Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Tobacco Use Disorder


Related Terms

  • Cigarette Addiction
  • Smokeless Tobacco Addiction
  • Smokeless Tobacco Dependence
  • Smoking Addiction
  • Tobacco Addiction

Differential Diagnosis

  • Caffeine intoxication
  • Medication-induced muscle restlessness (akathisia)
  • Psychological disorders
  • Sleep disorders

Specialists

  • Clinical Psychologist
  • Family Physician
  • Internal Medicine Physician
  • Occupational Therapist
  • Psychiatrist
  • Pulmonologist

Comorbid Conditions

  • Psychiatric disorders

Factors Influencing Duration

Mild physical discomfort, cravings, sleep disturbance, drowsiness, and irritability usually occur during withdrawal, which typically lasts 4 to 5 days, but there is no significant disability associated with nicotine addiction. Disability is attributable to the type and severity of associated physical illness. The number of cigarettes or tobacco products used daily, the nicotine yield of the product, and the number of years of use can affect the ability to quit as well as the severity of physical or medical consequences.

Medical Codes

ICD-9-CM:
305.1 - Nicotine Dependence
989.84 - Toxic Effects, Substances Chiefly Nonmedicinal as to Source, Tobacco

Overview

Nicotine is a widely used addictive compound found naturally in tobacco (cigarettes, cigars, chewing tobacco) and now available in pharmaceutical preparations such as chewing gum, skin patches, nasal spray, and electronic cigarettes. Some would consider nicotine among the most addictive drugs known, and no matter which form is used, there is potential for dependence. Cigarette smoking is the most addictive method of using nicotine. In DSM-5, these problems are subsumed under the title Tobacco Use Disorder.

The case for nicotine's addictive potential becomes even more compelling when considering that initial exposure typically leads to nausea and dizziness. Unlike alcohol or cocaine, there is little, if any, pleasurable sensation or psychological relief at first. After habitual use, improved concentration and mood and decreased anger may be reported. There is some evidence that nicotine use may be a form of self-medication for some individuals who have attention problems or who are seeking relief from mild depression or other psychological symptoms.

Despite full knowledge of nicotine's harmful physical effects and a strong desire not to become addicted, casual users may become dependent. Most smokers develop dependence within a few years of daily smoking. Few self-quitters are able to remain totally abstinent on the first attempt, and only a small number are able to quit successfully on any given subsequent attempt, although some individuals are able to quit eventually after multiple attempts. Factors leading to addiction include that the effect of nicotine is almost instantaneous, as it reaches the brain within 10 seconds after inhalation, and the smoker easily controls the dose and frequency.

Note: For the substance/medication-induced disorders approach established by the DSM-IV-TR, and the DSM-5, please see the following topics: Substance/Medication-Induced Anxiety Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Substance/Medication-Induced Depressive Disorder, Substance/Medication-Induced Major or Mild Neurocognitive Disorder, Substance/Medication-Induced Obsessive-Compulsive and Related Disorder, Substance/Medication-Induced Psychotic Disorder, Substance/Medication-Induced Sexual Dysfunction, and Substance/Medication-Induced Sleep Disorder.

Incidence and Prevalence: An estimated 1.1 billion people smoke worldwide; in the US, smoking occurs among approximately 34% of men and 22% of women, and the incidence rate is higher among American Indians, Alaskan Natives, whites (29.5%), blacks (27%), and Hispanics (22%) (Lande). The incidence rate is also higher among blue-collar workers, less educated people, and people of lower socioeconomic status.

According to the DSM-5, cigarettes are the most commonly used tobacco product (over 90% of tobacco/nicotine use). In the US, 57% of adults have never been smokers, 22% quit the habit, and 21% are current smokers. About 20% of US smokers do not smoke daily. The prevalence of smokeless tobacco use is less than 5%, and the prevalence of tobacco use in pipes and cigars is less than 1% (DSM-5).

The 12-month prevalence of DSM-IV nicotine dependence in the US is 13% among adults age 18 years and older. Rates are similar among adult males (14%) and females (12%) and decline with age. The prevalence of current nicotine dependence is greater among Native American and Alaska Natives (23%), followed by whites (14%), African Americans (10%), Asian Americans and Pacific Islanders (6%), and Hispanics (6%). The prevalence among current daily smokers is about 50% (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

There is a genetic predisposition for nicotine dependence/tobacco use disorder, including first-degree relatives as users, and certain behavioral traits, such as rebelliousness and impulsiveness, that increase the risk of nicotine dependence/tobacco use disorder.

Source: Medical Disability Advisor



Diagnosis

History: A diagnosis of nicotine dependence is based on criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).

The DSM-IV-TR describes Individuals with nicotine dependence as having a maladaptive pattern of nicotine use that leads to clinically significant impairment or distress, as manifested by at least 3 of the following, occurring at any time in the same one-year period. The individual
• develops a tolerance for nicotine, manifested by a more intense effect of the substance, with the first use during the day and the absence of nausea and dizziness with repeated consumption, despite regular use of considerable amounts of nicotine.
• experiences a well-defined withdrawal syndrome when abstaining from nicotine use; many users take the substance to relieve withdrawal symptoms or to avoid them upon awakening in the morning, after being in a place where use is restricted, or despite being sick.
• often takes the substance in larger amounts or over a longer period than was intended; smokers and other nicotine users often use up their supply of cigarettes or other nicotine-containing products faster than intended.
• has a persistent desire to use tobacco or may make unsuccessful efforts to cut down or control substance use. More than 80% of smokers express a desire to quit and 35% try to do it each year, but fewer than 5% are successful in unaided attempts to quit.
• spends a great deal of time using the substance. In the case of nicotine this is best exemplified by chain-smoking. Nicotine sources are readily and legally available, so spending a great deal of time attempting to procure the substance is rare.
• gives up or reduces important social, occupational, or recreational activities due to substance use; a smoker may give up such activities if they occur in smoking-restricted areas.
• continues use despite knowledge of medical problems related to tobacco use, for example, continuing to smoke despite having chronic bronchitis or chronic obstructive lung disease (COPD). This is a particularly important health problem (DSM-IV-TR).

The DSM-5 describes Tobacco Use Disorder as a problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a year. The individual
• uses tobacco for a longer period of time or in larger amounts than was intended.
• makes unsuccessful efforts to cut down or control tobacco use.
• spends a great deal of time in activities necessary to obtain or use tobacco.
• has a strong desire, craving, or urge to use tobacco.
• uses tobacco so often that he or she fails to fulfill major obligations at home, school, or work.
• continues tobacco use despite recurrent or persistent social or interpersonal problems caused or exacerbated by the use of tobacco.
• gives up important occupational, social, or recreational activities because of tobacco use.
• uses tobacco recurrently in situations in which it may be physically hazardous (for example, smoking in bed).
• continues to use tobacco, despite knowledge of having a persistent or recurrent physical or psychological problem caused or intensified by tobacco use.
• develops a tolerance, manifested either by a markedly diminished effect after use of the same amount of tobacco or a marked increase in the amount of tobacco necessary to achieve the desired effect.
• goes into withdrawal, with the characteristic withdrawal syndrome, and/or takes tobacco or a closely related substance to relieve or avoid withdrawal symptoms.

If 2-3 of these issues are present, Tobacco Use Disorder is defined as mild. If 4-5 of the symptoms are present, it is moderate. If 6 or more of the symptoms listed are present, then the disorder is severe.

Almost by definition, any use of tobacco products constitutes abuse. Withdrawal symptoms include sweating or rapid pulse, increased hand shaking (tremor), nausea or vomiting, depression, insomnia, irritability, anxiety, difficulty concentrating, restlessness, or increased appetite. Smoking cessation is associated with improvement in the senses of taste and smell.

Withdrawal syndrome: In individuals who have used tobacco daily for several weeks, withdrawal syndrome appears within 24 hours after abrupt cessation of tobacco use, or reduction in the amount of tobacco used, and consists in at least 4 of the following: irritability, frustration, or anger; anxiety; difficulty concentrating; increased appetite; restlessness; depressed mood; and insomnia. The signs or symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; are not attributable to another medical condition, and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance (DSM-5).

For individuals in the process of quitting, it is necessary to specify if the tobacco use disorder is in early remission, or in sustained remission, as well as if the individual is on maintenance therapy, or in a controlled environment where access to tobacco is restricted.

Physical exam: Upon examination, a smoker may have a dry or productive cough, increased heart rate (tachycardia), high blood pressure (hypertension), weight loss, excessive skin wrinkling, or tobacco stains on the fingers. Signs of nicotine withdrawal may include weight gain due to increase in appetite, and decreased heart rate; smoking cessation is associated with a decrease in blood pressure. If the individual has used tobacco for many years, he or she may show evidence of COPD or complications of existing cardiovascular disease.

Tests: Routine urine toxicology tests can detect nicotine use. Continued smoking can be inferred from elevated levels of carbon monoxide in the blood. Pulmonary function tests (PFT) may be used to assess lung damage. Blood tests may show decreased levels of catecholamines and cortisol or increased mean corpuscular volume (MCV) of the red blood cells. Electrocardiogram (ECG) and chest x-ray may show the effects of chronic smoking on the heart and lungs.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

The goal of treatment is abstinence. Because it is difficult for many individuals to quit on their first attempt, various strategies should be used in combination, with as much outside support as possible. Although some people are able to quit "cold turkey," the presence of uncomfortable withdrawal symptoms commonly causes relapse within 48 hours.

Nicotine replacement therapies (NRT) (nicotine gum, the transdermal patch, nasal spray, and inhaler) relieve withdrawal symptoms while providing users with lower overall nicotine levels than they received with tobacco, and increases the quit rate by 50% to 70% (Lande). Although there is always a potential for the development of dependence on these substitutes, the individual is not likely to become dependent on these replacements, since they do not produce the pleasurable effects of tobacco products. They are also safer, as they do not contain the carcinogens and gases associated with tobacco smoke. All are considered equally effective.

Although the main treatment focus has been nicotine replacement, there are now available two non-nicotine prescription drugs, bupropion and varenicline. The atypical antidepressant bupropion contains no nicotine, can be taken in pill form, and has been demonstrated to be helpful in reducing withdrawal symptoms in some individuals. Bupropion has been shown to double quit rates. it is usually begun 1 week prior to the quit date and is taken for several weeks thereafter, it is effective in those who are not depressed, and its most common side effect is dry mouth. Varenicline prevents withdrawal symptoms, but this drug should be used with caution in individuals with known cardiovascular problems. Its use may produce serious new health problems.

Behavioral interventions play an important role in treatment. Treatment approaches include hypnosis, acupuncture, aversive conditioning, psychotherapy, medications, and use of tobacco substitutes. Key recovery factors involve avoiding smokers and smoking environments, getting support from family and friends, and learning coping skills for both short- and long-term prevention of relapse. Smokers must not only learn behavioral and cognitive tools to prevent relapse, but must also be ready to apply those skills in a crisis. Smoking cessation programs are available in clinics, many community and public health settings, and by telephone and in written formats.

Source: Medical Disability Advisor



Prognosis

Those who are motivated and make persistent efforts to quit using nicotine have some chance of success. Once an individual abstains from tobacco use, his or her risk of heart disease and cancer declines with time and may even return to normal. More advanced pulmonary problems, such as chronic bronchitis and emphysema, can be slowed down or arrested, and early damage may be reversible. More than 90% of people who attempt to quit do so cold turkey; for those seeking treatment to help quit, there is a 20% cessation rate after 1 year (Lande).

Source: Medical Disability Advisor



Complications

Lung cancer, mouth cancers, chronic obstructive pulmonary disease, emphysema, ulcers, and heart disease are some of the major illnesses resulting from exposure to tobacco products. Smokers are also believed to be more susceptible to minor respiratory illness such as viral infection, and may be at higher risk for other types of cancer such as bladder cancer. Both asthma and allergies are exacerbated by exposure to smoke. Maternal and fetal complications may also occur in pregnant women who use tobacco products; women who smoke during pregnancy are at a greater risk for miscarriage (spontaneous abortion) in the first trimester and premature delivery, and their children may weigh less at birth or have developmental delays. A large majority of individuals with mental disorders smoke, and tobacco use may be more common in those with mood, anxiety, and other substance-abuse disorders than in the general population. Alcohol abuse and other substance abuse (particularly marijuana and cocaine dependence) may affect recovery and lengthen disability. Cigarette smoking increases the metabolism of many medications; stopping smoking can therefore increase the blood levels of these medications and other substances, sometimes to a clinically significant degree.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Many workplaces and public buildings are now smoke-free. It is up to the employer to provide smoking areas. Employers who encourage a smoke-free environment may be able to encourage employees to quit and remain off tobacco. Specific accommodations may include modifying specific environments that trigger memories or the desire to smoke, providing education and/or smoking-cessation courses, and providing stress-management and relaxation courses.

Risk: There is usually no risk to working with nicotine dependence. However, some smokers who are unable or unwilling to quit may present a small safety risk to themselves or their coworkers if they allow their cravings for nicotine to distract them from their work, or if they rush through a work assignment in an effort to go on a smoke break.

Capacity: Capacity is typically not affected by nicotine dependence. Prolonged nicotine dependence, especially for individuals who obtain nicotine through cigarette smoking, may result in cardiopulmonary problems and cancers that may affect capacity in the long term.

Tolerance: Tolerance is not a concern with this diagnosis.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 3 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Because a comprehensive assessment is essential when developing the treatment plan, did individual's evaluation include detailed history of past and present substance use, including a persistent desire to quit or unsuccessful efforts made to control the amount used, family and social history, general medical and/or psychiatric history and examination, and physical exam to assess any associated serious medical complications? If not, what areas were omitted?
  • Would this information affect the current treatment plan? If so, what changes could be made?

Regarding treatment:

  • Is individual on NRT?
  • If not satisfied with one product, does individual realize that there are several equally effective alternatives?
  • If other nicotine replacement products have been unsuccessful, would individual be willing to try a non-nicotine prescription drug?
  • Since behavioral interventions play an important role in treatment, does individual's current treatment include behavioral therapy?
  • Has individual learned behavioral and cognitive tools to prevent a relapse?
  • Are both short- and long-term coping skills a major focus of the therapeutic regime? Is individual ready to apply those skills in a crisis?
  • Is individual uncomfortable in a clinic-based, formal, smoking-cessation program? Would the individual be willing to change to a different format such as community or public health settings, or telephone, or written format?

Regarding prognosis:

  • Since studies have shown it to be the most effective approach, is individual involved in a combination of both behavioral therapy and drug therapy?
  • Does individual participate in a group therapy program for additional support?

Source: Medical Disability Advisor



References

Cited

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Lande, R. Gregory, et al. "Nicotine Addiction." eMedicine. 16 Apr. 2014. Medscape. 6 May 2015 <http://emedicine.medscape.com/article/287555-overview>.

Source: Medical Disability Advisor






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