Tobacco (Nicotine) Use Disorder

Tobacco (Nicotine) Use Disorder is a substance use disorder characterized by a problematic pattern of tobacco (nicotine) use leading to clinically significant impairment or distress. Like with all substance use disorders, there is a complex interplay between biological, social, psychological, and cultural factors.

Nicotine is a stimulant and potent parasympathomimetic alkaloid that is naturally produced in the nightshade family of plants.


Nicotine use is associated with numerous medical complications and diseases, including cancer, cardiac disease, pulmonary disease, perinatal problems, cough, shortness of breath, and accelerated skin aging.

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

When individuals stop smoking, the withdrawal symptoms are precipitated by nicotine withdrawal. This is usually most intense in 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 can also produce clinically significant mood changes and functional impairment.

Approximately half of users who abstain from smoking for 2 or more days will have symptoms that meet criteria for tobacco withdrawal. The most common symptoms are anxiety, irritability, and difficulty concentrating. Tobacco withdrawal usually begins within 24 hours of cessation, peaks 2 to 3 days after abstinence, and lasts 2 to 3 weeks. Symptoms beyond 1 month are uncommon. Abstinence can increase constipation, coughing, dizziness, intense dreams or nightmares, nausea, and sore throat.

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 first, followed by non-nicotine pharmacotherapy such as varenicline or bupropion.

Nicotine Dosing

Amount smoked Patch Dose Gum Dose
< 5 cigarettes per day, or if unable to tolerate NRT 7mg daily • Adjunct to patch: 2mg piece q1-2h PRN (max 15 pieces)
• Monotherapy: 2mg piece q1-2h PRN (max 20 pieces)
5-10 cigarettes daily 14mg daily Same as above
10-25 cigarettes daily 21mg daily • Adjunct to patch: 2mg piece q1-2h PRN (max 15 pieces)
• Monotherapy: 4mg (FOUR) piece q1-2h PRN (max 20 pieces)
> 25 cigarettes daily 21mg x 2 daily Same as above

If withdrawal symptoms (e.g. - cravings, irritability, frustration, anger, anxiety, difficulty concentrating, and/or restlessness) continue despite NRT, consider adding non-nicotine pharamcotherapies such as bupropion SR.