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What is Tobacco Use Disorder?
Despite the name of the disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Tobacco Use Disorder (TUD) encompasses both tobacco and nicotine addiction.
There are several types of nicotine and tobacco products, which are either smoked or smokeless. Smoked tobacco products include cigarettes, cigars, and hookahs. The only smoked nicotine product is a vape, also known as an electronic cigarette. Smokeless tobacco products include chewing tobacco, dipping tobacco, dissolvable tobacco, and snus. Smokeless nicotine products include nicotine pouches, nicotine gels, and nicotine lozenges, gums, and patches.
According to the National Institutes of Health (NIH), tobacco is used by more than a billion people worldwide. Unfortunately, because it is such a commonly used substance, it is often viewed as a trivial substance, despite the high morbidity rate due to prolonged usage of tobacco and/or nicotine products.
Innovations in processing tobacco and nicotine have led to newer products containing extremely potent forms of tobacco and nicotine, leading to higher addiction probabilities than ever before.
The Psychology Behind Tobacco Use Disorder
According to the National Library of Medicine, the most common substance use disorder is for nicotine, tobacco use disorders.
Tobacco use disorder has physical and psychological components.
Evolutionarily, the human body seeks out positive rewards from stimuli that boost dopamine and seeks to avoid negative stimuli. The problem with this is that drugs like nicotine, a positive stimuli, increase dopamine in the brain with repeated use which is incredibly dangerous and addictive.
According to Centre for Addiction and Mental Health, Dopamine released by nicotine is also released in the same areas of the brain where dopamine is released from other addictive substances, such as opioids, alcohol, and cocaine. Since nicotine/tobacco is smoked, the hit takes only 20 seconds to reach the brain; therefore, nicotine is comparably addictive as opioids, alcohol, and cocaine.
Repeated use of nicotine causes long term changes in the brain leading to nicotine dependence. When one stops using tobacco or nicotine, nicotine levels in the brain decrease and the brain seeks to maintain the prior equilibrium causing cravings and urges which reinforce tobacco addiction. If one tries to quit without any outside aid, they will have withdrawals that are extremely undesirable and only go away with using nicotine again. Attempting to quit without assistance will likely cause unpleasant withdrawal symptoms, which only subside with using nicotine again.
Use of tobacco or nicotine long-term can cause tolerance where an individual will no longer feel the desired effects unless the dose is increased.
Triggers, or conditioned signals, are psychological factors for tobacco use. For example, people may regularly smoke right after waking up for alertness or when they feel anxious. When put in these situations, these situations are their trigger and make the problem behavior of using tobacco hard to quit.
Important Factors
A major risk factor for developing a Tobacco Use Disorder (TUD) is a family history of the condition. Using tobacco or other substances at a young age also increases risk. Adverse childhood experiences or mental illnesses are also major risk factors.
Symptoms & Signs
Effects of nicotine in the short term can include heightened heart rate and blood pressure, feelings of pleasure, enhanced alertness, muscle relaxation, nausea, and headaches. In the long-term, effects can include weight gain, constipation, tremors, heart problems, addiction, and heightened potential for cancer.
Some signs of physical dependence on nicotine are having the urge to smoke within half an hour of waking up and smoking regularly at intervals throughout the day.
Signs of nicotine withdrawal include irritability, insomnia, fatigue, difficulty concentrating, and increased anxiety.
TUD is characterized by the presence of cravings.
Tobacco Use Disorder (TUD) exists on a spectrum.
The criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) consider 3 severities of TUD: mild, moderate, and severe. If a medical professional notes that you meet 2-3 symptoms, that characterizes mild TUD. Moderate TUD is characterized by the presence of 4-5 symptoms. Severe TUD is characterized by the presence of 6 or more symptoms.
TUD is described by problematic usage of tobacco despite negative consequences.
TUD includes tolerance and withdrawal. TUD is manifested by two or more of the following symptoms, occurring within the past 12-months:
- Tobacco is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.
- A great deal of time is spent in activities necessary to obtain or use tobacco.
- Craving, or a strong desire or urge to use tobacco.
- Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).
- 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).
- Important social, occupational, or recreational activities are given up or reduced because of tobacco use.
- Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed).
- 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.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of tobacco to achieve the desired effect.
- A markedly diminished effect with continued use of the same amount of tobacco.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for tobacco withdrawal).
- Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.
Recovery
Luckily, there are treatment options to make quitting nicotine easier: medications and behavioral counseling. Tobacco cessation is most successful when both medications and counseling are paired together.
- Nicotine replacement therapy is a great start to reducing withdrawal symptoms and slowly quitting tobacco by gradually lowering the dose. They are pure nicotine products that come in different forms such as gums, lozenges, patches, inhalers, and sprays. Patches are slow-acting and help relieve withdrawal symptoms over a 12 hours period. The other forms are faster-acting and help reduce both withdrawals and urges.
- Another medication is varenicline, which is a prescription medication used to treat nicotine dependence by thwarting withdrawal symptoms and urges. It has the highest cessation rate of all existing medication treatments.
- Bupropion is another medication which works on the brain to reduce nicotine withdrawal symptoms and cravings.
- Nortriptyline and Clonidine also are prescribed for smoking cessation but have more risks and side-effects, making them the least popular medication to aid in quitting tobacco.
- Cytisine is a natural over-the-counter medication which reduces cravings and makes tobacco less satisfying if one uses it. Cytisine is also the least expensive medication option.
Counseling includes one-on-one therapy where an individual meets with a therapist to make a quitting plan, learn coping skills, and prevent relapse, all while having support from their therapist.
Group counseling is when a counselor overlooks a group as they share experiences with their addiction and about trying to quit.
There are also quit-lines accessible through technology.
