Tobacco use disorder is a misuse of tobacco substances. Cigarettes are the most commonly used tobacco product, representing over 90% of tobacco/ nicotine use. Nicotine is found in cigarettes, pipes, cigars, chewing tobacco and snuff. Besides causing dependency, nicotine has many negative physical effects and a variety of withdrawal symptoms.The majority of U.S adolescents experiment with tobacco use, and by age 18 years, about 20% smoke at least monthly. Most of these individuals become daily tobacco users. Tobacco use is a pervasive public health problem and the leading cause of preventable morbidity and mortality in the United States.

Tobacco Use Disorder Defined

Tobacco use disorder is when an individual is dependent upon nicotine, which is found in tobacco. A psychoactive drug (affects the mind), nicotine is a highly addictive, central nervous system stimulant. The addictive nature of nicotine includes drug-reinforced behavior, obsessive use and recurrent use after abstaining from it, as well as physical dependence and tolerance. tobacco use disorder is common among individuals who use cigarettes and smokeless tobacco daily and is uncommon among individuals who not use tobacco daily or who use nicotine medications. Tobacco use disorder, with severity specified as mild, moderate, or severe, depending on the number of diagnostic criteria that have been met. While it can range from mild to severe, quitting tobacco is possible.


Different Types

There are not separate types of tobacco use disorders, but there are levels of severity. These levels are based on which criteria is met, which is listed under symptoms.

  • Mild: Presence of 2-3 symptoms.
  • Moderate: Presence of 4-5 symptoms.
  • Severe: Presence of 6 or more symptoms.


Tobacco Use Disorder Causes

There can be several causes to tobacco use disorder. Various factors like genetic, psychological, social and environmental factors can all impact how taking tobacco affects your body and behavior. For certain people taking opioids has a different and stronger impact that can lead to tobacco use disorder that it may not have on others. The onset, continuation, and development of tobacco use can be about 50% contributed to genetic factors. This risk can also be attributed to developing any substance abuse disorder. Individuals with externalizing personality traits are more likely to initiate tobacco use. Individuals with low incomes and low educational levels are more likely to initiate tobacco use and are less likely to stop.


Tobacco Use Disorder Symptoms

To be diagnosed with a tobacco use disorder, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met:

A problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.

  1. Tobacco is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.
  3. A great deal of time is spent in activities necessary to obtain tobacco or use tobacco.
  4. Craving, or a strong desire or urge to use tobacco.
  5. Recurrent stimulant 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 the effects of tobacco (e.g. 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 (e.g. smoking in bed).
  9. Continued tobacco use 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 of the following:
    • A. A need for markedly increased amounts of tobacco to achieve the desired effect.
    • B. A markedly diminished effect with continued use of the same amount of tobacco.
  11. Withdrawal, as manifested by either of the following:
    • A. The characteristic withdrawal syndrome for tobacco.
    • B. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

Tobacco use disorder can include periods of tobacco withdrawal.

Tobacco withdrawal:

To be diagnosed with tobacco withdrawal, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met:

A. Daily use of tobacco for at least several weeks.

B. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four (or more) of the following signs of symptoms:

  1. Irritability, frustration, or anger.
  2. Anxiety.
  3. Difficulty concentrating.
  4. Increased appetite.
  5. Depressed mood.
  6. Insomnia.

C. The signs of symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.


How to Approach a Loved One

There is not a perfect way to approach a loved one that you assume or know is struggling with tobacco use disorder. Many people with tobacco use disorder hesitate to get treatment because they don’t consider their tobacco use a problem, so approaching them to tell them that they do have a problem can be difficult. If you’re concerned about someone who may have a tobacco use disorder, ask a professional experienced in drug addiction treatment for advice on how to approach that person. You can not force someone to seek professional care, but you can always offer your support and encouragement. Even though you may not be able to prevent your loved one from developing a tobacco use disorder, you can still talk with them about the health damaging effects of using tobacco and alternatives to using tobacco.


Types of Tobacco Use Disorder Treatment

There are effective treatments for tobacco use disorder. It is rare to treat a tobacco use disorder on the first try, especially without help. Medication and counseling combined have been proven to be effective treatments.


There are medications that can assist in the treatment of tobacco use disorder. Many treatments, including nicotine replacement therapy and non-nicotine medications, are proven to work as well as using more than one medication. It is important to speak to your healthcare provider about the right treatment for you. Talk to your doctor before taking any over-the-counter nicotine replacement products if you’re pregnant, breastfeeding, smoking fewer than 10 cigarettes a day, or you’re under age 18.


Nicotine Replacement Therapy
Nicotine replacement therapy provides nicotine without tobacco and the harmful chemicals in tobacco smoke. Nicotine replacement products help relieve the cravings of nicotine as well as withdrawal symptoms. The best time to start using nicotine replacement medication is the day you stop smoking.

The following are nicotine replacement products that can be purchased over the counter:

  • Nicotine gum (Nicorette, others)
  • Nicotine patch (NicoDerm CQ, Habitrol, others)
  • Nicotine lozenge (Commit, Nicorette mini lozenge, others)

The following are nicotine replacement products are available through prescription:

  • Nicotine inhaler (Nicotrol)
  • Nicotine nasal spray (Nicotrol NS)

The following are medication nicotine-free products that are available through prescription:

  • Varenicline (Chantix)
  • Nortriptyline (Pamelor)
  • Bupropion (Zyban)


Support Groups & Counseling
Combining medications with behavioral counseling provides the best chance for establishing long-term smoking abstinence.

Medications reduce withdrawal symptoms including tobacco craving and behavioral treatments help the development of skills needed to avoid tobacco over the long run.

There are various self-help groups that are options for individuals to attend, such as Narcotics Anonymous. Some people find that talking with others who have a tobacco use problem may be a helpful part of treatment. Through self-help groups, individuals find a forum of peer support, gaining strength as they share their feelings, and experiences with others who are facing the same obstacles as themselves.

Individual counseling helps you learn techniques for preparing to stop smoking and provides support during the process. There are specific treatment programs that offer tobacco treatment specialists in hospitals, health care plans and other healthcare providers. There is also telephone counseling available as well. Every state in the U.S. has a telephone quitline, and some have more than one. To find the options in your state, call 800-QUIT-NOW (800-784-8669). Finally, Internet-based programs are also available. Several websites offer support and strategies for people who want to stop smoking like BecomeAnEX.


Support and Coping
Lifestyle changes are also crucial in remaining tobacco-free. Doing things that don’t trigger you to engage in tobacco use as well as avoiding drinking alcohol situations, as those are considered high-risk situations. Ensuring that your family and friends are aware that you are no longer engaging in tobacco use and develop a support system of friends and family who can support your cessation of tobacco use is key. If you have people in your life that use tobacco, it may impact your course of treatment. Finally, continuing to engage in other healthy habits is necessary for treatment. This can include managing stress in a healthy way, set smoke-free boundaries, reward yourself, stay motivated and remember relapse is common. If you relapse, do not be harsh on yourself. Learn from your experience and take the steps to try again.


Methods to Avoid
Substituting tobacco use with another form of tobacco is not the best way to help tobacco use disorder. All forms of tobacco use are not safe as well as products that deliver nicotine without tobacco. These products include; e-cigarettes, flavored cigarettes, hookah (narghiles), dissolvable tobacco products, nicotine lollipops and balms, smokeless tobacco and snuff, pipes and cigars.


Differences Between Common Disorders

While tobacco use disorder symptoms are not similar to other disorders, tobacco withdrawal overlap with those of other substance withdrawal syndrome (e.g., alcohol withdrawal; sedative, hypnotic, or anxiolytic withdrawal; stimulant withdrawal, caffeine withdrawal; opioid withdrawal). Reduction in symptoms with the use of nicotine medications confirms the diagnosis.



American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders.
(5th ed.) Arlington, VA: American Psychiatric Association.

Jackson, C. (2017). Tobacco use disorder: Assessment and diagnosis. Retrieved from:

National Institute on Drug Abuse. (n.d.). What are treatments for tobacco dependence? Retrieved from:

Nicotine dependence. (2018). Retrieved from:

Tobacco Use Disorder: Causes, Symptoms, Treatment. (2017). Retrieved from:

Ziedonis, D., Das, S., & Larkin, C. (2017). Tobacco use disorder and treatment: new challenges and opportunities. Dialogues in Clinical Neuroscience, 19(3), 271–280.