Tobacco use disorder: Causes, symptoms, and treatment options

Nicotine-containing products, alongside caffeinated beverages like coffee, are some of the most commonly used psychoactive substances in the U.S.—though we rarely think of them as drugs. Even though tobacco and nicotine use has steadily dropped in the U.S. since 2005, many of us know someone who smokes, chews, or uses nicotine products. And in some cases, regular users can develop a condition known as tobacco use disorder. 

As Kate Hanselman, PMHNP at Thriveworks explains, “tobacco use disorder is a mental health diagnosis that is made when an individual’s tobacco/nicotine use causes significant impairment or distress.” Nicotine is the addictive chemical found in cigarettes, cigars, chewing tobacco, snuff, and other tobacco products. Besides causing dependency, nicotine has many negative physical effects and a variety of withdrawal symptoms. 

The addictive nature of nicotine makes quitting smoking, vaping, or chewing forms of tobacco difficult. Hanselman also notes that “nicotine is highly addictive, and can lead individuals to experience dependence, tolerance, and significant difficulty quitting, often over multiple attempts.” However, quitting can be easier with the help of a substance use therapist, a behavioral therapist, or a qualified psychiatric provider.  

What Are the DSM-5 Criteria for Tobacco Use Disorder?

The DSM-5 defines tobacco use disorder 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.” 

When an individual uses tobacco for more than a year and a minimum of two of the following sub-features appear, the disorder is diagnosed. Symptoms of tobacco use may entail: 

• Taking tobacco in larger amounts or over a longer period than intended
• Unsuccessful attempts to cut down or control one’s tobacco use
• Large amounts of time spent trying to find and use tobacco
• Intense cravings for tobacco
• Tobacco use that results in failure to fulfill obligations at work, school, or home 
• Persistent or recurrent social or interpersonal problems caused or worsened by tobacco use
• Lost hobbies and relationships because one’s tobacco use gets in the way
• Tobacco use in dangerous situations, such as near flammable chemicals or while in bed
• Continued tobacco despite physical or psychological problems that are likely to have been caused or made worse by tobacco use

The severity of someone’s dependence on tobacco may vary significantly, depending on how long they’ve been using, how often they use, and how disruptive their habit is to other aspects of daily life.

How Is Tobacco Use Disorder Categorized?

The disorder is separated into three categories—mild, moderate, and severe. If between two and three symptoms from the criteria exist, the individual’s tobacco use disorder is considered mild.

When four to five of the above criteria are met, the tobacco use disorder is recognized as moderate. With the presence of six or more of the criteria, the tobacco use disorder is given the diagnosis of severe.

Tobacco Use Disorder Risk Factors

According to the DSM-5, some of the risk factors for developing the disorder include:

• Belonging to a lower income bracket
• Belonging to a lower education level
• Being a child or teen with ADHD
• Being an adult with anxiety, depression, bipolar disorder I or II, personality disorders, or other pre-existing conditions

Other at-risk groups include those with a family history of nicotine addiction and substance use. 

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What Are the Effects of Tobacco Use Disorder?

Besides nicotine addiction, the effects of tobacco use disorder can possibly include: 

• Nausea
• Weight loss
• Diminished social life
• Health effects, such as low blood oxygen levels, emphysema, high blood pressure, and respiratory cancers 
• Anxiety
• Irritability

Tobacco use disorder is a condition that highlights the disruptive and addictive effects of nicotine consumption. Those with tobacco use disorder will often smoke within 30 minutes of waking up, and may even wake up at night to smoke. 

What Is Tobacco Withdrawal? 

When an individual makes an effort to stop the use of nicotine, then tobacco withdrawal (DSM-5 292.0 F17.203) may occur. The DSM-5 criteria for tobacco withdrawal include: 

• Problems concentrating and focusing
• Anxiousness 
• Headaches
• Weight gain 
• Slower heart rate
• Difficulty sleeping
• Agitation and aggression 
• Depressed mood 
• Substance use to cope with withdrawal symptoms

These symptoms will spike in the first several days after last using nicotine and gradually fade within 30 days (but can last longer) as the individual’s dependence on nicotine is reduced. A mental health professional may add the following to the diagnosis, including the individual’s remission timeline: 

• The individual has not used tobacco for three to 13 months (early remission).
• The person has not used tobacco for more than one year (sustained remission).
• The individual is undergoing therapy to stop smoking, such as using a nicotine transdermal patch that can be part of a complete program that includes counseling, support groups, and behavioral changes.

Health Risks of Tobacco Use

Tobacco causes many risks to a person’s health, including:

• Cancer, including mouth, esophagus, lungs, and throat
• Emphysema
• Heart disease
• Chronic bronchitis
• Stroke
• Upper respiratory infections
• Roughness to the voice
• Gum disease
• Tooth decay
• Chronic obstructive pulmonary disease

There are also numerous other risks related to tobacco, including:

• Facial wrinkles (prematurely)
• Breath odor
• Decreased sense of smell and taste
• Staining on teeth and fingers
• Odor is left on the skin, clothes, and hair
• Tobacco use is a costly habit
• Residue from chewing tobacco gets stuck between the teeth

Also not to be discounted is the risk that tobacco smoke poses to the health of others. Because smoke from cigarettes is composed of toxic chemicals, such as arsenic, cyanide, tar, and nicotine, secondhand smoke can be a serious health issue for those living or working in close proximity to the smoker.

Facts About Tobacco Usage

Cigarettes are the most commonly used of all tobacco products and account for 90% of all tobacco use in the U.S. By the time they are 18 years old, approximately 20% of young adults in the U.S. will use cigarettes every month. Many of them will become smokers on a daily basis. The DSM-5 also points out that: 

• About 22% of adults in the country used to smoke.
• About 21% of people in the U.S. are smokers currently.
• 20% of smokers in the U.S. are considered casual or sporadic smokers.

Interestingly, people who chew tobacco and use snuff account for less than five percent of tobacco users in the U.S.

Can Tobacco Change Your Personality?

Tobacco may not directly affect someone’s personality, but nicotine affects the brain’s reward system, hijacking it in a certain sense. 

This can result in a personality change of sorts. Nicotine usage has also been shown to decrease neuroplasticity, and decrease the number of neurons in the brain, along with altering the brain’s structure. Over long periods of time (likely decades), these changes could result in cognitive decline that causes personality changes.  

How Do You Control a Tobacco Addiction?

The most effective way to control one’s tobacco addiction is to stop using all forms of tobacco—and more specifically, nicotine. Products like nicotine pens and vaporizers may not contain tobacco (and initially appear safer than traditional forms of tobacco use) but are still addictive. 

Some people switch from smoking or chewing to using nicotine gum in order to wean themselves off of the chemical. Tapering off one’s nicotine supply can be an easier, less punishing form of quitting. 

Some individuals may find it easy to quit on their own. But for other people, having the help of a mental health professional can make the process easier. 

What Is the Treatment for Tobacco Use Disorder?

There are an assortment of methods that can help people successfully quit using tobacco products. Cognitive behavioral therapy (CBT), in particular, can help the individual stay committed to cessation. Acceptance and commitment therapy (ACT), along with motivational interviewing (MI) can also be effective treatments. 

A therapist can work with individuals to help them identify other healthier habits that will help replace the “feel good” effects of smoking. The right therapist will also assist them in dealing with their cravings for nicotine. And as the client and therapist move forward as a team, they’ll work to identify the triggers that drive the individual to want to use tobacco. 

In other circumstances, a psychiatric provider can help provide the former smoker with a prescription medication that helps alleviate the withdrawals associated with nicotine cravings. 

In addition to these treatment options, some people may find solace in support groups for smokers who are trying to quit. Having the empathy and encouragement of an entire group, rather than a single individual, may make quitting easier for those suffering from tobacco use disorder.