Nicotine withdrawal

Essential (Required) Features:

• The presence of a clinically significant cluster of symptoms, behaviours, and/or physiological features that occurs upon cessation or reduction in the use of nicotine in individuals who have developed dependence on nicotine or have used nicotine for a prolonged period or in large amounts.
• Presenting features of Nicotine Withdrawal may include depressed or dysphoric mood, insomnia, irritability, anger, anxiety, difficulty concentrating, restlessness, bradycardia, increased appetite, and craving for tobacco or other nicotine-containing products. Other physical symptoms may include increased cough and mouth ulceration.
• The severity and duration of Nicotine Withdrawal is variable, related to the amount, frequency and duration of tobacco smoked (or otherwise consumed) or of nicotine products taken prior to cessation of use.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Additional Clinical Features:

• Onset of Nicotine Withdrawal is typically 6 to 24 hours after cessation or reduction of use. Psychological and physiological features typically last up to 10 days. Physical features such as increased cough and mouth ulceration may persist for 2 to 3 weeks.
• Craving for tobacco (or other nicotine-containing products) is prominent throughout the duration of Nicotine Withdrawal.
• Characteristic features of Nicotine Withdrawal are opposite to the acute pharmacological effects of nicotine.
• Nicotine Withdrawal symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.

Boundary with Normality (Threshold):

• Nicotine Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of nicotine. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Nicotine Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
• Some individuals who have previously had Nicotine Dependence may experience symptoms similar to those of Nicotine Withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g., drug paraphernalia) and contexts (e.g., location where use was frequent) previously associated with past nicotine use. These symptoms are more transient than those observed during Nicotine Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Nicotine Withdrawal should not be assigned under these circumstances.

Course Features:

• Nicotine Withdrawal is time-limited. Factors that influence the features and time course of Nicotine Withdrawal include: (1) the severity of Nicotine Dependence, if present, (2) the dose, frequency of use, and duration of nicotine use prior to cessation or reduction of that use, (3) the half-life and duration of action of nicotine, and (4) the presence of comorbid medical conditions (e.g., metabolic disturbances).

Culture-Related Features:

• Symptoms of withdrawal depend largely on the psychotropic characteristics of nicotine. However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Nicotine Dependence: Many individuals with Nicotine Dependence develop Nicotine Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Nicotine Dependence and Nicotine Withdrawal should be diagnosed. However, Nicotine Withdrawal can be diagnosed in the absence of a diagnosis of Nicotine Dependence.
• Boundary with Nicotine Intoxication: The onset of Nicotine Intoxication occurs immediately or shortly after the consumption of nicotine. In contrast, Nicotine Withdrawal occurs upon cessation or reduction in the amount of nicotine in the context of Nicotine Dependence or when nicotine has been taken for a prolonged period or in large amounts. For nicotine, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with other mental disorders: Various symptoms associated with Nicotine Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Nicotine Withdrawal occur in specific temporal relationship to the cessation of use of nicotine and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of nicotine use, the symptoms persisting for a substantial period of time after cessation of nicotine or withdrawal (e.g., 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g., a history of prior episodes not associated with nicotine use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Nicotine Withdrawal (e.g., restlessness, increased appetite, decreased heart rate, sleep disruption) and those that are characteristic of other medical conditions. Symptoms of Nicotine Withdrawal occur in specific temporal relationship to the cessation of use of nicotine and diminish with the passage of time.
• Boundary with Foetus or Newborn Affected by Maternal Use of Tobacco, Alcohol, or Other Drugs of Addiction: The ICD-11 chapter on Certain Conditions Arising During the Perinatal Period contains categories for ‘Foetus or newborn affected by maternal use of tobacco, alcohol, and other drugs.’ A neonate exhibiting signs of Nicotine Withdrawal may also be Nicotine Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.