ICD-116C4A	DISORDERS DUE TO USE OF NICOTINE Disorders due to use of nicotine
ICD-10F17	Mental and behavioural disorders due to use of tobacco
DSM-5-TRF17.200	Tobacco Use Disorder, Moderate or Severe

1. Definition and nosology

Nicotine use disorders (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. Leading preventable cause of mortality worldwide.

2. History

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

3. Epidemiology

• Global: 1.3 bln users; annual 8 mln+ 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. Aetiology 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, 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 the single DSM-5-TR 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 Source-specific clarifications

• 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

1. Clinical interview (5A).
2. Fagerström Test for Nicotine Dependence (FTND).
3. Expired CO monitoring (motivation).
4. 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

• FTND.
• CO ekspirator.
• Spirometry (COPD screening).

8. Treatment

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

1. 5A model (Ask, Advise, Assess, Assist, Arrange).
2. First-line pharmacotherapy:
   • NRT — Nicotine Replacement Therapy (patches, gum, lozenge, inhaler, spray) — combination (long-acting + short-acting) is superior to monotherapy.
   • Varenicline (Chantix) — α4β2 partial agonist; most effective single agent (Cahill K. Cochrane 2013 meta-analysis).
   • Bupropion SR (Zyban) — dopaminergic and noradrenergic effect.
3. Behavioral intervention — CBT, MI, telephone ‘quitline’ service; intensity increases effect.
4. Combination — pharmacotherapy + behavioral therapy is superior.
5. 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.
6. Comorbidity (MDD, schizophrenia) — tobacco cessation does not worsen psychiatric condition, but improves it (Taylor G. BMJ 2014 meta-analysis).

8.2 Source-specific clarifications

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

Treatment methods

1. 5A Model (Ask, Advise, Assess, Assist, Arrange) — Ask (inquire), Advise (recommend), Assess (evaluate), Assist (support), Arrange (organize follow-up).
2. Nicotine Replacement Therapy Combination (NRT) — Long-acting patch + short-acting (cheek, lozenge) ‘rescue.’
3. Varenicline — 1 mg × 2/day; 12 weeks standard.
4. Bupropion SR — 150 mg × 2/day; seizure risk.
5. CBT and Motivational Interviewing (MI) — Trigger management, motivation enhancement.
6. Telephone Support Line (Quitline) — Community-based support; evidence base extensive.

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 failure rate is high (~5% after three months); pharmacotherapy increases effect 2–3 times.

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

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

Myth 3: “Varenicline increases suicide risk”

Evidence: initial FDA warning later reevaluated with 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 effective in schizophrenia, MDD patients.

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: “Once ‘cut and return’ prohibition”

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

11. Sources

1. WHO. ICD-11. 6C4A Disorders due to use of nicotine. 2024.
2. APA. DSM-5-TR. 2022.
3. USPSTF. Interventions for tobacco smoking cessation in adults. JAMA 2021;325(3):265–279.
4. NICE NG209. Tobacco. 2021.
5. 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.
6. 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.
7. Taylor G. et al. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ 2014;348:g1151.
8. Hajek P. et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. NEJM 2019;380(7):629–637.