Tobacco Use Disorder in Adults

Tobacco use disorder may be defined as a problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

• Tobacco is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.
• A great deal of time is spent in activities necessary to obtain or use tobacco.
• Craving, or a strong desire or urge to use tobacco.
• Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).
• 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).
• Important social, occupational, or recreational activities are given up or reduced because of tobacco use.
• Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed).
• 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.
• Tolerance, as defined by either of the following:
• A need for markedly increased amounts of tobacco to achieve the desired effect.
• A markedly diminished effect with continued use of the same amount of tobacco.
• Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for tobacco:
• Daily use of tobacco for at least several weeks.
• 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 and symptoms:
• Irritability, frustration, or anger.
• Anxiety.
• Difficulty concentrating.
• Increased appetite.
• Restlessness.
• Depressed mood.
• Insomnia.
• Tobacco (or closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

More than 16 million Americans live with smoking-related disease. In recent years, smoking has declined – in 2005, 20.9% of U.S. adults were current smokers.

Smokeless tobacco products are a known cause of cancer, and are not a safe alternative to cigarettes. Cigars have many of the same health risks of cigarettes, including causing certain cancers. Not enough is currently known about electronic cigarettes to determine the health consequences and safety of these products.

Many factors influence whether individuals try tobacco, such as peer and family influences. Most adults who smoke cigarettes began during their teen years. Because nicotine is highly addictive, many people who try smoking will become addicted. Individuals who have other psychiatric and substance use disorders are particularly susceptible to tobacco use disorder.

• Brief Treatments

• Assessment and treatment from a primary care physician or other provider

• Behavioral / Psychosocial Treatments

  Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective:

  • Practical counseling (problem-solving/skills training)
  • Social support and encouragement delivered as part of treatment

  Intensive counseling is especially effective. There is a strong dose-response relation between counseling intensity and quitting success. In general, the more intense the treatment intervention, the greater the rate of abstinence. Treatments may be made more intense by increasing (a) the length of individual treatment sessions and (b) the number of treatment sessions.

  
  

  Other effective modalities include:

  • Telephone quitline counseling
  • Motivational techniques

  Pharmacological Interventions

  Numerous effective medications are available for tobacco dependence, except when medically contraindicated or with specific adult populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers). Medications may be used alone or in combination. The combination of medications and counseling have been found to be more effective than either alone.

  • First-line medications
    • Bupropion SR
    • Nicotine gum
    • Nicotine inhaler
    • Nicotine lozenge
    • Nicotine nasal spray
    • Nicotine patch
    • Varenicline
  
  
  • Second-line medications
    • Clonidine
    • Nortriptyline

  
  Additional Treatments to Consider
  To learn more about drug prescribing for Tobacco Use Disorder, click here.

  Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered:

  • Short-term tangible reinforcement (e.g. collecting money that would normally be used to purchase tobacco or related products, and saving it to purchase a reward for quitting)
  • Hypnosis
  • Physiological feedback
  • Exercise as an adjunct to relieve nicotine cravings