576 Substance-Related and Addictive Disorders
Prevalence
Approximately 50% of tobacco users who quit for 2 or more days will have symptoms that
meet criteria for tobacco withdrawal. The most commonly endorsed signs and symptoms
are anxiety, irritability, and difficulty concentrating. The least commonly endorsed symp-
toms are depression and insomnia. 
Development and Course
Tobacco withdrawal usually begins within 24 hours of stopping or cutting down on to-
bacco use, peaks at 2–3 days after abstinence, and lasts 2–3 weeks. Tobacco withdrawal
symptoms can occur among adolescent tobacco users, even prior to daily tobacco use. Pro-
longed symptoms beyond 1 month are uncommon. 
Risk and Prognostic Factors 
Temperamental. Smokers with depressive disorders,  bipolar disorders, anxiety disor-
ders, attention-deficit/hypera ctivity disorder, and other substance use disorders have
more severe withdrawal.
Genetic and physiological. Genotype can influence the probability of withdrawal upon
abstinence. 
Diagnostic Markers
Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or
urine, can be used to measure the extent of tobacco or nicotine use but are only weakly re-
lated to tobacco withdrawal.
Functional Consequences  of Tobacco Withdrawal
Abstinence from cigarettes can cause clinically significant distress. Withdrawal impairs
the ability to stop or control tobacco use. Whether tobacco withdraw al can prompt a new
mental disorder or recurrence of  a mental disorder is debatable,  but if this occurs, it would
be in a small minority of tobacco users. 
Differential Diagnosis
The symptoms of tobacco with drawal overlap with those of other substance withdrawal