Tobacco Withdrawal DSM-5 292.0 (F17.3)
DSM-5 Category: Substance-Related and Addictive Disorders
Tobacco Withdrawal
Introduction
Tobacco withdrawal is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who experience symptoms of withdrawal after reducing or quitting tobacco use - most commonly irritability, anxiety and difficulty concentrating.
Symptoms
Tobacco withdrawal affects around 50 per cent of tobacco users who quit for two or more days, manifesting in various ways but commonly with the user experiencing trouble concentrating alongside feelings of irritability and unease.
Withdrawal from tobacco use usually begins within 24 hours from the point that someone reduces or stops their tobacco use, peaking a couple of days later. Symptoms may last for between two and three weeks but it’s uncommon for the withdrawal effects to last longer than a month. (American Psychiatric Association 2013)
Alongside feeling grumpy and anxious, tobacco users may experience other withdrawal symptoms such as restlessness, insomnia and depressed mood. Some people find that their appetite increases, or that they crave sweet, sugary foods; others may experience a cough or a sore throat, nausea, constipation and dizziness.
Diagnostic criteria for tobacco withdrawal
For someone to be diagnosed with tobacco withdrawal, a number of criteria must be met in relation to type, frequency and duration of symptoms.
The DSM-5 outlines that the following four points should be checked off for a diagnosis to be made:
1) The individual has used tobacco daily for a minimum of several weeks or more
2) Tobacco use has been reduced or abruptly discontinued and four or more of the following symptoms have been experienced within the 24 hours since:
- Feeling irritable, angry or frustrated
- Feeling anxious
- Finding it difficult to concentrate
- Feeling restless
- Experiencing increased appetite
- Feeling depressed
- Having trouble sleeping
3) The symptoms experienced (mentioned above) must be causing the individual significant distress or affecting important areas of their life, such as social interactions or work.
4) The symptoms cannot be attributed to another medical condition or mental disorder, including intoxication or withdrawal from another substance.
Many of the symptoms experienced during tobacco withdrawal are caused by nicotine deprivation, and tend to be stronger in people who smoke cigarettes or who use smokeless tobacco as opposed to those who use nicotine medication. (American Psychiatric Association 2013)
Withdrawal symptoms are common among daily tobacco users but can be experienced by non-daily users, too.
Causes of tobacco withdrawal
Tobacco withdrawal is caused by a reduction or complete halt in tobacco use. During use, the nicotine in tobacco products enters the blood stream and stimulates the parts of the brain associated with pleasurable sensations.
When nicotine levels drop, cravings kick in, usually stifled with a cigarette or other tobacco product. Cravings often begin within hours of using tobacco; by reducing usage - or stopping altogether - symptoms of withdrawal begin to occur.
Everyone who reduces or quits using tobacco will have a different experience but there are a few genetic, physiological and temperamental risk factors associated with more extreme withdrawal.
For example, tobacco smokers with bipolar, anxiety or depressive disorders tend to have a more severe withdrawal, as do individuals with attention-deficit/hyperactivity disorder or other substance use disorders.
An individual’s genetic makeup can also influence the probability of withdrawal on quitting tobacco. In fact, research suggests that genetics influence an individual’s risk of experiencing withdrawal symptoms by between 30 and 50 per cent. Genetic variation as a predictor of smoking cessation success. (Quaak et al 2009)
Broadly, a person’s genes may influence their response to, and metabolism of, nicotine, or predispose a person to addictive behavior as a result of how their brain’s pleasure pathways are affected.
Differential diagnosis
Tobacco withdrawal is characterized by symptoms that overlap with withdrawal from other substances, such as alcohol and caffeine, which can make it difficult to identify tobacco withdrawal in the first instance.
Some symptoms also correlate with sleep disorders, depressive conditions and bipolar disorder. Individuals admitted to hospital or voluntary smoking cessation facilities may also experience withdrawal symptoms that disguise, mimic or intensify other disorders, or the adverse effects of medications.
In these cases, a diagnosis of tobacco withdrawal can be confirmed when symptoms are reduced through the use of nicotine medication. (American Psychiatric Association 2013)
Living with tobacco withdrawal
Tobacco withdrawal can be an uncomfortable experience - both physically and psychologically. Tobacco contains the drug nicotine, which activates the brain’s pleasure and reward systems, causing an increase in happy hormone dopamine.
The effects of nicotine on the brain are long lasting, even after relatively short exposure. (National Institute on Drug Abuse 2003) Over time, nicotine changes the brain’s chemistry, so it follows that once the nicotine-high runs out, the brain has to adapt to not having the stimulation it’s become used to, and withdrawal symptoms occur as a result. (National Institute on Drug Abuse 2009)
For the first few days, an individual in withdrawal from tobacco use may experience physical symptoms like restlessness, difficulty sleeping and an increased appetite, which may abate after a few days until the last traces of nicotine have left the body. The individual may experience psychological effects like low mood, irritability, cravings and mood swings for a longer period. (Medical News Today 2019)
During the withdrawal period, individuals may find that they’re snappy with friends and family, that they struggle to concentrate at work or at school and that they eat more as their appetite increases. Following the three to four week stage, the worst of the withdrawal has passed, and positive changes may be noted, such as easier breathing and improved sense of taste and smell.
Treatment for tobacco withdrawal
An individual experiencing tobacco withdrawal may seek out a range of treatments, both for the physical and psychological symptoms.
Although about 50 per cent of nicotine in the bloodstream is removed by the body a couple of hours after an individual smokes their last cigarette, nicotine is still present for a few days following.
Once the body is free of nicotine, the individual may still experience symptoms of withdrawal as the brain adjusts. Cravings may strike when the individual encounters triggers - or reminders - of using tobacco, such as seeing people smoking or visiting places they associate with their former tobacco use.
During the withdrawal period, many people find that distractions can help. When cravings kick in, taking a brisk walk, drinking a glass of water, calling a friend or keeping busy in some other way are all distractions that can relieve the urge to use tobacco. (British Lung Foundation 2019)
Aside from these distractions, there are various options for treatment during the tobacco withdrawal process, including:
Nicotine replacement therapy
Replacing tobacco with a form of nicotine replacement therapy (NRT) can help curb cravings - especially in the early stages of withdrawal. Various types of NRT are available over the counter, such as patches, gum and lozenges, and they’re equally effective at helping tobacco users quit.
Most types of NRT work by giving tobacco users a quick fix of nicotine as and when needed, without the other harmful compounds associated with tobacco. Individuals using patches receive a constant supply of nicotine over the course of the day.
Research suggests that NRTs increase quit rates by between 50 and 70 per cent, with a combination of NRTs being the most effective at reducing withdrawal symptoms and cravings. (National Institute on Drug Abuse 2019)
Medication
Some individuals may be offered medication as a means of handling withdrawal from tobacco use. Several types of medication can be used to treat nicotine withdrawal, including:
Bupropion - Also known as Zyban, bupropion can be used as an antidepressant and to reduce cravings.
Varenicline - Also known as Chantix, varenicline may be prescribed to reduce cravings and block the feelings of reward associated with tobacco use. (Medical News Today 2019)
Therapy
There are various types of therapy that may be helpful during the withdrawal period, including cognitive behavioural therapy (CBT).
Through CBT, individuals are assisted with understanding the triggers that affect their behavior, and then taught coping strategies to overcome their difficulties and prevent relapse.
Motivational interviewing may also be used, with counselors challenging individuals’ values and goals to explore how they feel about quitting and boost their motivation.
Another form of therapy that can be helpful is mindfulness. During mindfulness sessions, individuals are encouraged to become more aware of feelings, thoughts and desires regarding tobacco use and tasked with reframing them to become more tolerable.
Other forms of treatment include the self-directed use of electronic cigarettes - although the risks are as yet unknown - and pioneering treatments like transcranial magnetic stimulation. (National Institute on Drug Abuse 2019)
While rates of smoking are on the decline, many individuals may attempt to quit six or seven times before managing to give up for the long term. The good news is that the body begins to recover just 20 minutes after an individual stops smoking and the health benefits continue to manifest over the coming weeks, months and years. (Royal College of Nursing 2019)
Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com), a neuroscience-based behavior change consulting firm.
References
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
M. Quaak, M., van Schayck, C. P., Knaapen, A. M., van Schooten, F. J.
A promising preventive and intervention tool for chronic respiratory diseases?
European Respiratory Journal Mar 2009, 33 (3) 468-480; DOI: 10.1183/09031936.00056908 https://erj.ersjournals.com/content/33/3/468 Date Accessed: 11/26/19.
National Institute on Drug Abuse (2003) Nicotine's Multiple Effects on the Brain's Reward System Drive Addiction https://archives.drugabuse.gov/news-events/nida-notes/2003/03/nicotines-multiple-effects-brains-reward-system-drive-addiction Date Accessed: 11/26/19.
National Institute on Drug Abuse (2009) Abstinent Smokers' Nicotinic Receptors Take More Than a Month to Normalize https://archives.drugabuse.gov/news-events/nida-notes/2009/10/abstinent-smokers-nicotinic-receptors-take-more-than-month-to-normalize Date Accessed: 11/26/19.
Medical News Today (2019) Nicotine withdrawal symptoms and how to cope
https://www.medicalnewstoday.com/articles/323012.php#symptoms Date Accessed: 11/26/19.
British Lung Foundation (2019) What about withdrawal symptoms from stopping smoking? https://www.blf.org.uk/support-for-you/smoking/withdrawal-symptoms-from-quitting-smoking Date Accessed: 11/26/19.
National Institute on Drug Abuse (2019) What are treatments for tobacco dependence? https://www.drugabuse.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence Date Accessed: 11/26/19.
Royal College of Nursing (2019) Smoking cessation https://www.rcn.org.uk/clinical-topics/public-health/smoking-cessation Date Accessed: 11/26/2019.
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