DSM-III

In DSM-III, this disorder is called Tobacco Dependence

Diagnostic Criteria

A. Continuous use of tobacco for at least one month.

B. At least one of the following:

  1. serious attempts to stop or significantly reduce the amount of tobacco use on a permanent basis have been unsuccessful
  2. attempts to stop smoking have led to the development of Tobacco Withdrawal
  3. the individual continues to use tobacco despite a serious physical disorder (e.g., respiratory or cardiovascular disease) that he or she knows is exacerbated by tobacco use

Differential Diagnosis

The major differential diagnostic problems will be to determine whether or not a particular physical disorder, in an individual who is a heavy smoker, is exacerbated by tobacco use, and how long a period of abstinence from tobacco justifies the judgment that the disorder is no longer present or is in a state of remission.

DSM-IV

In DSM-IV, this disorder is called Nicotine Dependence

For more information, see Substance Dependence

Some of the generic Dependence criteria do not appear to apply to nicotine, whereas others require further explanation. Tolerance to nicotine is manifested by the absence of nausea, dizziness, and other characteristic symptoms despite using substantial amounts of nicotine or a diminished effect observed with continued use of the same amount of nicotine-containing products. Cessation of nicotine use produces a well-defined withdrawal syndrome. Many individuals who use nicotine take nicotine to relieve or to avoid withdrawal symptoms when they wake up in the morning or after being in a situation where use is restricted (e.g., at work or on an airplane). Individuals who smoke and other individuals who use nicotine are likely to find that they use up their supply of cigarettes or other nicotine-containing products faster than originally intended. Although over 80% of individuals who smoke express a desire to stop smoking and 35% try to stop each year, less than 5% are successful in unaided attempts to quit. Spending a great deal of time in using the substance is best exemplified by chain-smoking. Because nicotine sources are readily and legally available, spending a great deal of time attempting to procure nicotine would be rare. Giving up important social, occupational, or recreational activities can occur when an individual forgoes an activity because it occurs in smoking-restricted areas. Continued use despite knowledge of medical problems related to smoking is a particularly important health problem (e.g., an individual who continues to smoke despite having a tobacco-induced general medical condition such as bronchitis or chronic obstructive lung disease).

Specifiers

The following specifiers may be applied to a diagnosis of Nicotine Dependence:

  • With Physiological Dependence
  • Without Physiological Dependence
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • On Agonist Therapy

 DSM-5

Diagnostic Criteria

A. 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:

  1. Tobacco is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.
  3. A great deal of time is spent in activities necessary to obtain or use tobacco.
  4. Craving, or a strong desire or urge to use tobacco.
  5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).
  6. 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).
  7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use.
  8. Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed).
  9. 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.
  10. Tolerance, as defined by either of the following:
    • a. A need for markedly increased amounts of tobacco to achieve intoxication or desired effect.
    • b. A markedly diminished effect with continued use of the same amount of tobacco.
  11. Withdrawal, as manifested by either of the following:
    • a. The characteristic withdrawal syndrome for tobacco.
    • b. Tobacco (or a closely related substance, such as a nicotine) is taken to relieve or avoid withdrawal symptoms.

Specify if:

  • In early remission: After full criteria for tobacco use disorder were previously met, none of the criteria for tobacco use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, "Craving, or a strong desire or urge to use tobacco," may be met).
  • In sustained remission: After full criteria for tobacco use disorder were previously met, none of the criteria for tobacco use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, "Craving, or a strong desire or urge to use tobacco," may be met).

Specify if:

  • On maintenance therapy: The individual is taking a long-term maintenance medication, such as nicotine replacement medication, and no criteria for tobacco use disorder have been me for that class of medication (except tolerance to, or withdrawal from, the nicotine replacement medication).
  • In a controlled environment: This additional specifier is used if the individual is in an environment where access to tobacco is restricted.

Note: If a tobacco withdrawal or tobacco-induced sleep disorder is also present, the comorbid tobacco use disorder is indicated in the tobacco-induced disorder. For example, if there is comorbid tobacco-induced sleep disorder and tobacco use disorder, only the tobacco-induced sleep disorder diagnosis is given, with the recording indicating whether the comorbid tobacco use disorder is mild, moderate, or severe (e.g., mild tobacco use disorder with tobacco-induced sleep disorder; moderate or severe tobacco use disorder with tobacco-induced sleep disorder).

Specify current severity:

  • Mild: Presence of 2-3 symptoms.
  • Moderate: Presence of 4-5 symptoms.
  • Severe: Presence of 6 or more symptoms.

Specifiers

"On maintenance therapy" applies as a further specifier to individuals being maintained on other tobacco cessation medication (e.g., bupropion, varenicline) and as a further specifier of remission if the individual is both in remission and on maintenance therapy. "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units.

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