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.

The third R one stands for Rewards, including improved health and saving money; while the fourth one stands for Roadblocks or potential barriers to quitting are withdrawal symptoms, weight gain, and depression.

Last but not least, there’s Repetition, which refers to repeating this discussion on routine follow-up visits. Again, don’t forget routine follow-up to monitor their progress and assess for new signs and symptoms.On the other hand, if your patient is motivated and ready to quit, their management is based on motivational counseling and cognitive behavioral therapy, or CBT, which teaches the patient to recognize smoking triggers and apply coping or problem-solving skills to resist tobacco cravings.

Now, the most effective management includes a combination of behavioral therapy with pharmacotherapy, which primarily involves nicotine replacement therapy, bupropion, and varenicline, in order to help maximize success in smoking cessation and reduce the risk of withdrawal symptoms.

Speaking of which, nicotine withdrawal symptoms should be discussed with your patient so they will know what to expect. Symptoms peak in the first 3 days of smoking cessation and subside over 3 to 4 weeks, and include increased appetite and weight gain, mood changes, irritability, anxiety, difficulty concentrating, insomnia, and restlessness.

Finally, make sure that your patient has routine follow-up, so you can monitor their progress and smoking status. Now, let’s go back and take a look at patients that do not meet the DSM-V criteria for tobacco use disorder.In this case, there is indeed tobacco use, but not enough criteria are met to classify it as a disorder.

Your patient is probably a social smoker, meaning they consume tobacco occasionally, typically while consuming alcohol. These individuals also require motivational counseling for smoking cessation, as well as routine follow-up to monitor their progress.

Finally, let’s go back all the way back to the assessment of tobacco use status and take a look at former users of tobacco.

In this case, it's important to assess the patient's risk of relapse based on how long ago they last smoked. Patients have a high risk of relapse if they stopped smoking less than 1 month ago.

In this case, consider cognitive behavioral therapy with or without pharmacotherapy, and schedule them for routine follow-up to monitor their progress.

On the other hand, patients have a moderate risk of relapse if they stopped smoking between 1 to 6 months ago. In this case, you could offer them pharmacotherapy if they are experiencing withdrawal symptoms, and schedule them for routine follow-up.

Finally, patients have a low risk of relapse if they quit smoking more than 6 months ago. In this case, again, offer pharmacotherapy if needed, and schedule routine follow-up.Alright, as a quick recap… Tobacco use disorder, or TUD for short, is a condition that develops after continued tobacco use, and it’s associated with nicotine dependence.

If you suspect this condition, use the DSM-V criteria to confirm the diagnosis. If your patient meets the criteria, diagnose tobacco use disorder and assess their readiness to quit smoking.

Management of individuals who are not ready to quit involves offering motivational counseling based on the 5 Rs. However, if they’re motivated and ready to quit, management is based on motivational counseling, as well as cognitive behavioral therapy, and you can consider pharmacologic therapy.

On the flip side, if your patient does not meet the DSM-V criteria, your patient is probably a social smoker, meaning they consume tobacco occasionally.

These individuals require motivational counseling for smoking cessation, as well as routine follow-up to monitor