Cultures and subcultures vary widely in their acceptance of the use of tobacco. The prev- alence of tobacco use declined in the United States from the 19605 through the 19905, but this decrease has been less evident in African American and Hispanic populations. Also, smoking in developing countries is more prevalent than in developed nations. The degree to which these cultural differences are due to income, education, and tobacco control ac— tivities in a country is unclear. Non-Hispanic white smokers appear to be more likely to develop tobacco use disorder than are smokers. Some ethnic differences may be biologi- cally based. African American males tend to have higher nicotine blood levels for a given number of cigarettes, and this might contribute to greater difficulty in quitting. Also, the speed of nicotine metabolism is significantly different for whites compared with African
Americans and can vary by genotypes associated with ethnicities.
Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or urine, can be used to measure the extent of current tobacco or nicotine use; however, these are only weakly related to tobacco use disorder.
Functional Consequences of Tobacco Use Disorder
Medical consequences of tobacco use often begin when tobacco users are in their 405 and usually become progressively more debilitating over time. One-half of smokers who do not stop using tobacco will die early from a tobacco-related illness, and smoking-related morbidity occurs in more than one-half of tobacco users. Most medical conditions result from exposure to carbon monoxide, tars, and other non-nicotine components of tobacco.
The major predictor of reversibility is duration of smoking. Secondhand smoke increases the risk of heart disease and cancer by 30%. Long-term use of nicotine medications does not appear to cause medical harm.
The most common medical diseases from smoking are cardiovascular illnesses, chronic obstructive pulmonary disease, and cancers. Smoking also increases perinatal problems, such as low birth weight and miscarriage. The most common psychiatric comorbidities are alcohol/substance, depressive, bipolar, anxiety, personality, and attention-deficit/hyper- activity disorders. In individuals with current tobacco use disorder, the prevalence of cur- rent alcohol, drug, anxiety, depressive, bipolar, and personality disorders ranges from 22% to 32%. Nicotine-dependent smokers are 2.7—8.1 times more likely to have these dis- orders than nondependent smokers, never-smokers, or ex-smokers.
. Tobacco Withdrawal
Diagnostic Criteria 292.0 (F17.203)
A. Daily use of tobacco for at least several weeks.
B. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four (or more) of the following signs or symptoms:
Irritability, frustration, or anger.
Anxiety.
Difficulty concentrating.
Increased appetite.
Restlessness.
Depressed mood.
Insomnia.
C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributed to another medical condition and are not bet- ter explained by another mental disorder, including intoxication or withdrawal from an- other substance.
Coding note: The ICD-9-CM code is 292.0. The lCD-10-CM code for tobacco withdrawal is F17.203. Note that the |CD-10-CM code indicates the comorbid presence of a moderate or severe tobacco use disorder, reflecting the fact that tobacco withdrawal can only occur in the presence of a moderate or severe tobacco use disorder. It is not permissible to code a comorbid mild tobacco use disorder with tobacco withdrawal.