Tobacco Withdrawal (TW)

A Paper On Analysis

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Psychology Research & Review

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DSM-5 Category: Substance-Related and Addictive Disorders


Tobacco Withdrawal (TW), formerly classified in the DSM-IV-TR as Nicotine Withdrawal, refers to a maladaptive pattern of tobacco use occurring as manifested by three or more symptoms at any time in the same 12-month period. Tobacco-related disorders along with alcohol and other substance use disorders, anxiety disorders, and depressive disorders are highly prevalent (Lucidarme, Seguin, Daubin, Ramakers, Terzi, Beck, Charbonneau, & du Cheyron, 2010). Tobacco use commonly co-occurs with other potentially addictive substances. Lucidarme et al. (2010) state that smoking is highly addictive, and the authors explain the relationship between nicotine abstinence and withdrawal syndrome in hospitalized patients. Studies observing hospitalized patients show that those who smoke respond to sudden nicotine abstinence. Researchers agree that many manifestations emerge, including bradycardia, irritability, confusion, anxiety, agitation, or hallucinations (Lucidarme et al., 2010).

Symptoms of Tobacco Withdrawal

Hardin, Yungang, Javitz, Wessel, & Bergin (2009) reported smoking was the underlying reason for 4.8 million premature deaths globally in 2000. Of the total, both industrialized nations and developing nations had roughly equal numbers of premature deaths. The DSM-5 states that most smokers who attempt to quit have difficulty remaining free of tobacco due to the substantial number of Tobacco Withdrawal (TW) symptoms. There is substantive research reporting the relationship between the severities of TW symptoms and smoking cessation success.

Experts used more than two-dozen research-based techniques to describe Tobacco Withdrawal symptoms. The DSM-5 explains TW symptoms characterize a smoker's level of restlessness, insomnia, concentration, irritability, depression, appetite, cravings, and urges for tobacco. These can also range from weeks to years. There is a correlation between TW symptoms and methods used to summarize these symptoms, including the use of latent class analyses along with Rasch models (Hardin et al., 2009). "How to handle" (2010) describes various ways that TW symptoms can manifest, including:

  • Anger
  • Irritability
  • Depression
  • Drowsiness
  • Trouble concentrating
  • Tobacco cravings
  • Headache
  • Increased appetite
  • Moodiness
  • Dry mouth
  • Trouble sleeping
  • Frustration
  • Stress

According to the DSM-5, quitting smoking can bring about short-term problems. This is especially true for persons who smoked heavily for years before they decided to stop. TW symptoms tend to be greatest during the first week after quitting. After that, the intensity of TW symptoms drops across the first month. Research explains that roughly half of all smokers report having at least four withdrawal symptoms when they quit. Some TW sufferers report experiencing additional symptoms, such as dizziness, headaches, and increased dreaming.

Triggers for Smoking

The DSM-5 lists common triggers to help persons suffering TW from relapsing. According to the DSM-5, in addition to tobacco cravings, there are reminders in one's daily life of when one used to smoke. Any of these reminders may trigger one to relapse. Some common triggers include: places, moods, feelings, and things done in daily life that create the desire to smoke. Other triggers identified by researchers include:

  • Being around smokers
  • Starting the day
  • Feeling stressed
  • Being in a car
  • Drinking coffee or tea
  • Enjoying a meal
  • Drinking an alcoholic beverage
  • Feeling bored

Treatment of Tobacco Withdrawal Disorder

Paddock (2014) discusses another possible reason why nearly 80% of those who quit smoking relapse within six months. The author states that there may be a neurological basis for smoking relapse. Researchers using functional magnetic resonance imaging (fMRI) brain scans reported that smokers suffering from TW showed weaker connections between particular networks in their brains, specifically, the default mode, the salience, and the executive control networks. In addition, the weakened connectivity during the TW state was related to increased withdrawal symptoms, negative moods, and smoking urges. The researchers posit that weaker inter-network connectivity may be why so many struggle to quit smoking. The DSM-5 reports that previous investigations examined the effects of tobacco on brain connections during the resting state; in other words, when the research participant had no specific goal to engage that part of the brain. In addition, Paddok (2014) states that the magnetic brain stimulation could help TW sufferers quit smoking. Using a single 15-minute session significantly reduced cue-induced cravings among TW participants.

Along with magnetic brain stimulation, tobacco replacement therapies (NRTs) lessen the symptoms associated with TW for the initial six-month period. However, after six months of use NRTs lose their efficacy leaving TW sufferers as likely to relapse as persons who choose to quit "cold turkey." Studies show that nearly 50% to 70% of TW sufferers have a greater success rate overall of quitting with an NRT than relying solely on willpower. The DSM-5 lists the following types of NRTs: nicotine lozenges, nicotine chewing gum, and nicotine patches. Luty (2014) reports that NRTs and other alternative forms of psychosocial treatments for smoking cessation are overall effective.

Pignataro, Ohtake, Swisher and Dino (2014) discuss the possible relief that physical therapy may have on TW sufferers. The authors assert that physical therapy affords substantial unmet demand and opportunities that promote nicotine cessation. Further, although studies indicate a connection between counselling by health care providers and nicotine cessation, less than 40% of insured adults indicated they received this recommendation. Physical therapy practitioners use non-invasive measures that develop and maintain the patient's optimal wellness, and tobacco cessation intervention is consistent with the profession's mission to improve immediate health and prevent secondary complications of chronic disease.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Hardin, J., Yungang, H., Javitz, H. S., Wessel, J., & Bergin, A. W. (2009). Nicotine withdrawal sensitivity. Linkage to chr6q26, and Association of OPRMI SNPs in the SMOking in FAMilies sample. Cancer Epidemiology Biomarkers Prev, 18, 3399. doi: 10. 1158/1055-9965. EPI-09-0960

Hudson, W. (2012, January 9). Study: Nicotine gums, patches only help with withdrawal. CNN: The Chart. Retrieved from

Lucidarme, D., Seguin, A., Daubin, C., Ramakers, M., Terzi, N., Beck, P., Charbonneau, P., & du Cheyron, D. (2010). Nicotine withdrawal and agitation in ventilated critically ill patients. Critical Care, 14: R58. Doi: 10.1186/cc8954

Luty, J. (2014). Nicotine addiction and smoking cessation treatments. Advances in Psychiatric Treatment (2002) 8, pp. 42 – 48. Retrieved from

How to handle withdrawal symptoms and triggers when deciding to quit smoking. (2010). Retrieved March 11, 2014, from

Paddock, C. (2014). Brain links weakened by nicotine withdrawal may explain smoker's relapse. Penn Medicine News Today. Retrieved from

Pignataro, R. M., Ohtake, P. J., Swisher, A., & Dino, G. (2014). The role of physical therapists in smoking cessation: opportunities for improving treatment outcomes. Retrieved from

Rufener, B. (2012). Manage nicotine withdrawal. Retrieved from

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