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Tobacco use disorder: Assessment and diagnosis

Key points

  • The Diagnostic and Statistical Manual of Mental Disorders (DSM) is used to make a formal diagnosis. In DSM-5, the DSM-IV-TR categories of nicotine abuse and dependence have been replaced with an overarching category called tobacco use disorder. This change was made to avoid confusion between dependence and addiction.
  • People being assessed for a tobacco use disorder should also be assessed for other substance use and mental health disorders.


  • The level of tobacco dependence can be assessed with tools such as the Fagerström Test for Nicotine Dependence and the Calculation of Pack Year History. The latter assigns a numerical value to lifetime tobacco exposure. This information should be clearly visible in clients' charts. Use this formula: number of cigarettes per day times number of years smoked divided by 20 equals pack years.

  • The person should be assessed for other substance use and mental health disorders.

  • Watch this video of a tobacco use assessment interview.



DSM-5 criteria for tobacco use disorder

A. A problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  1. Tobacco is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.
  3. A great deal of time is spent in activities necessary to obtain or use tobacco.
  4. Craving, or a strong desire or urge to use tobacco.
  5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use).
  7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use.
  8. Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed).
  9. Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.
  10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of tobacco to achieve the desired effect.

b. A markedly diminished effect with continued use of the same amount of tobacco.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for tobacco withdrawal).

b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

Evidence summary

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.

Herie, M., Dragonetti, R. & Selby, P. (2012). Alcohol and tobacco use problems. In A. Khenti, J. Sapag, S. Mohamound & A. Ravindran (Eds.), Collaborative Mental Health: An Advanced Manual for Primary Care Professionals (pp. 195–214). Toronto, ON: Centre for Addiction and Mental Health.


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Interesting... I have been smoking a pipe ONLY for about 50 years. I smoke the equivalent of perhaps two (2) cigarettes per day, never more, often less. I enjoy smoking and at the level I smoke the beneficial effects of nicotine use far outweigh the negative side effects of tar etc. A pipe is far less damaging according to life insurance statistics and I am considered to be a non-smoker by my insurance company.

As is so often the case and was strongly exhibited in the use of alcohol, there are positive effects given by nicotine, as long as you do not over dose. Nicotine has beneficial effects, especially on the brain. It improves general cognition, it reduces the chance of Alzheimer's and Parkinsons and it reduces the amount of damage that occurs in a haemorrhagic stroke. If one overdoses then the bad effects dominate and can even kill. When used properly the good effects are predominant, as in my case. I have had three haemorrhagic strokes and two of them caused no apparent focal neurological damage after 24 hours. The second stroke was fairly large and has caused a very pure and mild amount of anomic aphasia. In many people with similar bleeds the amount of damage would have been devastating. Did my smoking protect me? There is no way to measure that but I suspect it did.

I am not addicted, but then I am the type of person that does not addict to anything, even the very most addictive drugs, such as benzodiazepines. I do not drink. I do not like drugs with only the exception of my smoking which I do only very occasionally and can do without by simply putting my pipe down and walking away. I do not always take it with me when leaving my home nor do I care if I leave it. The cancer risk for me is about the same as living in Vancouver as a non smoker.
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