6.1Defining nicotine as a drug of addiction

Last updated: January 2018

Suggested citation: Christensen, D. 6.1 Defining nicotine as a drug of addiction. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from http://www.tobaccoinaustralia.org.au/chapter-6-addiction/6-1-defining-nicotine-as-a-drug-of-addiction

Nicotine is only one of 4,000+ compounds released from burning tobacco but is the major addictive substance from tobacco use (see Section 6.2 for the pharmacokinetics).1 The most widely used criteria for assessing nicotine as a drug of addiction are the criteria for tobacco use disorder or dependence.  These are reported in the International Classification of Diseases (ICD) of the World Health Organization, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), compiled by the American Psychiatric Association. Both of these classification schemes undergo major periodic revision, the most recent versions are the ICD-10 (1990),2 and DSM-5 (2013)3. The ICD-11 (Nicotine Dependence, Compulsive Tobacco Use Syndrome, Tobacco Dependency Syndrome, Nicotine Addiction, and Tobacco Addiction) is currently under development. The main features from the DSM-5 and ICD-10 are summarised in Table 6.1.1, and include:

 

  • a strong desire to use tobacco
  • taking tobacco in larger amounts or for longer than intended
  • difficulty in controlling tobacco use
  • spending a great deal of time in obtaining, using or recovering from the effects of tobacco use
  • giving a higher priority to tobacco use than to other activities and obligations
  • continued tobacco use despite harmful consequences
  • tolerance (i.e., increasing tobacco use to achieve the desired effect or diminished effects from the same amount of tobacco use).
  • withdrawal symptoms (e.g., after sustained daily tobacco use, abrupt cessation or reduction results in: irritability, anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, insomnia causing clinically significant distress or impairment).

Table 6.1.1
Summary of diagnostic criteria of Tobacco Use Disorder from classifications developed by the American Psychiatric Association (DSM-Five) and Tobacco Dependence from classifications by the World Health Organization (ICD-10)

DSM-Five

ICD-10

A problematic pattern of tobacco use leading to clinically significant impairment or distress. Endorsement of at least two criteria in the past 12-months:

A cluster of behavioural, cognitive and physiological phenomena in which the use of tobacco takes on a much higher priority than other behaviours that once had a greater value. Endorsement of three or more criteria present at some time during the past 12-months:

Tobacco is often taken in larger amounts or over a longer period than intended

 

Persistent desire or unsuccessful efforts to cut down or control tobacco use

Difficulty in controlling toabcco use

A great deal of time is spent in activities necessary to obtain or use tobacco

 

Craving, or a strong desire or urge to use tobacco

A strong desire to consume tobacco

Recurrent tobacco use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., interference with work)

 

Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., argument with others about tobacco use)

 

Important social, occupational or recreational activities given up or reduced because of substance use 

Progressive neglect of alternative pleasures or interests because of tobacco use, increased amount of time necessary to obtain or take tobacco or to recover from its effects

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

 

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     

Persistent tobacco use despite clear evidence of harmful consequences.

Tolerance: need for markedly increased amounts of tobacco to achieve the desired effect or markedly diminished effect with continued use of the same amount of tobacco     

Evidence of tolerance, where greater tobacco use is needed to achieve the same effects originally produced by lower doses

Withdrawal: the characteristic withdrawal syndrome for tobacco or tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms 

A physiological withdrawal state when tobacco use has ceased or been reduced, demonstrated by withdrawal or use of the same (or closely related) substance to avoid withdrawal symptoms

Source: Derived from the Diagnostic and Statistical Manual for Mental Disorders: Tobacco Use Criteria - 5 and the ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines

The DSM-5 specifies tobacco use disorder in early or sustained remission, in maintenance therapy, or in a controlled environment. Further, it specifies severity rating based on endorsement of 2–3 criteria (mild), 4–5 criteria (moderate), and 6 or more (severe).

 

References

1. Advocat C, Comaty J, and Julien R, Julien’s primer of drug action.  13th ed New York: Worth Publishers; 2014. Available from: http://www.ncbi.nlm.nih.gov/nlmcatalog/101666863 

2. World Health Organization. Nomenclature and classification of drug-and alcohol-related problems: A who memorandum. Bulletin of the World Health Organization, 1964; 59(2):225–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/6972816

3. American Psychiatric Association, Diagnostic and statistical manual of mental disorders.  5th ed Arlington, VA: American Psychiatry Association; 2013.

 

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