Tobacco Documents Online

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I 1 I I ~ I I I I I I I I I I 176 Diagnostic Categories for at least a month that causes impairment in social or occupational functioning. The essential features of Cannabis Dependence are impairment in social or oc- cupational functioning due to cannabis use, and tolerance (withdrawal has not been conclusively demonstrated). The existence and significance of tolerance (Cannabis Dependence) with regular heavy use of cannabis are controversial. Course. Many users stop or decrease their use of cannabis spontaneously or when impairment in functioning develops. Diagnostic criteria for Cannabis Abuse A. Pattern of pathological use: intoxication throughout the day; use of cannabis nearly every day for at least a month; episodes of Cannabis De- lusional Disorder. 6. Impairment in social or occupational functioning due to cannabis use: e.g., marked loss of interest in activities previously engaged in, loss of friends, absence from work, loss of job, or legal difficulties (other than due to a single arrest for possession, purchase, or sale of the substance). C. Duration of disturbance of at least one month. Diagnostic criteria for Cannabis Dependence A. Either a pattern of pathological use or impairment in social or occupa- tional functioning due to cannabis use. Pattern of pathological use: intoxication throughout the day; use of cannabis nearly every day for at least a month; episodes of Cannabis Delusional Disorder. Impairment in social or occupational functioning due to cannabis use: e.g., marked loss of interest in activities previously engaged in, loss of friends, absence from work, loss of job, or legal difficulties (other than a single arrest due to possession, purchase, or sale of an illegal sub- stance). B. Tolerance: need for markedly increased amounts of cannabis to achieve the desired effect or markedly diminished effect with regular use of the same amount. 305.1x Tobacco Dependence The essential features are continuous use of tobacco for at least one month with either (1) unsuccessful attempts to stop or significantly reduce the amount of tobacco use on a permanent basis, (2) the development of Tobacco With- drawal, or (3) the presence of a serious physical disorder (e.g., respiratory or cardiovascular disease) that the individual knows is exacerbated by tobacco use. In practice this diagnosis will be given only when either the individual is seeking professional help to stop smoking, or, in the judgment of the diagnosti- , © ~ CT? 00 00 CJt . - ~

I I I I ~ I I I I I I I I I I I I Substance Use Disorders 177 cian, the use of tobacco is seriously affecting the individual's physical health. It should also be noted that a heavy smoker who has never tried to stop smoking, who has never developed Tobacco Withdrawal, and who has no tobacco- related serious physical disorder, according to the criteria in this manual, does not have the disorder of Tobacco Dependence, even though physiologically the individual is almost certainly dependent on tobacco. At present, the most common form of Tobacco Dependence is associated with the inhalation of cigarette smoke. Pipe and cigar smoking, the use of snuff, and the chewing of tobacco are less likely to lead to Tobacco Dependence for several reasons. First of all, the probability of developing serious health com- plications is lower than with cigarette smoking, probably because relatively little smoke is inhaled; consequently, there is less distress arising from health con- cerns about the need to take the substance repeatedly. Second, the more rapid onset of nicotine effects with cigarette smoking leads to a more intensive habit pattern that is more difficult to give up owing to the frequency of reinforce- ment or the greater physical dependence on nicotine. In recent years the evidence that tobacco use predisposes to a variety of serious physical disorders has led many individuals who are heavy smokers to attempt to give up the habit. However, many are unable to stop at all or, if they do, often resume tobacco use within a matter of months. The difficulty in giving up tobacco use on a long-term basis, particularly with cigarettes, may be due to the unpleasant nature of the withdrawal syn- drome, the highly overlearned nature of the habit that stems from the repeated effects of nicotine, which rapidly follow the inhalation of cigarette smoke (75,000 puffs per year for a pack-a-day smoker), and the likelihood that a desire to use tobacco is elicited by environmental cues, such as the ubiquitous presence of other smokers and the widespread availability of cigarettes. When efforts to give up smoking are made, Tobacco Withdrawal may develop. (For a discussion of Tobacco Withdrawal, see p. 159.) The most common tobacco-related serious physical disorders are bronchitis, emphysema, coronary artery disease, peripheral vascular disease, and a variety of cancers. The diagnostician must assess the role of tobacco use as an etiological or exacerbating factor for the particular individual after considering both indi- vidual circumstances and the latest available scientific information. If the indi- vidual with a serious case of one of the tobacco-related physical disorders con- tinues to use tobacco, despite awareness of its harmful effects, a reasonable in- ference can be made that the individual is dependent on tobacco. Associated features. Individuals with this disorder are frequently distressed at their inability to stop tobacco use, particularly when they have serious physi- cal symptoms that are aggravated by tobacco use. Some individuals who are dependent on tobacco may have difficulty remaining in social or occupational situations that prohibit smoking. Age at onset. Tobacco Dependence usually begins in late adolescence or early adult life. I

I I I I 1 I I I I I I 1 I I I 178 Diagnostic Categories Course. The course of Tobacco Dependence is variable. Some individuals repeatedly attempt to give up tobacco use without success. Others have a brief course, in that when they experience concern about tobacco use they make a prompt effort to stop and are successful in total cessation, although in many cases they may experience a period of Tobacco Withdrawal lasting from days to weeks (see p. 159). Studies of treatment outcome suggest that the relapse rate is greater than 50% in the first six months, and approximately 70% within the first twelve months. After a year's abstinence subsequent relapse is unlikely. Impairment. Since tobacco use rarely causes any identifiable state of intoxi- cation as does alcohol, there is no impairment in social or occupational func- tioning as an immediate and direct consequence of tobacco use. Prevalence and sex ratio. A large proportion of the adult population of the United States uses tobacco, the prevalence among men being greater than that among women. Among teenage smokers, boys are affected approximately as often as girls. The prevalence of Tobacco Dependence as defined here is not known. Some individuals give up smoking as they grow older without ever meeting the criteria for the disorder. However, since surveys have shown that approxi- mately 50% of smokers express a desire to be able to stop and are unable to do so, and since serious physical disorders that are aggravated by smoking are common, Tobacco Dependence is obviously widespread. Familial pattern. Cigarette smoking among family members of individuals with Tobacco Dependence is more common than in the general population. However, the evidence for a genetic factor is extremely weak. Differential diagnosis. The major differential diagnostic problems will be to determine whether or not a particular physical disorder, in an individual who is a heavy smoker, is exacerbated by tobacco use, and how long a period of abstinence from tobacco use justifies the judgment that the disorder is no longer present or is in a state of remission. Diagnostic criteria for Tobacco Dependence A. Continuous use of tobacco for at least one month. B. At least one of the following: (1) serious attempts to stop or significantly reduce the amount of tobacco use on a permanent basis have been unsuccessful (2) attempts to stop smoking have led to the development of Tobacco Withdrawal (see p. 159) (3) the individual continues to use tobacco despite a serious physical disorder (e.g., respiratory or cardiovascular disease) that he or she knows is exacerbated by tobacco use z4g) . ~ C~7 W 00 ~ ^ ~