Overview
Tobacco use is a globally witnessed problem that plagues public health care systems, as the morbidity and mortality associated with it is wholly preventable. With extensive options offering tobacco and nicotine consumption, it surpasses the mortality rates of alcohol and illicit drugs combined.
The health effects of Tobacco Use Disorder include cardiovascular disease, chronic obstructive pulmonary disease, cancers, and lung diseases. Risks of immune system disorders, certain eye diseases, and tuberculosis are also increased.
While a reported 80% of individuals involved in sustained tobacco use make an attempt to quit at some point, 60% relapse within a week. Although, persistent attempts of quitting can lead to eventual abstinence. Only 5% are able to achieve complete abstinence.
Extensive literature suggesting the commencement of tobacco use in adolescence also point towards adulthood being a period of sustained and excessive tobacco use, attributable to the disorder. The onset and continuation of tobacco use are attributable to genetic and hereditary components.
A range of psychosocial and socioeconomic factors contribute to tobacco use during adolescence. Individuals with underlying psychiatric disorders are about twice as likely to develop Tobacco Use Disorder.
Pharmacological and psychosocial interventions have proven to be extremely effective in managing symptoms of tobacco use.
Signs and Symptoms
The symptoms of Tobacco Use Disorder can include:
- Smoking within 30 minutes of waking
- Smoking daily
- Waking at night in order to smoke more cigarettes
- A persistent urge to use tobacco
- Inability to cut down on tobacco use in spite of a continual desire or effort to do so
- Use of tobacco in higher quantities than intended
- Interference of tobacco use with day-to-day activities such as work or education
- Continued tobacco use in spite of the effects of tobacco use causing social and interpersonal problems
- Interference of tobacco use with social activities
- Use of tobacco in situations where it may be physically hazardous to do so (such as near flammable objects or substances)
- Continual use of tobacco in spite of knowledge and awareness of its physical and psychological negative effects
- Continual use of tobacco in spite of having contracted a physical or psychological problem due to it, even if the problem worsens with tobacco use
- Tolerance towards tobacco manifested as a need to use larger quantities of tobacco to achieve desired effects or diminished effect of the same amount of tobacco
- Withdrawal from tobacco manifested as characteristic withdrawal symptoms (headache, irritability, insomnia, etc.) or the consumption of tobacco in order to relieve withdrawal symptoms
Risk Factors
Tobacco use, especially through cigarette smoking, has been widely normalized in society. The development of newer modes of tobacco use such as e-cigarettes and dissolvable tobacco products have also garnered attention, owing to marketing and accessibility.
Epidemiological studies show that adolescence is usually the period wherein tobacco use is experienced for the first time, with sustained or regular use starting around the age of 18. One study marked that individuals with an early onset of tobacco use along with a steep increase in usage reported the most problematic use of tobacco in their early twenties.
Lags in demographic transitions suggest a higher prevalence in males in early ages, which is equalized by the phenomenon of increase in use by females at later stages. Genetic factors, mainly heritability, greatly contribute to the onset, development, and continuation of tobacco use, as in other substance use disorders.
Individuals with mental illnesses or other addictive conditions make up an important cohort of the population affected by Tobacco Use Disorder. Psychiatric comorbidities commonly include substance or alcohol use disorders, depressive, bipolar, anxiety, personality, and attention/deficit hyperactivity disorders.
Higher rates of smoking and nicotine dependence have been evident among individuals with opioid use disorders, demonstrated across several studies.
Among the youth, aspects such as lower socioeconomic status, lower levels of academic achievement, high access to tobacco products, lack of skills such as refusal skills or self-efficacy that are necessary to avoid tobacco use, normalized perceptions of tobacco use leading to the belief that it is not harmful, use and approval of tobacco by significant others, and lack of parental support have been associated as potential risk factors for tobacco use.
One study has also explored the link between experiences of discrimination and tobacco use among several minority populations, establishing an increased risk among those who are subjected to multiple minority stressors.
In such groups, tobacco use can provide perceived temporary relief from stress caused by discrimination, but also contributes to increased morbidity and mortality.
Diagnosis
The diagnostic criteria for Tobacco Use Disorder have been outlined in the DSM-5, and are similar to those for Substance Use Disorder. These can be effectively used to determine the diagnosis of the disorder. The DSM-5 puts forth three categories based on severity: mild, moderate, and severe.
Specifiers for Tobacco Use Disorder also offered as follows:
- In early remission: wherein the criteria for Tobacco Use Disorder were previously met, but currently none of them are being met, and have not been met for a minimum of less 3 months but not over 12 months (except cravings/strong urges of tobacco use)
- In sustained remission: wherein previously met Tobacco Use Disorder criteria have not currently been met for 12 months or more (except cravings/strong urges of tobacco use)
- On maintenance therapy: wherein the individual is being maintained on tobacco cessation medication and no criteria of substance use disorder are being met for that medication (except tolerance or withdrawal)
- In a controlled environment: wherein the individual is in an environment where access to tobacco is restricted
Primarily, interview methods will be implemented in diagnostic efforts. Questions pertaining to the type of the tobacco product used, frequency and intensity of use is determined through self-report measures.
Laboratory tests may be carried out in order to detect cotinine, a metabolite of nicotine, which can be found in urine, saliva or blood samples for up to 7 days after tobacco use. Breath carbon monoxide can be used to detect evidence of smoking in the last 24 hours. It is not very common to make use of these procedures.
Medical comorbidities such as cardiovascular illnesses, chronic obstructive pulmonary disease, and cancers are common. In case of psychiatric comorbidities, complete inclusive assessment must be carried out in order to determine ideal time for treatment of Tobacco Use Disorder.
Treatment
Extensive evidence-based options of treatment, including pharmacotherapy and psychosocial interventions are available, with promising emerging methods.
With the majority of individuals with Tobacco Use Disorder also having underlying psychiatric disorders, it is important to take into consideration their course of treatment, and adapt treatment procedures for Tobacco Use Disorder accordingly.
Pharmacological courses of treatment include non-nicotine replacements, bupropion and varenicline, and nicotine-replacement therapies.
Nicotine-replacement therapies include patches, gum, and lozenges which are available over-the-counter, and prescription options such as inhalers and nasal sprays. Evidence shows that varenicline is the most effective, followed by bupropion and nicotine-replacement therapies.
Maximum efficacy has been found upon implementing a combination of psychosocial and pharmacological modes. Individual and group counselling, behavioral therapy, and phone counselling (helplines and SMS interventions to quit) are considered to be helpful.
Comorbidity
The most common medical diseases from smoking are cardiovascular illnesses, chronic obstructive pulmonary disease, and cancers. The most common psychiatric comorbidities are alcohol/substance, depressive, bipolar, anxiety, personality, and attention-deficit/hyperactivity disorders and perinatal problems.
Specialist
Primary healthcare providers provide necessary consultation with regards to tobacco use and attempts of tobacco cessation. Pharmacological and social intervention is determined in accordance with the severity of the disorder.
Having social support in place in the form of support groups, or web-based programs can provide additional help.
In cases of Tobacco Use Disorder where there is some form of psychiatric comorbidity, the consulting psychiatrist or clinical psychologist will be able to determine the course of action with regards to tobacco cessation.
In Conclusion
When you need nicotine and can’t stop using it, you become dependent on it. The substance in tobacco called nicotine makes it difficult to stop using it. Nicotine causes your brain to feel good, but these feelings are fleeting. As a result, you light another cigarette.
The greatest approach to avoid developing a nicotine addiction is to never consume tobacco.
The easiest approach to prevent kids from starting to smoke is to quit. Children who have non-smoking parents or parents who have successfully quit smoking are far less likely to start smoking themselves.
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