Tobacco-related disorders include tobacco use disorder and tobacco withdrawal. Tobacco and tobacco-based products contain many harmful substances, including nicotine, a highly addictive chemical that causes changes in the brain that result in cravings for more nicotine. Those with tobacco-use disorder continue to use tobacco, whether through smoking or chewing/dipping, even though they know it is harmful. Tobacco use disorder is the most common substance use disorder in the U.S., as well as a major cause of disability and early death. Exposure to tobacco smoke can also cause early death in nonsmokers.
Tobacco use disorder is defined by the DSM-5 as a problematic pattern of tobacco use leading to clinically significant impairment or distress, involving at least two of the following within a 12-month period:
- Tobacco is taken in larger dosages and/or for a longer period of time than intended
- There is a persistent desire and/or failed attempts to reduce tobacco use
- A large amount of time goes into procuring or using tobacco
- An overwhelming desire or urge to use tobacco
- The inability, due to tobacco use, to maintain obligations for one's job, school, or home life
- Continued tobacco use in the face of social/interpersonal problems that result from, or are made worse by, the use of the stimulant
- Tobacco use becomes prioritized to such an extent that social, occupational, and recreational activities are either given up on completely or are reduced drastically
- Tobacco use occurs even in situations where it becomes physically hazardous
- Use of tobacco continues even though one knows the physical and psychological risks and problems associated with it
- A considerable increase in the amount of tobacco is needed to achieve the desired effect, or the same amount of tobacco no longer produces the desired effect
- Withdrawal symptoms characteristic of tobacco use are present, or tobacco is taken to relieve or avoid withdrawal symptoms
Symptoms of tobacco withdrawal set in within 24 hours, and may include:
Symptoms peak at two to three days after abstinence and last two to three weeks.
The active drug in both tobacco and vaping is nicotine. Vaping is a relatively new, and increasingly popular way to consume nicotine. It does not contain the harmful carcinogens cigarettes do, but it may come with its own health hazards. After decades of declines in cigarette smoking, vaping has become popular among adolescents. In 2019, 27.5 percent of high school students and 10.5 percent of middle school students reported the current use of vaping.
Research finds that for individuals with tobacco use disorder, the likelihood of developing schizophrenia spectrum disorders, which include psychosis, is around twice as high as for the general population. The evidence substantially, but not conclusively, supports the idea that smoking causes this increase in schizophrenia spectrum disorders, rather than the other way around (people with schizophrenia spectrum disorders being more likely to smoke in the first place).
The studies found this result after adjusting for many confounding factors, including cannabis use, environmental, and genetic factors.
This finding occurs primarily in individuals who begin smoking in their teens, when brains and neural pathways are still developing. Nicotine alters the functions of several neurotransmitter systems, particularly in adolescence. Excess nicotine impact in early adolescence has been associated with abnormal white and grey matter development in adult brains.
Tobacco-related disorders result from the addictive nature of the substance itself. A majority of users report experiencing cravings when they do not smoke for several hours. Studies have found that people with alcohol-related and other substance use disorders are more likely to use tobacco and have a lower rate of quitting tobacco use than those who do not have such disorders. Children of parents who use tobacco are more likely to use it themselves, compared with children of parents who do not use tobacco. Many individuals with tobacco use disorder continue to use tobacco products to relieve or prevent withdrawal symptoms.
Smoking has been associated with a range of mental or mood disorders, although it’s not clear in which direction the causation goes.
Research has found that those with ADHD are at significant risk to start consuming nicotine as a result of their condition. Nicotine’s effects on the central nervous system can help calm mood and anxiety, and may lead to people with undiagnosed ADHD attempting to self-medicate.
Other conditions with high rates of smokers include anxiety, and depression, where rates of smoking are roughly twice as high as those without these disorders.
Different studies have found those with schizophrenia are five to seven times more likely to smoke.
It has also been found that smokers with a high level of psychological distress smoke more per day than other smokers.
One idea on environmental causes for tobacco use comes from how early life adversity (such as child abuse, neglect, sexual abuse, or poverty) can alter the development of the neural circuitry of the brain, leaving those who’ve suffered these events more likely to have altered executive control networks, seek short-term rewards over long-term wellbeing, to overcome blunted reward pathways through the dopaminergic effects of nicotine, and to smoke as a coping mechanism. Some evidence supports the argument that nicotine is effective at reducing emotional reactivity (Duffy, et al., 2019).
In contrast, a meta-analysis of more than 80 papers and studies on the topic, with a total of more than 241,000 sum participants found no convincing or highly suggestive evidence of environmental factors as risk factors for tobacco use disorder, however it did identify several statistically weakly linked factors (Solmi, 2020).
Tobacco use disorder is considered highly treatable when the appropriate pharmacological, behavioral, and psychosocial interventions are used. Treatment may include education about the nature and health consequences of tobacco addiction, individual and group addiction support programs, relapse prevention counseling, and separate, tailored treatments for those with lower or higher motivation to quit. Any of a number of FDA-approved medications may also be used to treat nicotine dependence.
The most common methods for quitting smoking are nicotine replacement therapies, which deliver progressively smaller amounts of nicotine through chewing gum, a patch on the skin, or tablets and lozenges, in order to lessen the symptoms of withdrawal.