Nicotine Addiction Clinical Presentation

Updated: Jul 16, 2018
  • Author: R Gregory Lande, DO, COL (Ret), FACN, FAOAAM; Chief Editor: Glen L Xiong, MD  more...
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Nicotine addiction is now referred to as tobacco use disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). [2]

There are 11 possible criteria, of which at least 2 must be present in the last 12 months:

1. Tobacco taken in larger amounts or over longer periods of time

2. Persistent desire or unsuccessful efforts to cut down or control use

3. A great deal of time is spent on activities necessary to obtain or use tobacco

4. Craving or a strong desire or urge to use tobacco

5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home

6. Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by effects of tobacco (eg, arguments with others about tobacco use)

7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use

8. Recurrent tobacco use in situations in which it is physically hazardous (eg, smoking in bed)

9. 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

10. Tolerance, as defined by either the need for markedly increased amounts of tobacco to achieve the desired effect or a markedly diminished effect with continued use of the same amount of tobacco.

11. Withdrawal, as manifested by either the characteristic withdrawal syndrome or the use of tobacco to relieve or avoid withdrawal symptoms.

Symptoms of withdrawal 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 attempts to quit smoking should be obtained.

The time to first cigarette and total cigarettes per day are the 2 strongest predictors of nicotine addiction. The nicotine dependence and nicotine withdrawal could be treated by means of the following [4, 30] :

  • Other forms of nicotine delivery

  • Drugs that selectively target one or more of the underlying mechanisms

  • Behavioral treatments, acupuncture, and other therapies


Physical Examination

The physical effects of nicotine use include increased heart rate, accelerated blood pressure, and weight loss. The 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.

In addition to its physical effects, nicotine exerts a strong behavioral influence. A complete mental status examination would begin with a general observation of the patient, which commonly a smoky 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. Speech may also be accelerated in line with behavior. Tobacco use can contribute to irritability, which is often soothed by a dose of nicotine. The early phases of withdrawal can present with more irritability, anxiety, and agitation. Although people ostensibly use tobacco for the pleasure derived from the nicotine, but anxiety and depression commonly coexist with tobacco use.

Tobacco use by itself is not considered a significant risk factor for suicide. However, concomitant 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 attempt to determine whether 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 an actual attempt.

As a general rule, nicotine does not 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.