The CAPNOS Evidence Library: 50 Studies on Oral Fixation, the Hand-to-Mouth Habit and Nicotine Withdrawal

Focus groups, 115 US adults

Smokers described addiction as more than nicotine, naming oral fixation, a smoking routine and responses to cues.

Paper: Addicted to smoking or addicted to nicotine? Loud EE, Duong HT, Henderson KC, Reynolds RM, Ashley DL, Thrasher JF, Popova L.

Credentials: Addiction (2022) · Read the study

Interviews, 20 young adults

Young adults named oral fixation, self-control and flavor appeal as barriers specific to quitting nicotine vapes.

Paper: Barriers and facilitators to nicotine and cannabis vaping cessation among young adults. Nguyen N, Satterfield JM, Keyhani S, Marcus GM, Ling PM.

Credentials: Annals of Behavioral Medicine (2025) · Read the study

Lab study

Numbing the mouth and airway with a local anesthetic blocked the immediate drop in craving that a puff normally produces.

Paper: Sensory blockade of smoking satisfaction. Rose JE, Tashkin DP, Ertle A, Zinser MC, Lafer R.

Credentials: Pharmacology Biochemistry and Behavior (1985) · Read the study

Lab study, 20 smokers

Free access to ordinary chewing gum reduced craving and withdrawal when smokers were not allowed to smoke.

Paper: The effect of chewing gum on tobacco withdrawal. Cohen LM, Collins FL Jr, Britt DM.

Credentials: Addictive Behaviors (1997) · Read the study

Experiment, 49 smokers

Over 48 hours without smoking, gum lowered anxiety and tension, and which flavor people chewed made a difference.

Paper: The effect of chewing gum flavor on the negative affect associated with tobacco abstinence. Cohen LM, Collins FL Jr, Vanderveen JW, Weaver CC.

Credentials: Addictive Behaviors (2010) · Read the study

Meta-analysis of 62 studies

Quitters gain 4 to 5 kg on average within a year, and most of that gain arrives in the first 3 months.

Paper: Weight gain in smokers after quitting cigarettes: meta-analysis. Aubin HJ, Farley A, Lycett D, Lahmek P, Aveyard P.

Credentials: BMJ (2012) · Read the study

Observational study

One of the first attempts to measure oral traits in smokers, showing how long researchers have been studying the question.

Paper: Orality, impulsivity and cigarette smoking in men. Jacobs MA, Anderson LS, Champagne E, et al.

Credentials: Journal of Nervous and Mental Disease (1966) · Read the study

Experiment, 81 smokers

The hand-to-mouth and inhaling motions reduced craving in their own right, alongside the effect of nicotine.

Paper: The importance of conditioned stimuli in cigarette and e-cigarette craving reduction by e-cigarettes. Van Heel M, Van Gucht D, Vanbrabant K, Baeyens F.

Credentials: International Journal of Environmental Research and Public Health (2017) · Read the study

Randomized experiment, 32 smokers

With nicotine and expectation held constant, the smoking ritual by itself reduced the urge to smoke and smoking behavior.

Paper: Pharmacological, sensorimotor, and expectancy effects on tobacco withdrawal. Guillot CR, Stone MD, Geary BA, Kirkpatrick MG, Tidey JW, Cook JW, Leventhal AM.

Credentials: Human Psychopharmacology (2015) · Read the study

Randomized lab study, 86 smokers

Twenty minutes after use, a zero-nicotine e-cigarette had reduced desire to smoke. Simply holding the device had not.

Paper: The electronic-cigarette: effects on desire to smoke, withdrawal symptoms and cognition. Dawkins L, Turner J, Hasna S, Soar K.

Credentials: Addictive Behaviors (2012) · Read the study

Randomized trial, 120 smokers

A nicotine-free plastic inhalator made no difference overall. Among the smokers most attached to the ritual, 66.7% had quit at 24 weeks versus 19.2% without it.

Paper: Effect of a nicotine-free inhalator as part of a smoking-cessation programme. Caponnetto P, Cibella F, Mancuso S, Campagna D, Arcidiacono G, Polosa R.

Credentials: European Respiratory Journal (2011) · Read the study

Questionnaire development

Researchers built an 11-item questionnaire to measure how much of a person's dependence is behavioral rather than chemical.

Paper: Developmental history of the Glover-Nilsson smoking behavioral questionnaire. Glover ED, Nilsson F, Westin A, Glover PN, Laflin MT, Persson B.

Credentials: American Journal of Health Behavior (2005) · Read the study

Focus groups, 11 former smokers

Former smokers credited the hand-held, inhaled routine and its social side, not only the nicotine, for keeping them off cigarettes.

Paper: Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users. Barbeau AM, Burda J, Siegel M.

Credentials: Addiction Science and Clinical Practice (2013) · Read the study

Interviews, 40 vapers

Ex-smokers described their device as replacing the physical, psychological and social sides of smoking.

Paper: The unique contribution of e-cigarettes for tobacco harm reduction in supporting smoking relapse prevention. Notley C, Ward E, Dawkins L, Holland R.

Credentials: Harm Reduction Journal (2018) · Read the study

Review

Habits form by repeating the same response in the same context, and then run as the default mode of behavior.

Paper: Psychology of habit. Wood W, Runger D.

Credentials: Annual Review of Psychology (2016) · Read the study

12-week study, 96 volunteers

New daily behaviors took anywhere from 18 to 254 days to become automatic. Missing a single day did not derail the process.

Paper: How are habits formed: modelling habit formation in the real world. Lally P, van Jaarsveld CHM, Potts HWW, Wardle J.

Credentials: European Journal of Social Psychology (2010) · Read the study

Lab study, 80 smokers

Smoke with the nicotine removed cut craving and was rated satisfying. Nicotine given by IV cut craving but produced no satisfaction at all.

Paper: Dissociating nicotine and nonnicotine components of cigarette smoking. Rose JE, Behm FM, Westman EC, Johnson M.

Credentials: Pharmacology Biochemistry and Behavior (2000) · Read the study

Review

The parts of smoking that are not nicotine, including the physical sensations, deliver many of its rewarding effects. Substitutes for those sensations may help relieve craving.

Paper: Nicotine and nonnicotine factors in cigarette addiction. Rose JE.

Credentials: Psychopharmacology (2006) · Read the study

Two experiments

Satisfaction from a nicotine-free pocket inhaler tracked closely with how strong a throat sensation it produced.

Paper: Development of a citric acid aerosol as a smoking cessation aid. Levin ED, Rose JE, Behm F.

Credentials: Drug and Alcohol Dependence (1990) · Read the study

Lab study, 15 smokers

A citric acid mist that mimicked the feel of smoke in the windpipe was rated more satisfying than puffs of plain air.

Paper: Citric acid aerosol as a potential smoking cessation aid. Rose JE, Hickman CS.

Credentials: Chest (1987) · Read the study

3-week trial, 74 smokers

A hand-held citric acid inhaler eased craving and negative mood, and raised abstinence among the heavier smokers in the trial.

Paper: Clinical evaluation of a citric acid inhaler for smoking cessation. Behm FM, Schur C, Levin ED, Tashkin DP, Rose JE.

Credentials: Drug and Alcohol Dependence (1993) · Read the study

Randomized, double-blind trial, 100 smokers

Adding an airway-sensation inhaler to the nicotine patch raised 10-week abstinence to 19.5% versus 6.8% with a placebo inhaler. The gap had closed by 6 months.

Paper: Airway sensory replacement combined with nicotine replacement for smoking cessation. Westman EC, Behm FM, Rose JE.

Credentials: Chest (1995) · Read the study

Randomized lab study, 48 smokers

After a night without cigarettes, puffing black pepper vapor reduced craving compared with a mint device or an empty one.

Paper: Inhalation of vapor from black pepper extract reduces smoking withdrawal symptoms. Rose JE, Behm FM.

Credentials: Drug and Alcohol Dependence (1994) · Read the study

Lab study, 7 smokers

After 12 hours without tobacco, denicotinized cigarettes eased acute withdrawal symptoms as much as regular ones did.

Paper: Smoking without nicotine delivery decreases withdrawal in 12-hour abstinent smokers. Butschky MF, Bailey D, Henningfield JE, Pickworth WB.

Credentials: Pharmacology Biochemistry and Behavior (1995) · Read the study

Lab study, 20 smokers

Cigarettes delivering virtually no nicotine still reduced ratings of craving and withdrawal.

Paper: Pharmacodynamic effects of new de-nicotinized cigarettes. Pickworth WB, Fant RV, Nelson RA, Rohrer MS, Henningfield JE.

Credentials: Nicotine and Tobacco Research (1999) · Read the study

11-day inpatient study, 30 smokers

Craving relief right after smoking held up for all 11 days with or without nicotine, while the drive to smoke the nicotine-free cigarettes faded slowly.

Paper: Smoking in the absence of nicotine: behavioral, subjective and physiological effects over 11 days. Donny EC, Houtsmuller E, Stitzer ML.

Credentials: Addiction (2007) · Read the study

Randomized, double-blind trial, 40 smokers

Over 24 hours without smoking, smoke-free cigarettes that contained nicotine eased irritability, poor concentration and urges more than placebo versions.

Paper: Effect of smoke-free cigarettes on 24 h cigarette withdrawal. Hajek P, Jarvis MJ, Belcher M, Sutherland G, Feyerabend C.

Credentials: Psychopharmacology (1989) · Read the study

Randomized cross-over trial, 40 smokers

A nicotine e-cigarette cut desire to smoke more than a zero-nicotine one, a reminder that nicotine itself still matters.

Paper: Effect of an electronic nicotine delivery device on desire to smoke and withdrawal. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M.

Credentials: Tobacco Control (2010) · Read the study

Balanced-placebo experiment, 128 vapers

What people were told was in the device shaped how much it reduced craving, showing that expectation is part of the effect.

Paper: How do electronic cigarettes affect cravings to smoke or vape? Palmer AM, Brandon TH.

Credentials: Journal of Consulting and Clinical Psychology (2018) · Read the study

Review

A review of the trials that tried replacing the sensations and motions of smoking rather than the nicotine.

Paper: The effect of sensorimotor replacement on smoking cessation and craving. Przulj D.

Credentials: The Open Addiction Journal (2012) · Read the study

Prospective study, 50 smokers

Craving, irritability, anxiety, poor concentration and restlessness rose after quitting, along with hunger and eating. Worse discomfort did not mean a lower chance of quitting.

Paper: Signs and symptoms of tobacco withdrawal. Hughes JR, Hatsukami D.

Credentials: Archives of General Psychiatry (1986) · Read the study

Review of 120 studies

Anger, anxiety, low mood, poor concentration, impatience, insomnia and restlessness peak within the first week and last 2 to 4 weeks.

Paper: Effects of abstinence from tobacco: valid symptoms and time course. Hughes JR.

Credentials: Nicotine and Tobacco Research (2007) · Read the study

Real-time diary study, 214 smokers

Tracked several times a day in real life, withdrawal symptoms had returned to baseline within 10 days of quitting.

Paper: Natural history of nicotine withdrawal. Shiffman S, Patten C, Gwaltney C, et al.

Credentials: Addiction (2006) · Read the study

Review

Withdrawal begins 4 to 24 hours after the last dose, peaks around day 3 and tapers off over the following 3 to 4 weeks.

Paper: Nicotine withdrawal. McLaughlin I, Dani JA, De Biasi M.

Credentials: Current Topics in Behavioral Neurosciences (2015) · Read the study

Review

The standard medical review of how nicotine acts on the brain and why stopping produces withdrawal.

Paper: Nicotine addiction. Benowitz NL.

Credentials: New England Journal of Medicine (2010) · Read the study

Pre-post clinical trial, 109 daily vapers

Daily vapers who stopped for 6 days showed the full set of withdrawal symptoms, somewhat milder than those seen after quitting cigarettes.

Paper: Withdrawal symptoms from e-cigarette abstinence among former smokers. Hughes JR, Peters EN, Callas PW, et al.

Credentials: Nicotine and Tobacco Research (2020) · Read the study

US national survey analysis

A minority of people who stopped e-cigarettes reported withdrawal, with fewer symptoms than people who stopped cigarettes.

Paper: Prevalence of withdrawal symptoms from electronic cigarette cessation. Hughes JR, Callas PW.

Credentials: Addictive Behaviors (2019) · Read the study

Cochrane review

The Cochrane review comparing doses and forms of nicotine replacement therapy, the medical treatment for the chemical side of withdrawal.

Paper: Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Theodoulou A, Chepkin SC, Ye W, et al.

Credentials: Cochrane Database of Systematic Reviews (2023) · Read the study

Meta-analysis of 41 studies

Across 41 studies, exposure to cues tied to the habit reliably raised craving, with an overall effect size of 0.92.

Paper: Meta-analysis of cue-reactivity in addiction research. Carter BL, Tiffany ST.

Credentials: Addiction (1999) · Read the study

Review

Sudden cravings set off by cues drive much of relapse, and steady-state medications such as the patch do not appear to block them.

Paper: The relevance and treatment of cue-induced cravings in tobacco dependence. Ferguson SG, Shiffman S.

Credentials: Journal of Substance Abuse Treatment (2009) · Read the study

Real-time diary study

Lapses clustered around low mood, available cigarettes and other smokers. People were 12 times more likely to be using a coping strategy in the temptations they got through.

Paper: First lapses to smoking: within-subjects analysis of real-time reports. Shiffman S, Paty JA, Gnys M, Kassel JA, Hickcox M.

Credentials: Journal of Consulting and Clinical Psychology (1996) · Read the study

Randomized study, 123 students

Brief urge-surfing instructions did not lower urges, but students who got them smoked fewer cigarettes over the next 7 days.

Paper: Surfing the urge: brief mindfulness-based intervention for college student smokers. Bowen S, Marlatt A.

Credentials: Psychology of Addictive Behaviors (2009) · Read the study

Meta-analysis of individual data

Short bouts of physical activity reduced desire to smoke in every trial analyzed. The authors call the evidence strong.

Paper: The acute effects of physical activity on cigarette cravings. Haasova M, Warren FC, Ussher M, et al.

Credentials: Addiction (2013) · Read the study

Lab study

A series of deep breaths every 30 minutes reduced craving, tension and irritability across 4 hours without smoking.

Paper: The effects of controlled deep breathing on smoking withdrawal symptoms in dependent smokers. McClernon FJ, Westman EC, Rose JE.

Credentials: Addictive Behaviors (2004) · Read the study

Randomized trial, 96 smokers

Ten minutes of breathing exercises reduced craving in the lab. A day later the benefit was gone, and few people had kept practicing.

Paper: The acute effects of yogic breathing exercises on craving and withdrawal symptoms in abstaining smokers. Shahab L, Sarkar BK, West R.

Credentials: Psychopharmacology (2013) · Read the study

Randomized controlled study

Five minutes a day of exhale-focused breathing improved mood and slowed breathing rate more than mindfulness meditation did.

Paper: Brief structured respiration practices enhance mood and reduce physiological arousal. Balban MY, Neri E, Kogon MM, et al.

Credentials: Cell Reports Medicine (2023) · Read the study

Systematic review, 15 studies

Breathing slower than 10 breaths a minute was linked to more relaxation and comfort and to less anxiety and arousal.

Paper: How breath-control can change your life: a systematic review on psycho-physiological correlates of slow breathing. Zaccaro A, Piarulli A, Laurino M, et al.

Credentials: Frontiers in Human Neuroscience (2018) · Read the study

Theoretical review

Proposes that slow breathing with long exhales calms the body by stimulating the vagus nerve.

Paper: Breath of life: the respiratory vagal stimulation model of contemplative activity. Gerritsen RJS, Band GPH.

Credentials: Frontiers in Human Neuroscience (2018) · Read the study

Lab study

After exposure to smoking cues, sniffing an odor reduced the urge to smoke compared with an odorless control.

Paper: Effects of olfactory stimuli on urge reduction in smokers. Sayette MA, Parrott DJ.

Credentials: Experimental and Clinical Psychopharmacology (1999) · Read the study

Small comparison study, 20 people

Two minutes of inhaling black pepper or angelica essential oil lowered craving and delayed the next use of tobacco.

Paper: The effects of aromatherapy on nicotine craving on a U.S. campus. Cordell B, Buckle J.

Credentials: Journal of Alternative and Complementary Medicine (2013) · Read the study