According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), nicotine dependence is considered to be a substance-related disorder. The key features of substance dependence are a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior (American Psychiatric Association, 2000).
The diagnosis of nicotine dependence in DSM-IV is fairly straightforward. Information needed to make the diagnosis can be obtained through interview and questionnaire, and can readily be collected along with other medical history data. Two National Institutes of Health publications (U.S. Department of Health and Human Services, 1986, 1989a), a report prepared by the American Psychiatric Association (1996), and a recently published clinical practice guideline (Fiore et al., 2000) are available to help physicians inquire about smoking, assess their patients' needs, and encourage patients to quit smoking.
Most of the criteria for psychoactive substance dependence are characteristic of cigarette smoking and other forms of tobacco use. Cigarette smokers often smoke more than they intend to, have difficulty quitting or simply cutting down, spend a great deal of time procuring cigarettes and smoking them, persist in smoking despite known risk and/or current illness, and readily develop tolerance, enabling them to smoke a larger number of cigarettes per day than they did when they first started smoking. The fact that most smokers who quit smoking in the past did so on their own, without formal treatment, seems to be somewhat at odds with the popular notion of addiction. However, it is important to note that most former heroin users also gave up heroin without formal treatment (Johnson, 1977).
When smokers, adolescents as well as adults, stop smoking, they may experience nicotine withdrawal as defined by DSM-IV-TR (American Psychiatric Association, 2000). About 50% of adults who attempt to stop smoking will meet DSM-IV criteria for nicotine dependence (American Psychiatric Association, 1996), and young smokers show signs of addiction within several months of taking up the habit (DiFranza et al., 2002). Diagnostic criteria for nicotine withdrawal are presented in DSM-IV-TR. Associated features include craving, a desire for sweets, and impaired performance on tasks requiring vigilance (American Psychiatric Association, 2000). Depression and difficulty sleeping are not uncommon. Associated laboratory findings include a slowing on elec-troencephalograph, decreases in catecholamine and cortisol levels, rapid eye movement (REM) changes, impairment on neuropsychological testing, and decreased metabolic rate (American Psychiatric Association, 2000). Nicotine withdrawal also may be associated with a dry or productive cough, decreased heart rate, increased appetite or weight gain, and a dampened orthostatic response (American Psychiatric Association, 2000).
When smokers quit smoking, there is a fairly high probability that they will return to smoking (relapse). Smokers often quit many times before they succeed in remaining abstinent. Relapse is most likely to occur soon after quitting. Studies of quit-smoking programs show that most smokers relapse within about 3 months (Hunt & Bespalec, 1974). Although ex-smokers are less likely to relapse after they have been abstinent for 3 months, the potential for relapse remains present for many years (Ockene, Hymowitz, Lagus, & Shaten, 1991).
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