Clinical Psychiatry

Disorders due to use of nicotine

ICD-10F17Mental and behavioral disorders due to use of tobacco
DSM-5-TRF17.200Tobacco Use Disorder, Moderate or Severe

1. Definition and nosology

Disorders due to use of nicotine (ICD-11: 6C4A; DSM-5-TR: F17.200 Tobacco Use Disorder) — impaired control over use of cigarettes, tobacco products, e-cigarettes, or other nicotine substances. The leading preventable cause of death worldwide.

2. History

  1. 1964 — Surgeon General Report (US) — recognition of tobacco as a cause of disease.
  2. DSM-IV — Nicotine Dependence; DSM-5 — Tobacco Use Disorder.
  3. 2003 — WHO FCTC (Framework Convention on Tobacco Control).
  4. 2010+ — e-cigarette epidemic, “EVALI” (e-cigarette/vaping product use-associated lung injury).

3. Epidemiology

  • Global: 1.3 billion users; annual 8 million+ deaths (WHO).
  • Sex: higher in males (but decreasing); increase observed in females in some regions.
  • Comorbidity: MDD, schizophrenia (~60–80% of patients smoke), anxiety, other substance use.
  • Tobacco — cancer, COPD, cardiovascular, stroke, perinatal complications.

4. Etiology and pathogenesis

  • Heritability 50%.
  • Neurobiological — nicotine α4β2 nicotinic acetylcholine receptors; increased dopamine reward.
  • Social-cultural, peer, marketing.

5. Clinical features

  • Dependence syndrome.
  • Withdrawal — irritability, anxiety, concentration difficulty, increased appetite, sleep disturbance, depressive mood; onset within 24 hours, peak 2–3 days, duration 2–4 weeks.
  • E-cigarette — nicotine dependence + EVALI risk.

6. Diagnosis

6.1 Unified diagnostic criteria

DSM-5-TR 11 criteria (AUD structure). Unlike DSM-5-TR, which uses a single severity scale, ICD-11 uses three separate categories: episode of harmful use, harmful pattern of use, and dependence. ICD-11 duration requirement: harmful pattern of use — at least 12 months if use is episodic, at least 1 month if continuous; dependence — at least 12 months, or at least 3 months if use is continuous (daily or almost daily).

6.2 Differences between sources

  • USPSTF — screening all adult patients for tobacco use; 5A approach (Ask, Advise, Assess, Assist, Arrange) for smokers.
  • NICE NG209 (Tobacco: preventing uptake, promoting quitting and treating dependence, 2021).

6.3 Diagnostic algorithm

  • Clinical interview (5A).
  • Fagerström Test for Nicotine Dependence (FTND).
  • Expired CO monitoring (motivation).
  • Comorbid cardiac and respiratory assessment.

6.4 Differential diagnosis

Differentiation among numerous tobacco products; electronic cigarette nicotine addiction can be presented in multiple ways.

7. Examination and assessment

  1. FTND.
  2. Expired-air CO monitor.
  3. Spirometry (COPD screening).

8. Treatment

8.1 General principles (USPSTF · NICE NG209 · APA 2010)

  • 5A model (Ask, Advise, Assess, Assist, Arrange).
  • First-line pharmacotherapy:
    1. NRT — Nicotine Replacement Therapy (patches, gum, lozenge, inhaler, spray) — combination (long-acting + short-acting) is superior to monotherapy.
    2. Varenicline (Chantix) — α4β2 partial agonist; most effective single agent (Cahill K. Cochrane 2013 meta-analysis).
    3. Bupropion SR (Zyban) — dopaminergic and noradrenergic effect.
  • Behavioral intervention — CBT, MI, telephone ‘quitline’ service; intensity increases effect.
  • Combination — pharmacotherapy + behavioral therapy is superior.
  • E-cigarettes as a smoking cessation aid are controversial — effective in some studies (Hajek P. NEJM 2019), but long-term safety and gateway risk are being investigated; NRT is preferred.
  • Comorbidity (MDD, schizophrenia) — tobacco cessation does not worsen psychiatric condition, but improves it (Taylor G. BMJ 2014 meta-analysis).

8.2 Treatment methods

  • 5A model (Ask, Advise, Assess, Assist, Arrange).
  • Nicotine Replacement Therapy Combination (NRT) — Long-acting patch + short-acting (gum, lozenge) ‘rescue.’
  • Varenicline — days 1–3: 0.5 mg, days 4–7: 0.5 mg × 2, then 1 mg × 2; 12 weeks.
  • Bupropion SR — 150 mg × 2/day; seizure risk.
  • CBT and Motivational Interviewing (MI) — Trigger management, motivation enhancement.
  • Telephone Support Line (Quitline) — Community-based support; evidence base extensive.

8.3 Differences between sources

  1. USPSTF 2021 — recommends intervention for all cigarette smokers.
  2. NICE NG209 — active intervention also in comorbid psychiatric disorders.
  3. Cahill K. et al. Cochrane 2013 — varenicline is most effective.

9. Prognosis

  • With multimodal intervention, 6-month abstinence is 25–35%.
  • Smoking cessation significantly reduces mortality and illness risk.

10. Myths and misconceptions

Myth 1: “Tobacco is not addictive and can be quit voluntarily”

Evidence: Nicotine has high addiction potential; voluntary cessation success rate is low (~3–5% after 6–12 months); pharmacotherapy increases effect 2–3 times.

Myth 2: “Weight gain after quitting smoking is harmful to health”

Evidence: The average weight gain is 4–5 kg, but the risk of continued tobacco use is significantly higher; weight can be managed.

Myth 3: “Varenicline increases suicide risk”

Evidence: the initial FDA warning was later reassessed in the EAGLES trial (Anthenelli R.M. Lancet 2016) — psychiatric adverse event rate not significantly higher than placebo; FDA boxed warning removed in 2016.

Myth 4: “A psychiatric patient cannot quit tobacco and should not”

Evidence: Taylor BMJ 2014 — smoking cessation improves psychiatric symptoms; cessation is effective in patients with schizophrenia or MDD.

Myth 5: “E-cigarettes are safer than tobacco”

Evidence: Current evidence indicates that electronic cigarettes are less harmful than combusted tobacco, but are not “safe”; EVALI, cardiac, respiratory risks; gateway to nicotine addiction in adolescents.

Myth 6: “Quitting is a one-time, all-or-nothing decision”

Evidence: Most cigarette smokers make 6–11 attempts to quit; each relapse is temporary, and an ongoing quit-attempt plan is recommended.

11. Sources

  • WHO. ICD-11. 6C4A Disorders due to use of nicotine. 2024.
  • APA. DSM-5-TR. 2022.
  • USPSTF. Interventions for tobacco smoking cessation in adults. JAMA 2021;325(3):265–279.
  • NICE NG209. Tobacco. 2021.
  • Cahill K., Stevens S., Perera R., Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;(5):CD009329.
  • Anthenelli R.M. et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES). Lancet 2016;387(10037):2507–2520.
  • Taylor G. et al. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ 2014;348:g1151.
  • Hajek P. et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. NEJM 2019;380(7):629–637.