Author: David Porter, MA, LADC













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Tobacco Use Disorder DSM-5 305.1 (Z72.0) (F17.200)

DSM-5 Category: Substance Abuse Disorder

Introduction

Tobacco Use Disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who are dependent on the drug nicotine due to use of Tobacco products. Tobacco contains the psychoactive drug nicotine, which is a CNS (Central Nervous System) stimulant. The immediate effects of nicotine administration are tachycardia, hypertension, increased respiration, hyperglycemia, enhanced memory storage, improved concentration, and appetite suppression. Nicotine can be administered through several routes, including Inhalation (smoking cigarettes, cigars, or pipes) Buccal (Chewing tobacco) and insulfation (snuff). The mechanism of action of nicotine is binding to nicotinic acetylcholine receptors. Nicotine also agonizes the catecholamines- Da (Dopamine), Se (Serotonin), and Ne (Norephinephrine) by MOA (Monoamine Oxidase) inhibition, and agonizes adrenaline by direct action on the adrenal medulla (Joiner, 2012). Nicotine has a half- life of about two hours. Nicotine produces dependence and withdrawal symptoms upon cessation of use, the onset of which occurs about one hour after the last dose. Withdrawal symptoms include Irritability, annoyance, anxiety, and cravings for nicotine. (Icahn School of Medicine, 2014). Features of tobacco products that enhance their addictive potential include the rewarding properties of nicotine, the behavioral reinforcement of the hand- to -to mouth habit, lack of social support to cease smoking, the ease of access of tobacco products, and the cultural acceptance of tobacco products. Another factor which enhances nicotine's addictive qualities is bioengineering by Tobacco companies, which add ammonia to nicotine to facilitate absorption and bioavailability.(Personal Communication, Richter, D., 2012.).

Symptoms of Tobacco use Disorder

According to the DSM-5, there are three Criterion with 15 sub features, and four specifiers to diagnose Tobacco Use disorder. Use of tobacco products over one year has resulted in at least two of the following sub features:

A, Larger quantities of tobacco over a longer period then intended are consumed.

1. Unsuccessful efforts to quit or reduce intake of tobacco

2. Inordinate amount of time acquiring or using tobacco products

3. Cravings for tobacco

4. Failure to attend to responsibilities and obligations due to tobacco use

5. Continued use despite adverse social or interpersonal consequences

6, Forfeiture of social, occupational or recreational activities in favor of tobacco use

7. Tobacco use in hazardous situations

8. Continued use despite awareness of physical or psychological problems directly attributed to tobacco use

B. Tolerance for nicotine, as indicated by:

9. Need for increasingly larger doses of nicotine in order to obtain the desired effect

A noticeably diminished effect from using the same amounts of nicotine

C. Withdrawal symptoms upon cessation of use as indicated by

10. The onset of typical nicotine associated withdrawal symptoms is present

11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms

The clinician may also add the following specifiers

1. Early remission- no use of Tobacco products for 3-13 months.

2. Sustained remission- no use of Tobacco products for > 12 mos.

3. On maintenance therapy- e.g., transdermal nicotine.

4. In a controlled environment- e.g., hospital or correctional facility where smoking is forbidden.

Additional specifiers indicate the level of severity of Tobacco use disorder

1. 305.1 (Z72.0) Mild: two or three symptoms are present.

2. 305.1 (F17.200) Moderate: four or five symptoms are present.

3. 305.1 (F17.200) Severe: Six or more Symptoms are present

(American Psychiatric Association, 2013).

Onset

The DSM-5 notes that many people in the US try cigarettes in their teens, about 20% will use monthly by age 18, and many of this subset will become daily smokers (American Psychiatric Association, 2013).

Prevalence

According to the DSM-5, the annual prevalence of Tobacco Use Disorder. Cigarettes are the most commonly used tobacco product accounting > 90% of tobacco use. In the United States, 22% of adults are former smokers, and 21% are current smokers About 20% of U.S. smokers are sporadic/occasional smokers The prevalence of smokeless tobacco ( chew and snuff) use is < 5%, and the prevalence of tobacco use in pipes and cigars is < 1% (American Psychiatric Association, 2013).

Risk Factors

The DSM-5 indicates that risk factors for Tobacco Use Disorder include low-income levels, low level of Education, and diagnosis of the following disorders: ADD/ADHD. Conduct disorder, Depressive Disorder, anxiety disorders, personality disorders, psychotic disorders, and other substance use disorders There is also a genetic component to Tobacco Use Disorder, (American Psychiatric Association, 2013).

Comorbidity

The DSM-5 indicates that Tobacco Use Disorder is comorbid with the other disorders listed above in Risk Factors.(American Psychiatric Association, 2013). Schizophrenics smoke heavily (Hanson, 2012) Substance abuse disorders have high comorbidity with Tobacco Use Disorder. People in early recovery from other drugs or alcohol tend to smoke heavily or chew tobacco. There is evidence that continued use of tobacco products impairs recovery. (Kalman, DiGirolamo, Smelson, & Ziedonis 2010). Some increase their use of tobacco products substantially upon cessation of use of their substance(s) of choice, in what is a questionable state of sobriety. Nicotine activates the nucleus accumbens, which is the area of the brain linked with pleasure and reward. By continuing to stimulate this area with nicotine, addicts and alcoholics continue to feed their addiction so to speak. As noted under Impact on functioning, multiple medical problems accompany Tobacco Use disorder.

Treatment for Tobacco Use Disorder

The DSM-5 does not specify treatment options for Tobacco Use Disorder (American Psychiatric Association, 2013). There are a number of methods to attempt smoking cessation, some of which are evidenced based, others are lacking in empirical evidence for their efficacy, and may be ill advised. Methods that have been attempted include Hypnosis, Social support through smoking cessations self help groups, Exercise as an adjunct to relieve nicotine cravings, Aversion therapy, which is not a recommended course of action, a s it entails chain smoking to the point of illness, which can result in a potentially fatal overdose of nicotine, (CBT) Cognitive Behavioral therapy,. Some individuals find it helpful to have a short term tangible reinforcement for not smoking, which is called a Quitting Jar, it consists of a jar or other container which the smoker deposits money in every day that would normally be used to purchase cigarettes or other tobacco products,. The money is saved and used to purchase a reward for quitting. RYO (Roll Your Own) is another method , in which the smoker rolls their own cigarettes from bulk tobacco to can reduce the frequency in which tobacco is consumed, NRT ( Nicotine Replacement Therapy) is the use of Electronic cigarettes ( currently not FDA approved devices) which vaporize nicotine and give the smoker a dose of nicotine to alleviate cravings, rather than obtaining through the more hazardous method of administration, e.g., smoking or chewing carcinogenic tobacco- Nicotine gum, or transdermal Nicotine (Icahn School of Medicine, 2014). There are also pharmacological interventions such as Zyban (Wellbutrin) and Chantix, a Nicotine antagonist

Impact on Functioning

Tobacco Use disorder will inevitably have a have strong affects on health. (American Psychiatric Association, 2013). Long term effects of use of tobacco products includes: Increased incidence of upper respiratory infections, partly due to cilliary compromise , reduced cardiovascular capacity, impaired sense of smell ,Impaired sense of taste, gravelly, rough voice, yellow/brown stains on fingers, halitosis, offensive odor on skin, hair, and clothes, tooth decay, gum disease, chronic cough, chronic bronchitis, Emphysema, COPD (Chronic Obstructive Pulmonary Disease), increased risk of CHD (Coronary Heart Disease), CVA (Cerebrovascular Accident) [stroke], MI/CA (Myocardial Infarction/Cardiac Arrest) , and cancers of the Lungs, Throat, Esophagus, Mouth, and Jaw (Icahn School of Medicine, 2014).

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Hanson, D. (2012). Smoking’s Ties to Schizophrenia. The Dana Foundation. Retrieved February 22, 2014, from: http://dana.org/News/Details.aspx?id=43220

Kalman D, DiGirolamo, K.S., Smelson, G. and Ziedonis D. (2010). Addressing tobacco use disorder in Smokers in early remission from alcohol dependence: the case for integrating smoking cessation Services in substance use disorder. Treatment programs. Clinical Psychology Review. 30(1):12-24. doi: 10.1016/j.cpr.2009.08.009.

Icahn School of Medicine. (2014). Tobacco Use Disorder. Mt. Sinai Hospital. Retrieved March 12, 2014 From http://www.mountsinai.org/patient-care/health-library/diseases-and-conditions/tob acco-usedisorder

Joiner, W. (2012). Pharmacology of Nicotine. Pharmacology 255. Retrieved March 15, 2014 from http://pharmacology.ucsd.edu/graduate/courseinfo/Biom255-Nicotine_Joiner_2012.pdf

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