The article below cited in the journal Addiction examines the effectiveness of e-cigarettes for smoking cessation. Apart from underlining differences between American and British views of the marketing of medications and appliances, it underscores an important philosophic difference in the definition of the illness state. In the most recent American iteration of diagnostic language (DSM5), the addiction that involves nicotine is referred to as a tobacco use disorder. This has resulted in a particular focus on smokable (combustible) tobacco products as the agent of harm or as the basis for a description of the illness. A SAMHSA-supported document on NSDUH’s handling of tobacco use classifications touches on the transition in nomenclature from DSM-IV TR (nicotine dependence) to DSM5 (tobacco use disorder) as does a comprehensive examination of criteria valences from collaborators in New York. 

The argument for regressively focusing on “tobacco” as the root of the disorder in DSM5 is unconvincing. This is probably not the place to launch into a lengthy disquisition on the problems arising from constant nicotine exposure alone, other than to say that in sidelining nicotine as a culprit we have encouraged the emergence of alternate forms of nicotine delivery that effectively preserve the tobacco industry’s profitability. I doubt that this was the intent of the DSM5 committee; it is certainly not my intent when attempting to help patients to abstain altogether from nicotine-containing products, even if I am able to obtain only a reduction in harm. The repeated use of the term “abstinence” is confusing under these study conditions. What seems instead to have been studied is a nicotine maintenance approach, possibly a useful public health measure when the comorbidity of pulmonary injury is considered, but not what we  commonly mean by “abstinence.”  It shouldn’t be that the nomenclature is more difficult to resolve than the disorder itself.

- Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM