Clinical ReviewEffects of nicotine on sleep during consumption, withdrawal and replacement therapy
Introduction
Cigarette smoking is a major public health problem. One half of all long-term smokers die prematurely as a consequence of tobacco consumption.1 In industrialised countries smoking is recognised as the most significant avoidable single cause for a multiplicity of chronic diseases.2 Although the health consequences of smoking are well documented, the influence of nicotine consumption, nicotine withdrawal and substituted nicotine on sleep have not been extensively studied.
Nicotine stimulates cholinergic neurotransmission via the wide-spread α7 and α4β2 nicotinergic acetylcholine (ACh) receptors and indirectly alters the glutaminergic, dopaminergic and serotonergic systems in the brain.3 Chronic nicotine consumption is usually coupled with physical and psychological dependence. Withdrawal symptoms include sleep disturbances, the craving for tobacco, dysphoria, fear, anhedonia, irritability or restlessness and increased appetite. Insomnia complaints during nicotine withdrawal are reported in up to 39% of cases.4, 5
Additionally, depressive symptoms are common in prolonged nicotine withdrawal,6 and there is a complex relationship between nicotine dependence and depression. Not only do depressive patients smoke more frequently, but during nicotine withdrawal there is also an increase in depressive episodes.7 Furthermore, sleep disturbances and changes in REM sleep are common in depressive patients; and the presence of depressive symptoms is associated with lower nicotine abstinence rates.8
It is speculated that the negative health effects of smoking could at least partly be related to the effects of nicotine on sleep.9 Disturbed sleep due to nicotine use in turn might worsen the withdrawal process, and may therefore be a relevant risk factor for relapse. This implies the necessity to adapt smoking cessation therapies to the specific requirements of groups at risk, e.g., smokers with depression (most of whom also have insomniac symptoms) or sleep problems.
The present descriptive review aims to provide an overview of investigations on smoking and its effect on sleep as well as smoking cessation with and without nicotine substitution. Also included in the review were studies, which investigated patients with depression, looked at nocturnal respiration in smokers and examined the therapeutic use of nicotine.
Section snippets
Methods
The electronic data bases Medline+ (Ovid), PreMedline (Ovid), Cumulative Index to Nursing & Allied Health Literature – CINAHL (Ovid), PsycINFO (Elton B. Stephens Company – EBSCO), and Embase were searched in October 2007 for relevant publications regarding the effects of nicotine on sleep. The keywords included “sleep”, “sleep disturbance”, “insomnia”, “smoking”, “smoking cessation”, “nicotine”, “nicotine withdrawal”, “tobacco” and “tobacco withdrawal”. Both German and English original articles
Studies investigating the effects of nicotine on sleep in animals
Out of the eight studies in animals, six investigated in vivo nicotine effects on the sleep EEG, one specified the nicotine receptors relevant to sleep in knock-out mice, and one reported on neural sleep regulation on the basis of rat midbrain slices (see Table 1). Lena et al.17 showed that the effects of nicotine on sleep in β2-AchR-knock-out mice were transmitted mainly by the β2 subunit of the ACh receptors. Several of the studies described a dose-dependent effect of nicotine on sleep, with
Outlook
Both in population-representative samples and under controlled conditions, smoking and acute nicotine application led to complaints of insomnia, increased sleep fragmentation and sleep onset latency, decreased sleep efficiency, reduced SWS time and increased daytime sleepiness. These symptoms appear to be reversible after cessation.40, 33
Similar sleep changes were also observed during acute nicotine withdrawal. The extent of the sleep impairment correlated with individual plasma nicotine
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