Psych · Addiction psychiatry — nicotine and behavioural addictions
Nicotine and behavioural addictions
Also known as Tobacco use disorder · Nicotine dependence · Smoking cessation · Varenicline · NRT · Gambling disorder · Pathological gambling · Gaming disorder · Internet gaming disorder · Behavioural addiction
Exam-exhaustive fellowship reference on nicotine/tobacco use disorder (FTND, combination NRT, varenicline, bupropion, e-cigarettes, EAGLES, dual diagnosis with SMI), gambling disorder, and gaming/internet-use disorders (ICD-11 vs DSM-5-TR). FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Therapeutic nihilism about smoking in severe mental illness — smoking drives a large share of excess mortality; offer full cessation care
- Gambling crisis with debt and suicidal ideation — risk assessment, safety plan, financial safeguards; do not treat as mere lifestyle issue
- Bupropion in seizure risk, current eating disorder, or abrupt alcohol/benzodiazepine withdrawal — contraindicated or high-risk
- Dopamine agonist-induced impulse control (gambling, hypersexuality, shopping) in Parkinson disease or restless legs — review neurology medication, not only 'primary addiction'
- Ward smoke-free policy without proactive NRT — under-treatment fuels agitation and inequity
- Pathologising all heavy gaming without functional impairment, or missing ADHD/autism/mania differentials
Meet the patient
A 47-year-old man with schizophrenia is admitted under the psychiatry team. He smokes forty a day, lights up within two minutes of waking, and has never been offered cessation treatment. The ward is smoke-free, and by evening he is irritable, tremulous, and refusing to engage — labelled in the handover as "behavioural."[14][21]
He is not behavioural. He is in untreated nicotine withdrawal on a ward that forgot his NRT. Tobacco is the leading modifiable cause of early death in severe mental illness, and the "they need cigarettes to cope" line is not a treatment plan.[1][21]
This topic covers three exam pillars in one place: tobacco and nicotine, gambling disorder, and gaming and internet-use problems — framed so you neither over-pathologise a hobby nor miss a genuine disorder.[16][18]
References22ShowHide
- [1]Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial Lancet, 2016.PMID 27116918
- [2]Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB, et al. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial JAMA, 2006.PMID 16820546
- [3]Jorenby DE, Hays JT, Rigotti NA, Azoulay S, Watsky EJ, Williams KE, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial JAMA, 2006.PMID 16820547
- [4]Tonstad S, Tønnesen P, Hajek P, Williams KE, Billing CB, Reeves KR, et al. Effect of maintenance therapy with varenicline on smoking cessation: a randomized controlled trial JAMA, 2006.PMID 16820548
- [5]Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T Nicotine receptor partial agonists for smoking cessation Cochrane Database Syst Rev, 2016.PMID 27158893
- [6]Cahill K, Stevens S, Perera R, Lancaster T Pharmacological interventions for smoking cessation: an overview and network meta-analysis Cochrane Database Syst Rev, 2013.PMID 23728690
- [7]Theodoulou A, Chepkin SC, Ye W, Fanshawe TR, Bullen C, Hartmann-Boyce J, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation Cochrane Database Syst Rev, 2023.PMID 37335995
- [8]Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T Antidepressants for smoking cessation Cochrane Database Syst Rev, 2014.PMID 24402784
- [9]Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire Br J Addict, 1991.PMID 1932883
- [10]Grant JE, Kim SW, Hartman BK A double-blind, placebo-controlled study of the opiate antagonist naltrexone in the treatment of pathological gambling urges J Clin Psychiatry, 2008.PMID 18384246
- [11]Hodgins DC, Stea JN, Grant JE Gambling disorders Lancet, 2011.PMID 21600645
- [12]Cowlishaw S, Merkouris S, Dowling N, Anderson C, Jackson A, Thomas S Psychological therapies for pathological and problem gambling Cochrane Database Syst Rev, 2012.PMID 23152266
- [13]Dowling N, Merkouris S, Lubman D, Thomas S, Bowden-Jones H, Cowlishaw S Pharmacological interventions for the treatment of disordered and problem gambling Cochrane Database Syst Rev, 2022.PMID 36130734
- [14]Tsoi DT, Porwal M, Webster AC Interventions for smoking cessation and reduction in individuals with schizophrenia Cochrane Database Syst Rev, 2013.PMID 23450574
- [15]Evins AE, Cather C Effective Cessation Strategies for Smokers with Schizophrenia Int Rev Neurobiol, 2015.PMID 26472528
- [16]Petry NM, Rehbein F, Gentile DA, Lemmens JS, Rumpf HJ, Mößle T, et al. An international consensus for assessing internet gaming disorder using the new DSM-5 approach Addiction, 2014.PMID 24456155
- [17]Brand M, Young KS, Laier C, Wölfling K, Potenza MN Integrating psychological and neurobiological considerations regarding the development and maintenance of specific Internet-use disorders: An Interaction of Person-Affect-Cognition-Execution (I-PACE) model Neurosci Biobehav Rev, 2016.PMID 27590829
- [18]Grant JE, Potenza MN, Weinstein A, Gorelick DA Introduction to behavioral addictions Am J Drug Alcohol Abuse, 2010.PMID 20560821
- [19]Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T Physician advice for smoking cessation Cochrane Database Syst Rev, 2013.PMID 23728631
- [20]Lindson N, Butler AR, McRobbie H, Bullen C, Hajek P, Begh R, et al. Electronic cigarettes for smoking cessation Cochrane Database Syst Rev, 2024.PMID 38189560
- [21]Williams JM, Ziedonis D Addressing tobacco among individuals with a mental illness or an addiction Addict Behav, 2004.PMID 15236808
- [22]Rigotti NA Strategies to help a smoker who is struggling to quit JAMA, 2012.PMID 23073954