From the Guidelines
The DSM-5-TR does not include criteria for nicotine abuse, dependence, or misuse specifically, instead using the term "Tobacco Use Disorder" to diagnose problematic patterns of tobacco use, as recommended by the American Journal of Psychiatry in 2013 1. The diagnosis requires at least 2 of 11 criteria occurring within a 12-month period, including:
- using tobacco in larger amounts or longer than intended
- persistent desire or unsuccessful efforts to cut down
- spending considerable time obtaining, using, or recovering from tobacco
- craving
- continued use despite social problems
- giving up important activities due to tobacco
- using despite physical/psychological problems
- tolerance
- withdrawal symptoms
- and continued use despite knowing it causes problems. The severity is specified as mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6+ symptoms), as supported by the study published in the American Journal of Psychiatry in 2013 1. This diagnostic approach reflects the understanding that nicotine is highly addictive due to its rapid action on brain reward pathways, particularly dopamine release in the nucleus accumbens, and is consistent with the recommendations for competence and training in the prevention of cardiovascular disease, which includes knowledge of the pathophysiology of smoking addiction and methods of assessing physiologic levels of nicotine addiction 1. The DSM-5-TR criteria focus on the behavioral and physiological aspects of addiction rather than separating abuse from dependence as in earlier versions, recognizing tobacco use disorder as a chronic condition requiring appropriate treatment approaches, as decided by the American Journal of Psychiatry in 2013 1.
From the Research
DSM-5-TR Criteria for Nicotine Abuse, Dependence, or Misuse
The DSM-5-TR criteria for nicotine abuse, dependence, or misuse have undergone changes compared to the DSM-IV criteria. The key changes include:
- Lowering the threshold from three to two symptoms for diagnosis 2
- Increasing the number of criteria used for diagnosis from seven to 11 2
- Including new criteria such as craving and DSM-IV abuse criteria 3, 4
Validity of DSM-5 Nicotine Use Disorder Criteria
Studies have examined the validity of the DSM-5 nicotine use disorder criteria, including:
- A study of 734 Israeli lifetime smokers found that each DSM-5 NUD criterion was significantly associated with validators, and the DSM-5 criteria were more discriminating than DSM-IV ND criteria 3
- A study of adolescents and young adults found that the proposed DSM-5 nicotine use disorder criteria had substantial limitations and low concurrent validity 2
- A study of adults with problematic substance use found that DSM-5 TUD diagnostic measures demonstrated concurrent and prospective validity, and inclusion of new criteria improved validity and clinical relevance 5
Comparison with DSM-IV Nicotine Dependence Criteria
Comparisons between the DSM-5 and DSM-IV criteria have been made, including:
- A study found that DSM-5 TUD and DSM-IV ND were associated with most baseline validators, but DSM-5 TUD had stronger associations with number of days smoked and cigarette craving scale 5
- A study found that prevalence of proposed DSM-5 NUD was higher than DSM-IV nicotine dependence, but prevalence of DSM-5 severe NUD was similar to DSM-IV nicotine dependence 2
Implications for Diagnosis and Treatment
The changes to the DSM-5-TR criteria for nicotine abuse, dependence, or misuse have implications for diagnosis and treatment, including:
- The use of new criteria such as craving and DSM-IV abuse criteria may improve diagnosis and treatment of nicotine use disorder 3, 4
- The lower threshold for diagnosis may increase the prevalence of nicotine use disorder, but may also lead to earlier intervention and treatment 2
- Alternative and innovative approaches to cigarette smoking treatment may be needed for patients with opioid use disorder 6