Screening and assessment of tobacco smoking and nicotine dependence
Ask all new patients routinely and others (adolescents and adults) opportunistically and periodically about tobacco smoking or vaping as part of a general screen for disorders of substance use and gambling; these disorders are common (and often co-exist) and people are reluctant to disclose them, often due to fear of stigma. Screening and assessment of substance use and addictive behaviours outlines history-taking (including use of the ASSIST-Lite tool), examination, and investigations that should be considered in a broad review of substance use and addictive behaviour.
Ask if a patient smokes cigarettes (including roll-your-own cigarettes with cannabis), uses ‘heat-not burn’ tobacco products, chews tobacco or uses nicotine vaping products. Document the number of cigarettes smoked daily as a baseline; this is useful to increase motivation by tracking the savings a patient makes as they reduce or stop smoking.
The most useful questions to identify high nicotine dependence include:
- How soon after waking is your first cigarette (or other nicotine intake)? (Smoking within 30 minutes of waking is the best indicator of high dependence)
- Have you experienced cravings or other withdrawal symptoms for cigarettes while using drug therapy to manage previous efforts to cut down or stop smoking?
- Do you smoke (or use other forms of nicotine) as much as usual when you are unwell?
McLaughlin, 2015World Health Organization (WHO), 2022
Withdrawal can be recognised by 2 or more of the following symptoms starting within 24 hours of nicotine reduction or stopping; some features can last 3 to 4 weeks [NB1]:
- cravings for nicotine [NB2]
- anxiety
- irritability or restlessness
- reduced concentration
- malaise
- increased cough
- dysphoria
- mouth ulceration
- insomnia
- increased appetite.
NB1: Withdrawal symptoms occurring during previous drug therapy for tobacco smoking are markers of high nicotine dependence.
NB2: Cravings for nicotine can persist for months after the withdrawal periodNational Cancer Institute, 2022.
Smoking within 30 minutes of waking is the strongest predictor of high nicotine dependence, regardless of total cigarettes smoked in the dayBaker, 2007Branstetter, 2016Branstetter, 2015Branstetter, 2013Branstetter, 2020Fagerström, 2003Muscat, 2009.
Awareness of the ‘time to first cigarette’ after waking is important to avoid undertreating a patient with high nicotine dependence who smokes comparatively few cigarettes1. This is a shift from previous advice that placed more emphasis on the number of cigarettes smoked per dayThe Royal Australian College of General Practitioners (RACGP), 2021; the number of cigarettes smoked per day does not correlate well with abstinence at 6 monthsBaker, 2007 or biomarkers of nicotine ingestion (eg the serum concentration of cotinine, a metabolite of nicotine)Fagerström, 2003Kassel, 2007Muscat, 2009Veilleux, 2011. A person who smokes 10 cigarettes per day and starts within 30 minutes after waking may have a higher serum cotinine concentration than a person who smokes 20 cigarettes per day but starts later than 30 minutes after wakingMuscat, 2009. Duration and cumulative amount of smoking remain important to assess the risk of harms (eg cardiovascular disease and lung cancer) from cumulative tobacco exposurePleasants, 2020.