Nicotine Addiction Clinical Presentation

  • Author: R Gregory Lande, DO, FACN; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: May 10, 2012
 

History

  • Nicotine addiction is classified as nicotine use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The criteria for this diagnosis include any 3 of the following within a 1-year time span:
    • Tolerance to nicotine with decreased effect and increasing dose to obtain same effect
    • Withdrawal symptoms after cessation
    • Smoking more than usual
    • Persistent desire to smoke despite efforts to decrease intake
    • Extensive time spent smoking or purchasing tobacco
    • Postponing work, social, or recreational events in order to smoke
    • Continuing to smoke despite health hazards
  • Nicotine withdrawal is classified as a nicotine-induced disorder according to the DSM-IV-TR. Symptoms include difficulty concentrating, nervousness, headaches, weight gain due to increased appetite, decreased heart rate, insomnia, irritability, and depression. These symptoms peak in the first few days but eventually disappear within a month.
  • Symptoms of nicotine toxicity, otherwise known as acute nicotine poisoning, include nausea, vomiting, salivation, pallor, abdominal pain, diarrhea, and cold sweat.
  • A previous history of depression, use of antidepressants in the past, and onset of depression during previous quit attempts should be obtained.
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Physical

  • Physical effects of nicotine use include increased heart rate, accelerated blood pressure, and weight loss.
  • Physical effects of nicotine withdrawal and smoking cessation include weight gain due to increase in appetite, decreased heart rate, and improvement in the senses of taste and smell.

Mental Status Examination

  • Aside from the physical effects, nicotine exerts a strong behavioral influence. A complete mental status examination would begin with a general observation of the patient that commonly discloses the odor of smoke, tar-stained teeth, and premature skin aging.
  • Nicotine may enhance an individual's level of alertness, although tobacco abuse and dependence may simulate a frantic, almost manic, picture. The speech may also be accelerated in line with the behavior. Tobacco use can contribute to irritability, often soothed by a dose of nicotine. The early phases of withdrawal can present with more irritability, anxiety, and agitation.
  • People ostensibly use tobacco for the pleasure derived from the nicotine, but anxiety and depression commonly coexist.
  • Tobacco use by itself would not be a significant risk factor for suicide. The co-occurring disorders such as depression and anxiety do increase the risk of suicide. The clinician should inquire about the patient's safety and probe further if the patient endorses suicidal ideation. The clinician should investigate if the suicidal ideation has matured to include a plan, and if so, what factors either aggravate or mitigate the patient's propensity to convert ideation to actual attempt.
  • Nicotine would not normally produce perceptual or thought disorders such as visual hallucinations or delusions.
  • The use of nicotine should not negatively impact memory, the ability to perform simple calculations, abstract thinking, or judgment.
  • Tobacco use disorders should not cause delirium or dementia.
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Contributor Information and Disclosures
Author

R Gregory Lande, DO, FACN  Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center

R Gregory Lande, DO, FACN is a member of the following medical societies: American Osteopathic Academy of Addiction Medicine and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Sarah C Aronson, MD  Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland

Sarah C Aronson, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Otsuke Grant/research funds reseach; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati College of Medicine; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Sat Sharma, MD, FRCPC, and Morley Lertzman, MD, FRCP(C), to the development and writing of this article.

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