Tobacco Use Disorder (Nicotine Dependence)

Signs of tobacco use disorder

The DSM-5-TR lists 11 criteria. Two or more within 12 months indicate tobacco use disorder:

1. Using more or for longer than intended
2. Wanting to cut down but being unable to
3. Spending a lot of time obtaining or using tobacco
4. Cravings
5. Use interfering with work, school or home duties
6. Continuing despite social or relationship problems
7. Giving up activities because of tobacco
8. Using in hazardous situations, such as smoking in bed
9. Continuing despite knowing it harms health
10. Tolerance
11. Withdrawal, or using to avoid withdrawal

A practical sign of strong dependence: smoking or vaping within 30 minutes of waking.

Why nicotine is so addictive

Nicotine reaches the brain within seconds of inhaling and triggers release of dopamine, creating pleasure and reinforcing the habit. With repeated use, the brain adapts, and nicotine becomes needed to feel normal. Routines and cues such as coffee, meals, stress, alcohol and driving become strong triggers. E-cigarettes can deliver as much or more nicotine than cigarettes, and many young people become dependent on them.

Nicotine withdrawal

Withdrawal starts within hours of the last use, peaks in the first 3 days, and mostly fades over 2 to 4 weeks. Cravings can recur for months.

• Irritability, frustration or anger
• Anxiety and restlessness
• Low mood
• Difficulty concentrating
• Increased appetite and weight gain
• Insomnia
• Strong cravings

Health effects of tobacco

• Cancers: lung, mouth, throat, esophagus, stomach, pancreas, bladder, kidney, cervix and others. See lung cancer
• Heart and blood vessels: coronary artery disease, heart attack, stroke, peripheral artery disease and aortic aneurysm
• Lungs: COPD, worse asthma and more lung infections
• Diabetes risk and complications
• Pregnancy: miscarriage, preterm birth, low birth weight, stillbirth and sudden infant death
• Other: gum disease, tooth loss, cataracts, osteoporosis, erectile dysfunction, slower wound healing, earlier skin aging
• Secondhand smoke harms others, especially children

See smoking-related disorders for more.

Benefits of quitting

• Within 20 minutes: heart rate and blood pressure begin to fall
• Within weeks: circulation and lung function improve
• Within 1 year: risk of heart disease drops by about half compared with continuing smokers
• Over 5 to 15 years: stroke risk falls toward that of nonsmokers
• Quitting before 40 avoids most of the excess risk of death from smoking

Treatment

Medicines

The most effective options, according to US guidelines:

• Varenicline: reduces cravings and the reward from smoking. It is the single most effective medicine
• Combination nicotine replacement therapy (NRT): a long-acting patch plus a short-acting product (gum, lozenge, inhaler or nasal spray) for breakthrough cravings. More effective than a single product
• Bupropion: an antidepressant that reduces cravings and withdrawal

These medicines are safe for most people, including those with stable heart disease and many with mental health conditions. Treatment usually lasts at least 12 weeks, sometimes longer. Many people need several attempts before quitting for good.

Counseling and support

• Quitlines: free telephone coaching (1-800-QUIT-NOW in the US)
• Text and app programs (Smokefree.gov)
• Individual or group counseling
• Brief advice from a doctor, which increases quit rates

Combining medicine and counseling gives the highest success rates.

Practical tips

• Set a quit date within 2 weeks
• Identify triggers and plan alternatives
• Remove cigarettes, lighters and vapes from home and car
• Tell family and friends and ask for support
• Avoid alcohol early on
• Use cravings strategies: delay, deep breathing, drink water, do something else
• Expect withdrawal and remember it passes

E-cigarettes

E-cigarettes are not FDA-approved cessation aids. Some adults have used them to quit smoking, but long-term effects are uncertain, and many users continue vaping. If you switch, aim to quit vaping as well. FDA-approved medicines are the recommended first choice.

Special groups

• Pregnancy: counseling is first-line. NRT may be considered with your doctor
• Teens: counseling and behavioral support. Talk to a doctor about medicines
• Mental health conditions: people with depression, schizophrenia and other conditions smoke at higher rates and can quit successfully with support. Smoking cessation does not worsen mental health and often improves mood and anxiety. Some medicines, such as clozapine, may need dose adjustment after quitting

Frequently asked questions

What is tobacco use disorder?

Tobacco use disorder is addiction to nicotine from tobacco or e-cigarettes. It includes cravings, difficulty cutting down, using more than intended, continuing despite harm, and withdrawal symptoms when stopping.

What are nicotine withdrawal symptoms?

Common symptoms are irritability, anxiety, restlessness, low mood, trouble concentrating, increased appetite, sleep problems and strong cravings. They peak in the first few days and usually ease within 2 to 4 weeks.

What is the most effective way to quit smoking?

Using a stop-smoking medicine, especially varenicline or combination nicotine replacement, together with counseling or quitline support gives the best results. This combination more than doubles the chance of success compared with willpower alone.

Is vaping safer than smoking?

E-cigarettes expose users to fewer toxic chemicals than cigarettes, but they are not harmless and still cause nicotine addiction. Long-term effects are unknown. For quitting, FDA-approved medicines and counseling are recommended first.

How long does it take to stop craving cigarettes?

The strongest cravings fade within 2 to 4 weeks, though occasional cravings can come back for months, especially with triggers like alcohol or stress. Each craving usually lasts only a few minutes.