May 2019 By

Tobacco (Nicotine)

Smoking within 30 minutes of waking, smoking daily, smoking more cigarettes per day, and waking at night to smoke are associated with tobacco use disorder. Environmental cues can evoke craving and withdrawal. Serious medical conditions, such as lung and other cancers, cardiac and pulmonary disease, perinatal problems, cough, shortness of breath, and accelerated skin aging, often occur.

Tobacco Withdrawal

Withdrawal symptoms impair the ability to stop tobacco use. The symptoms after abstinence from tobacco are in large part due to nicotine deprivation. Symptoms are much more intense among individuals who smoke cigarettes or use smokeless tobacco than among those who use nicotine medications. This difference in symptom intensity is likely due to the more rapid onset and higher levels of nicotine with cigarette smoking. Tobacco withdrawal is common among daily tobacco users who stop or reduce but can also occur among nondaily users. Typically, heart rate decreases by 5-12 beats per minute in the first few days after stopping smoking, and weight increases an average of 4-7 lb (2-3 kg) over the first year after stopping smoking. Tobacco withdrawal can produce clinically significant mood changes and functional impairment.

Approximately 50% of tobacco users who quit for 2 or more days will have symptoms that meet criteria for tobacco withdrawal. The most commonly endorsed signs and symptoms are anxiety, irritability, and difficulty concentrating. The least commonly endorsed symptoms are depression and insomnia. Tobacco withdrawal usually begins within 24 hours of stopping or cutting down on tobacco use, peaks at 2-3 days after abstinence, and lasts 2-3 weeks. Tobacco withdrawal symptoms can occur among adolescent tobacco users, even prior to daily tobacco use. Prolonged symptoms beyond 1 month are uncommon. Craving for sweet or sugary foods and impaired performance on tasks requiring vigilance are associated with tobacco withdrawal. Abstinence can increase constipation, coughing, dizziness, dreaming/nightmares, nausea, and sore throat. Smoking increases the metabolism of many medications used to treat mental disorders; thus, cessation of smoking can increase the blood levels of these medications, and this can produce clinically significant outcomes. This effect appears to be due not to nicotine but rather to other compounds in tobacco.

Tobacco Use Disorder

Criterion A

A problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:

  1. Tobacco is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.
  3. A great deal of time is spent in activities necessary to obtain or use tobacco.
  4. Craving, or a strong desire or urge to use tobacco.
  5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).
  6. Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use).
  7. important social, occupational, or recreational activities are given up or reduced be cause of tobacco use.
  8. Recurrent tobacco use in situations in which it is physically hazardous (e.g., smok ing in bed).
  9. Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.
  10. Tolerance, as defined by either of the following: (A) A need for markedly increased amounts of tobacco to achieve the desired effect. (B) A markedly diminished effect with continued use of the same amount of tobacco.
  11. Withdrawal, as manifested by either of the following: (A) The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for tobacco withdrawal), (B) Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

Severity Specifier

Specify if:

  • Mild: Presence of 2-3 symptoms
  • Moderate: Presence of 4-5 symptoms
  • Severe: Presence of 6 or more symptoms

Tobacco Withdrawal

Criterion A

Daily use of tobacco for at least several weeks.

Criterion B

Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four (or more) of the following signs or symptoms:

  1. Irritability, frustration, or anger
  2. Anxiety
  3. Difficulty concentrating
  4. Increased appetite
  5. Restlessness
  6. Depressed mood
  7. Insomnia
Criterion C

The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion D

The signs or symptoms are not attributed to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from an other substance.


Treatment is recommended with either nicotine replacement (gum/patches), varenicline or bupropion.

Nicotine gum and patch dosing

Amount smoked Patch Dose Gum Dose
1/2 pack/day 7mg daily
  • Adjunct to patch: 2mg piece q1-2h PRN (max 15 pieces)
  • Monotherapy: 2mg piece q1-2h PRN (max 20 pieces)
1 pack/day 14mg daily Same as above
> 1 pack/day 21mg daily
  • Adjunct to patch: 2mg piece q1-2h PRN (max 15 pieces)
  • Monotherapy: 4mg (FOUR) piece q1-2h PRN (max 20 pieces)

For Patients