Scope & common presentations

• Nicotine dependence and withdrawal—craving, irritability, sleep disturbance, concentration difficulties.
• Tobacco-associated conditions—chronic cough, COPD exacerbation, cardiovascular events, oral mucosal lesions.
• Product-related harms—burn injuries, poisoning (accidental ingestion of e-liquids), dual-use complexities.
• Comorbidity—co-occurring mental health conditions (depression, anxiety, substance use) that complicate cessation.

Why specify matters (but don’t delay care)

Different tobacco products and patterns (heavy smokers, smokeless tobacco, e-cigarettes) influence dependence severity, withdrawal profile and treatment choice. However, lack of immediate clarity should not delay brief interventions and initial pharmacotherapy when indicated.

Assessment — quick clinical checklist

1. Ask and document tobacco use status (current/former/never), product type (cigarettes, bidis, smokeless, e-cigarettes), frequency and last use.
2. Assess dependence severity: Heaviness of Smoking Index (time to first cigarette and cigarettes per day) or Fagerström Test for Nicotine Dependence.
3. Screen for withdrawal symptoms and readiness to quit (Stages of Change model).
4. Check for comorbidities: COPD/asthma, cardiovascular disease, pregnancy, psychiatric illness, other substance use.
5. Evaluate for acute tobacco-related complications (e.g., COPD exacerbation, oral lesions) and need for urgent care.

Immediate management — brief interventions (the 5 A’s)

• Ask: about tobacco use at every opportunity.
• Advise: clear personalised advice to quit (health benefits, tailored to condition).
• Assess: willingness to make a quit attempt now.
• Assist: offer pharmacotherapy and brief counselling; provide practical quit plan.
• Arrange: follow-up within 1–2 weeks and ongoing support (telephone, mHealth, cessation clinics).

Pharmacotherapy options & guidance

• Nicotinic replacement therapy (NRT): patches, gum, lozenges, inhalator or combination therapy (patch + fast-acting NRT) for moderate–severe dependence.
• Bupropion SR: effective for smoking cessation; caution with seizure risk and interactions.
• Varenicline: first-line for many patients; monitor for neuropsychiatric side effects though evidence indicates safety in most populations.
• Combination approaches: NRT + varenicline or bupropion in specialist settings for treatment-resistant dependence.
• Consider product-specific needs: manage e-cigarette dependence with behavioural support and discuss nicotine reduction strategies; address smokeless tobacco with oral mucosal care and counselling.

Behavioural and psychosocial interventions

• Brief counselling (5–15 minutes) increases quit rates—use motivational interviewing techniques.
• Structured programs: CBT for relapse prevention, group therapy, telephone quitlines and mHealth apps.
• Tailor interventions for pregnancy, youth, psychiatric comorbidity and low-literacy populations.

Managing withdrawal and common complications

• Withdrawal peaks in first 72 hours and declines over 2–4 weeks; anticipate cravings, irritability, sleep disturbance and concentration problems.
• Use combination NRT or varenicline to reduce cravings and withdrawal; offer symptomatic treatments for sleep or mood as needed.
• Monitor and treat comorbid depression or elevated suicidality; liaise with mental health services when indicated.

Follow-up, relapse prevention and long-term care

• Arrange early follow-up (within 1–2 weeks) to troubleshoot medication side effects and reinforce quitting strategies.
• Provide booster counselling, offer relapse prevention programs and consider stepping up pharmacotherapy for persistent cravings.
• Address social determinants—workplace triggers, family smoking, financial stress—and link to community support.

Key takeaways

• Unspecified tobacco-related disorders require prompt identification of dependence and harms even if product details are unclear.
• Use the 5 A’s for brief intervention, assess dependence severity and offer evidence-based pharmacotherapy plus behavioural support.
• Tailor treatment to special populations and arrange early follow-up for relapse prevention.
• Link patients to smoking cessation services and address social factors to improve long-term success.