Psychiatry/Behavioral · PANCE / PANRE

Tobacco Use Disorder

Problematic tobacco/nicotine use meeting >=2 DSM-5-TR criteria; treat with combined pharmacotherapy and counseling.

Also known as: tobacco dependence, nicotine addiction, smoking cessation, nicotine use disorder

Overview

A problematic pattern of tobacco use causing clinically significant impairment or distress, with >=2 of 11 DSM-5-TR criteria in 12 months. Includes combustible tobacco, e-cigarettes/vaping, and smokeless tobacco.

Epidemiology

~12-14% of US adults currently smoke cigarettes; youth e-cigarette use rose sharply in late 2010s. Tobacco causes ~480,000 US deaths annually — leading preventable cause of death.

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Risk factors

Adolescent initiation, peer/family use
Mental illness (schizophrenia, bipolar, MDD, SUD) — higher prevalence and consumption
Lower socioeconomic status, lower education
Stress, occupational exposure

Pathophysiology

Nicotine binds nicotinic acetylcholine receptors on VTA dopaminergic neurons, releasing dopamine in nucleus accumbens. Tolerance develops via receptor upregulation. Withdrawal driven by reduced dopaminergic tone.

Clinical presentation

Symptoms

Withdrawal: irritability, anxiety, depressed mood, difficulty concentrating, increased appetite, insomnia, restlessness — peaks 2-3 days, lasts 2-4 weeks (cravings can persist months)
Loss of control, persistent desire to cut down, time spent obtaining, continued use despite harms — DSM-5-TR criteria parallel other SUDs

Signs / physical exam

Tobacco staining on fingers/teeth, halitosis, oral lesions, cough
Wheezing, decreased breath sounds in COPD
Elevated CO levels on exhaled testing

Differential diagnosis

Other SUDs — Frequent co-occurrence with alcohol, cannabis, stimulants
Anxiety/depression — Common comorbidity; tobacco often used for self-medication
ADHD — Higher rates of tobacco use; treat ADHD as part of cessation plan

Diagnostic workup

Diagnostic criteria

DSM-5-TR Tobacco Use Disorder: problematic pattern of tobacco use with >=2 of 11 criteria in 12 months. Severity by criterion count. Withdrawal symptoms support physiologic dependence.

Labs

Exhaled CO can confirm recent smoking (>=6-10 ppm)
Urine/serum cotinine — distinguishes recent use, confirms abstinence
Routine cardiovascular and pulmonary screening based on burden
Low-dose chest CT screening per USPSTF for ages 50-80 with >=20 pack-years and current smoking or quit within 15 years

Imaging

Low-dose chest CT for lung cancer screening as above

Diagnostic algorithm

Therapy	Notes
Varenicline	Most effective monotherapy; start 1 wk pre-quit; nausea, vivid dreams
NRT combo (patch + SA)	Long-acting baseline + short-acting for cravings
Bupropion SR	Avoid in seizure, eating disorder, active alcohol/benzo withdrawal
Behavioral counseling	Quitlines, text programs, individual or group
Combination Rx + counseling	Best outcomes

First-line tobacco cessation treatments.

Treatment

First-line

Brief intervention every visit — '5 As': Ask, Advise, Assess readiness, Assist, Arrange follow-up
Behavioral counseling — individual, group, telephone quitlines (1-800-QUIT-NOW), text-based programs
Pharmacotherapy (combine with counseling for best outcomes):
Varenicline — alpha-4-beta-2 nicotinic partial agonist; start 1 week before quit date; most effective single agent
Nicotine replacement therapy — combination of long-acting (patch) + short-acting (gum, lozenge, inhaler, nasal spray) outperforms monotherapy
Bupropion SR 150 mg — atypical antidepressant; avoid in seizure disorder, eating disorder, acute alcohol/benzodiazepine withdrawal

Second-line / adjunct

Combination pharmacotherapy: NRT patch + varenicline, or NRT patch + short-acting NRT, or NRT + bupropion
Nortriptyline, clonidine — less evidence
E-cigarettes as cessation aid — evidence growing but not FDA-approved for cessation; not first-line
Treat comorbid depression, anxiety, SUDs

Complications

Cancer: lung, oropharyngeal, esophageal, bladder, pancreatic, cervical, AML
Cardiovascular: CAD, stroke, peripheral arterial disease, AAA
Pulmonary: COPD, exacerbation of asthma
Pregnancy: low birth weight, preterm delivery, SIDS
Wound healing impairment, periodontal disease, osteoporosis

PANCE pearls

Even brief (<3 min) clinician advice to quit increases cessation rates — never miss an opportunity.
Cessation halves CV risk within 1 year; lung cancer risk falls toward baseline over 10-15 years.
Varenicline neuropsychiatric warning was removed from the FDA label in 2016 after EAGLES trial showed no increased risk vs placebo.
Patients with serious mental illness benefit from cessation without worsening psychiatric symptoms — do not defer.
Pregnancy: prefer behavioral interventions; NRT can be considered after risk discussion if behavioral approaches fail; avoid varenicline and bupropion.

References

USPSTF 2021 — Interventions for Tobacco Smoking Cessation in Adults: USPSTF Recommendation Statement. JAMA 2021
Surgeon General 2020 — Smoking Cessation: A Report of the Surgeon General (2020)
EAGLES Trial — Anthenelli RM et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch (EAGLES). Lancet 2016
DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)

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