Tobacco use: Clinical sciences

Tobacco use disorder, or TUD for short, is a condition that develops after continued tobacco use, and it’s associated with nicotine dependence. These individuals have an increased risk of developing conditions like COPD, atherosclerosis, myocardial infarction, and sudden cardiac death. Now, based on the status of tobacco use, you can classify your patients into three main groups, including patients who never used tobacco, those who currently use tobacco, and former tobacco users.

Now, if a patient presents with a chief concern suggesting tobacco use disorder, your first step is to obtain a focused history and physical. Your patient will typically report a history of tobacco use, or they might report exposure to secondhand smoke. On physical exam, you will typically see signs, such as nicotine-stained fingertips or stained dentition.

At this point, you should suspect tobacco use disorder and assess the patient’s status of tobacco use. If your patient has never used tobacco, no further workup is needed, and your management should focus on prevention. This includes encouraging the patient to continue to abstain from smoking, and offering guidance on avoiding secondhand tobacco exposure.

On the other hand, if your patient is currently using tobacco, assess the DSM-V criteria for tobacco use disorder. To diagnose tobacco use disorder, your patient must present with at least two of the following criteria over 12 months.

First, your patient is consuming large amounts of tobacco over long periods. They have a persistent desire or effort to quit or cut down tobacco use. They are spending a considerable amount of time obtaining or using tobacco, and they have cravings and a strong desire to use tobacco.

Additionally, their tobacco use interferes with their daily responsibilities, but also with their social and occupational activities. Next, the patient continues to use tobacco despite it causing problems. They use tobacco in risky situations and continue to use it even after they develop physical and psychological problems.

The last two criteria include tolerance, meaning the patient needs to consume more tobacco to achieve the same effect; and lastly, withdrawal symptoms if tobacco is stopped, such as headaches, poor concentration, anxiety, or insomnia.

If your patient meets the DSM-V criteria, diagnose tobacco use disorder, and assess the patient's readiness to quit smoking. If your patient is not ready to quit, offer them motivational counseling, which is based on the 5 Rs. The first R stands for Relevance, which touches on the importance of stopping tobacco use, like addressing the patient’s current state of health or avoiding tobacco exposure for others in the household. The second one is for Risks, which covers the acute and long-term risks, like asthma exacerbation, respiratory infections, heart disease, stroke, and cancer.