to be significant
because it provides more accurate the
greater the chance of discovering significant
trends or results that would otherwise be

masked by a smaller sample size. Future
studies should examine whether nicotine
amounts predict the severity of cognitive
functioning deficits by using an objective
measure rather than a subjective measure,
and a larger sample size.
4.3 Implications of Results
Possible practical applications of our
current findings are the severity of
withdrawal symptoms that decreased
nicotine intake may be associated with. For
instance, the current study suggests when
quitting nicotine, that the severity of
withdrawal symptoms will increase (i.e.,
emotional dysregulation and craving). These
findings suggest that when quitting or
abstaining from nicotine, withdrawal
symptoms will increase in the short term,
and decrease in the long term, depending on
your intake of nicotine. Based on these
results, I suggest to non-smokers to continue
abstaining from nicotine, as the withdrawal
symptoms are aversive and severe, and I
suggest to smokers, when quitting or
reducing nicotine intake, to replace the
nicotine with a healthier alternative, such as
exercise or meditation.
4.4 Conclusion
I originally conducted the current studies
to understand the relationship between
nicotine intake and the manifestation of
withdrawal symptoms to help smokers better
cope with, manage, and recover from
nicotine addiction. The correlational results
in this study suggest that abstaining from
nicotine causes withdrawal to manifest itself
through craving intensity and difficulty
managing emotions, while there was no
significant relationship between cognitive
functioning and nicotine intake. It remains
for future studies to conduct an experiment
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with these significant variables to observe if
there is a causal relationship present, and
therefore discover ways to better manage
quitting nicotine.
References
Nasrallah, H. A. (1990). Cognitive SelfAssessment Rating Scale (C-SARS).
University of Missouri-Columbia,
Columbia, MO.
Robinson, J. D., Lam, C. Y., Carter, B. L.,
Minnix, J. A., Cui, Y., Versace, F.,
Wetter, D. W., & Cinciripini, P. M.
(2011). A multimodal approach to
assessing the impact of nicotine
dependence, nicotine abstinence, and
craving on negative affect in smokers.
Experimental and Clinical

Psychopharmacology, 19(1), 40–52.
doi:10.1037/a0022114
Rogers, A. H., Bakhshaie, J., Garey, L.,
Piasecki, T. M., Gallagher, M. W.,
Schmidt, N. B., & Zvolensky, M. J.
(2019). Individual differences in emotion
dysregulation and trajectory of
withdrawal symptoms during a quit
attempt among treatment-seeking
smokers. Behaviour Research and
Therapy, 115, 4–11.
https://doi.org/10.1016/j.brat.2018.10.007
Wesnes, K. A., Edgar, C. J., Kezic, I., Salih,
H. M., & de Boer, P. (2013). Effects of
nicotine withdrawal on cognition in a
clinical trial setting.
Psychopharmacology, 229(1), 133–140.
doi:10.1007/s00213-013-3089-6

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Table 1
Correlations for Study Variables
Variables

Nicotine amount &
Craving Intensity
Nicotine amount &
emotional regulation
Nicotine amount &
cognitive functioning

r

n

-.57*

21

.64*

21

-.30

21

Notes. r = correlation coefficient, n = number of days sampled.
* p < .05.

Figure 1

Craving Intensity (Scale 0-5; 0 = None at
All to 5 = Unbearable)

Association Between Nicotine Amount and Craving Intensity

5

4

3

2

1

0
0

0.5

1

1.5

2

2.5

3

Nicotine Amount (mg of Nicotine Consumed)

Notes. Marker colour differentiates participants: red = participant #1. Some data might not be
visible in the figure due to overlapping markers.
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Figure 2

Emotional Regulation (Scale 0 - 10, 0 = Not at All to 10
= A Great Deal)

Association Between Nicotine Amount and Emotional Regulation
12

10

8

6

4

2

0
0

0.5

1
1.5
2
Nicotine Amount (mg of Nicotine Consumed)

2.5

3

Notes. Marker colour differentiates participants: red = participant #1. Some data might not be
visible due to overlapping markers.

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Figure 3
Association Between Nicotine Amount and Cognitive Functioning

Cognitive Functioning (Score 0 - 36; 0 =
Normal Cognitive Functioning to 36 =
Severe Cognitive Impairements )

40
35
30
25
20
15
10
5
0
0

0.5

1

1.5

2

2.5

3

Nicotine Amount (mg of Nicotine Consumed)

Notes. Marker colour differentiates participants: red = participant #1. Some
data might not be visible in the figure due to overlapping markers.

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Appendix A
Cognitive Functioning Self-Assessment Scale

In the last 6 hours….
0 = never

1 = rarely

1.

2 = sometimes 3 = often 4 = always

I have difficulty staying focused on something I am reading or a Tv program I

am watching.
2.

I have difficulty remembering things that happen or what people told me

3.

I forget what I am supposed to do

4.

I forget where I put things

5.

When I am speaking I forget what I was going to say

6.

I have difficulty planning or making decisions

7.

When I am working hard on something, I still get distracted by events around me

8.

I do things without thinking

9.

I tend to be slow in mental/physical tasks

Totals
0 = never

1 = rarely

2 = sometimes 3 = often 4 = always

-

0 = normal cognition

-

Up to 12 = mild cognitive impairments

-

13 – 24 = moderate cognitive impairments

-

25 – 36 = severe cognitive impairments

Adapted and modified from the Cognition Self-Assessment Rating Scale (C-SARS;
Nasrallah, 1990).

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