DSM-III

For more information, see Withdrawal

Diagnostic Criteria

A. Use of tobacco for at least several weeks at a level equivalent to more than ten cigarettes per day, with each cigarette containing at least 0.5 mg of nicotine.

B. Abrupt cessation of or reduction in tobacco use, followed within 24 hours by at least four of the following:

  1. craving for tobacco
  2. irritability
  3. anxiety
  4. difficulty concentrating
  5. restlessness
  6. headache
  7. drowsiness
  8. gastrointestinal disturbances

Differential Diagnosis

The diagnosis of Tobacco Withdrawal is usually self-evident from the individual's history, and the disappearance of symptoms if smoking is resumed is confirmatory.

DSM-IV

In DSM-IV, this disorder is called Nicotine Withdrawal

For more information, see Substance Withdrawal

The essential feature of Nicotine Withdrawal is the presence of a characteristic withdrawal syndrome that develops after the abrupt cessation of, or reduction in, the use of nicotine-containing products following a prolonged period (at least several weeks) of daily use (Criteria A and B). The withdrawal syndrome includes four or more of the following: dysphoric or depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness or impatience; decreased heart rate; and increased appetite or weight gain. The withdrawal symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Criterion D).

These symptoms are in large part due to nicotine deprivation and are typically more intense among individuals who smoke cigarettes than among individuals who use other nicotine-containing products. The more rapid onset of nicotine effects with cigarette smoking leads to a more intensive habit pattern that is more difficult to give up because of the frequency and rapidity of reinforcement and the greater physical dependence on nicotine. In individuals who smoke cigarettes, heart rate decreases by 5 to 12 beats per minute in the first few days after stopping smoking, and weight increases an average of 2-3 kg over the first year after stopping smoking. Mild symptoms of withdrawal may occur after switching to low-tar/nicotine cigarettes and after stopping the use of smokeless (chewing) tobacco, nicotine gum, or nicotine patches.

Diagnostic Criteria

A. Daily use of nicotine for at least several weeks.

B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four (or more) of the following signs:

  1. dysphoric or depressed mood
  2. insomnia
  3. irritability, frustration, or anger
  4. anxiety
  5. difficulty concentrating
  6. restlessness
  7. decreased heart rate
  8. increased appetite or weight gain

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM-5

Diagnostic Criteria

A. Daily use of tobacco for at least several weeks.

B. 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 or symptoms:

  1. Irritability, frustration, or anger.
  2. Anxiety.
  3. Difficulty concentrating.
  4. Increased appetite.
  5. Restlessness.
  6. Depressed mood.
  7. Insomnia.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Note: Tobacco withdrawal can only occur in the presence of a moderate or severe tobacco use disorder. It is not permissible to code a comorbid mild tobacco use disorder with tobacco withdrawal.

Differential Diagnosis

The symptoms of tobacco withdrawal overlap with those of other substance withdrawal syndromes (e.g., alcohol withdrawal; sedative, hypnotic, or anxiolytic withdrawal; stimulant withdrawal; caffeine withdrawal; opioid withdrawal); caffeine intoxication; anxiety, depressive, bipolar, and sleep disorders; and medication-induced akathisia. Admission to smoke-free impatient units or voluntary smoking cessation can induce withdrawal symptoms that mimic, intensify, or disguise other disorders or adverse effects of medications used to treat mental disorders (e.g., irritability thought to be due to alcohol withdrawal could be due to tobacco withdrawal). Reduction in symptoms with the use of nicotine medications confirms the diagnosis.

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