There is a significantly higher prevalence of tobacco use disorder (TUD) among individuals with mental health conditions, and they account for nearly 40% of cigarettes smoked in the United States. Although the DSM-5 notes the high prevalence of co-occurring mental health conditions with TUD and that nicotine withdrawal symptoms mimic the symptoms of other mental health conditions such as anxiety, depressive, and bipolar disorders, the discussion of co-occurring mental health conditions in relation to TUD is limited. DSM-6 presents an important opportunity to expand diagnostic guidance, recognize shared and bidirectional etiological mechanisms, and recommend systematic screening and intervention approaches for TUD in the context of mental health treatment. Expanded guidance for differential diagnosis and treatment in DSM-6 could promote tobacco cessation as an essential component of mental health care, thereby improving clinical outcomes for people with TUD and co-occurring mental health conditions.

Since 1952, psychiatry has grappled with the concept of addiction in terms of diagnosis, treatment, and research; this work has been particularly complex given the common co-occurrence of other mental health concerns. Tracing the history of substance use disorder (SUD) comorbidity and exploring related concepts of dual diagnosis, co-occurring disorders, and multimorbidity highlights the necessity for a strong addiction comorbidity framework. In this commentary, we contend that to continue advancing our understanding of addiction comorbidities, a more nuanced and explicit framework is needed. Specifically, one that moves beyond the limitations of dual diagnosis and multimorbidity, and embraces a more integrative, biopsychosocial approach. The DSM offers a critical opportunity for dialogue and development of psychiatric comorbidity frameworks to guide future research, clinical practice, and educational initiatives in the field of addiction and mental health.