- Last edited on March 29, 2021
Tobacco (Nicotine) Withdrawal
Primer
Tobacco Withdrawal is a withdrawal syndrome that occurs when individuals stop tobacco/nicotine use. The withdrawal syndrome consists of irritability, anxiety, poor concentration, restlessness, poor focus, low mood, and insomnia. The syndrome is usually most intense in individuals who smoke cigarettes or use smokeless tobacco, due to the more rapid onset and higher levels of nicotine. Tobacco withdrawal can also produce clinically significant mood changes and functional impairment as well.
Epidemiology
- Approximately half of users who abstain from smoking for 2 or more days will have symptoms that meet criteria for tobacco withdrawal.[1]
Prognosis
- Tobacco withdrawal usually begins within 24 hours of cessation, and peaks 2 to 3 days after abstinence, and lasts for a total of 2 to 3 weeks.
- Symptoms beyond 1 month are uncommon.
- The most common symptoms are anxiety, irritability, and difficulty concentrating.
Comorbidity
- Abstinence can result in constipation, coughing, dizziness, intense dreams/nightmares, nausea, and/or sore throat.[2]
Risk Factors
- Smokers with depressive disorders, bipolar disorders, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and other substance use disorders will have a more severe withdrawal course.[3]
DSM-5 Diagnostic Criteria
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 at least 4 of the following signs or symptoms:
- Irritability, frustration, or anger
- Anxiety
- Difficulty concentrating
- Increased appetite
- Restlessness
- Depressed mood
- 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 another substance.
Signs and Symptoms
- The most common signs and symptoms are anxiety, irritability, and poor concentration.
- The least common symptoms are depression and insomnia.[4]
- The symptoms after abstinence from tobacco are caused by nicotine deprivation.[5]
- Tobacco withdrawal can produce clinically significant mood changes and functional impairment.[6]
Screening and Rating Scales
Pathophysiology
Differential Diagnosis
- Other substance withdrawals
- The symptoms of tobacco withdrawal can overlap with substance withdrawal syndromes (e.g. - alcohol withdrawal; sedative, hypnotic, or anxiolytic withdrawal; stimulant withdrawal; caffeine withdrawal; opioid withdrawal; and caffeine intoxication).
- Other mental disorders
- Anxiety disorders, depressive disorders, bipolar disorders, and sleep disorders can also present similarly
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- Admission to smoke-free inpatient units or voluntary smoking cessation can cause withdrawal symptoms that mimic, intensify, or disguise other disorders or adverse effects of medications used to treat mental disorders (e.g. - irritability thought to be due to alcohol withdrawal could be due to tobacco withdrawal). Seeing a reduction in withdrawal symptoms with the use of nicotine medications can confirm the diagnosis.
Treatment
Guidelines
Tobacco/Nicotine Guidelines
| Guideline | Location | Year | Website | |
|---|---|---|---|---|
| Canadian Medical Association Journal (CMAJ) | Canada | 2016 | - | Link |
| CAN-ADAPTT Guideline for Smoking Cessation | Canada | 2011 | - | Link |
| U.S. Public Health Service | US | 2008 | - | Link |
| Agency for Healthcare Research and Quality (AHRQ) | US | 2008 | - | Link |
| National Institute for Health and Care Excellence (NICE) | UK | 2018 | - | Link |