How does Nicotine Addiction Start?
Data from the Year 10 Survey
Joseph R DiFranza, MD
Department of Family Medicine and Community Health
University of Massachusetts Medical School
The Hound of the Baskervilles
Arthur Conan Doyle-1902
 “The more outré and grotesque an incident is the more
carefully it deserves to be examined, and the very point
which appears to complicate a case is, when duly considered
and scientifically handled, the one which is most likely to
elucidate it.” –Sherlock Holmes
The girl who didn’t read the text book
The Development and Assessment of
Nicotine Dependence in Youth (DANDY-1)
 681 7th year students were followed over 3 years
Addiction as a Loss of Autonomy
 From addictus, meaning assigned
 A Roman magistrate would assign the loser to perform work
or pay a forfeit to the victor.
 Addiction does not mean self-destruction, it means you have
an obligation to do something.
 Loss of Autonomy-when quitting requires an effort or
involves discomfort
Hooked on Nicotine Checklist
 1) Have you ever tried to quit, but couldn’t?
 2) Do you smoke now because it is really hard to quit?
 3) Have you ever felt like you were addicted to tobacco?
Hooked on Nicotine Checklist
 4) Do you ever have strong cravings to smoke?
 5) Have you ever felt like you really needed a cigarette?
 6) Is it hard to keep from smoking in places where you are
not supposed to?
Hooked on Nicotine Checklist
 When you haven't smoked for a while do you…
 7) find it hard to concentrate?
 8) feel more irritable?
 9) feel a strong need or urge to smoke?
 10) feel nervous, restless or anxious?
The Development and Assessment of
Nicotine Dependence in Youth (DANDY-1)
 Each of the 10 HONC symptoms had appeared within a few
weeks of initiating smoking.
 Median usage at symptom appearance was 2
cigarettes/week.
 Girls developed symptoms after a mean of 21 days and boys
after 183 days.
The Development and Assessment of
Nicotine Dependence in Youth (DANDY-1)
 The appearance of one or more HONC symptoms predicted
 A failed quit attempt (OR = 29)
 Continued smoking (OR = 44)
 Progression to daily smoking (OR = 58)
Trajectory of Use Before HONC Symptoms
Start: 2%
Intermittent
End: 4%
0.07
Start: 60%
Start: 30%
0.25
Sporadic
0.07
End: 14%
Occasional
0.42
0.05
Daily
0.02
End: 5%
0.53
Start: 9%
0.05
End: 4%
0.11
0.21
0.14
0.04
Start: 0%
Abstinent
End: 72%
Start: 0%
0.02
Escalating
End: 2%
Trajectory of Use After HONC Symptoms
Start: 0%
Intermittent
End: 10%
0.16
0.15
0.10
Start: 40%
Sporadic
End: 6%
Start: 46%
0.27
0.05
Start: 14%
0.46
Occasional
Daily
0.18
End: 15%
0.44
0.15
0.03
0.14
0.20
Abstinent
End: 21%
End: 26%
0.06
0.36
Start: 0%
Escalating
End: 22%
0.23
0.13
Start: 0%
0.29
Nicotine Dependence in Teens Study
 Quebec
 Ongoing 13-year longitudinal cohort
 n=1293 grade 7 students (age 12-13) in 10 high
schools
Figure 2.
Cumulative probability of attaining cigarette smoking onset milestones according to time
(months) since initiation (n=311)
1
0.9
0.8
Inhale into lungs
Whole cigarette
Probability
0.7
Mental addiction
Cravings
0.6
Physical addiction
Smoke monthly
0.5
Withdrawal symptoms
Tolerance
0.4
Smoke weekly
100 cigarettes
0.3
Smoke daily
ICD-10 dependent
0.2
0.1
0
0
6
12
18
24
30
36
42
48
54
Number of subjects at risk according to number of months after initiation
Inhale into lungs
311
112
62
44
32
22
13
10
5
1
Whole cigarette
311
161
113
83
62
42
23
14
5
0
Mental addiction
311 *
180
135
98
76
56
40
21
11
2
Cravings
311
201
162
121
98
77
51
30
17
3
Physical addiction
311 *
204
166
130
102
81
59
35
17
2
Smoke monthly
311
233
178
148
114
91
59
40
21
4
Withdrawal symptoms
311
221
187
150
121
98
70
37
15
2
Tolerance
311
236
198
157
127
97
68
38
19
4
Smoke weekly
311
246
210
170
141
115
84
49
24
4
100 cigarettes
311
250
213
169
135
107
79
50
22
2
Smoke daily
311
251
223
182
145
116
92
55
28
2
ICD-10 dependent
311
259
229
189
160
128
97
58
29
3
* 36 subjects reported mental addiction, and 15 subjects reported physical addiction prior to initiation. These subjects were considered to be incident cases at time 0.
They contributed 0 person-months to the denominator in the computation of time at risk for developing selected milstone.
Months
Figure 2.
Cumulative probability of attaining cigarette smoking onset milestones according to time
(months) since initiation (n=311)
1
0.9
0.8
Inhale into lungs
Whole cigarette
Probability
0.7
Mental addiction
Cravings
0.6
Physical addiction
Smoke monthly
0.5
Withdrawal symptoms
Tolerance
0.4
Smoke weekly
100 cigarettes
0.3
Smoke daily
ICD-10 dependent
0.2
0.1
0
0
6
12
18
24
30
36
42
48
54
Number of subjects at risk according to number of months after initiation
Inhale into lungs
311
112
62
44
32
22
13
10
5
1
Whole cigarette
311
161
113
83
62
42
23
14
5
0
Mental addiction
311 *
180
135
98
76
56
40
21
11
2
Cravings
311
201
162
121
98
77
51
30
17
3
Physical addiction
311 *
204
166
130
102
81
59
35
17
2
Smoke monthly
311
233
178
148
114
91
59
40
21
4
Withdrawal symptoms
311
221
187
150
121
98
70
37
15
2
Tolerance
311
236
198
157
127
97
68
38
19
4
Smoke weekly
311
246
210
170
141
115
84
49
24
4
100 cigarettes
311
250
213
169
135
107
79
50
22
2
Smoke daily
311
251
223
182
145
116
92
55
28
2
ICD-10 dependent
311
259
229
189
160
128
97
58
29
3
* 36 subjects reported mental addiction, and 15 subjects reported physical addiction prior to initiation. These subjects were considered to be incident cases at time 0.
They contributed 0 person-months to the denominator in the computation of time at risk for developing selected milstone.
Months
Months to Cigarette Use Milestones
0
12
24
Smokes daily
23
Smokes monthly
9
Whole cigarette
3
Inhalation
2
Smokes weekly
Lifetime 100 cigs
19
36
48 Months
Onset of ND Symptoms
0
12
Cravings
5
Tolerance
14
Withdrawal
12
Smokes monthly
9
Whole cigarette
3
Inhalation
2
24
Smokes daily
23
Smokes weekly
Lifetime 100 cigs
19
36
48 Months
ICD-10 Tobacco
dependence
46
DANDY 2 study
 N=217 inhalers followed up to 4 years
 10% had lost autonomy within 2 days
 25% had lost autonomy within 30 days
 25% had lost autonomy by the time they were smoking 1
cigarette/month
 Students were smoking an average of 2 cigarettes/week
when addiction started.
 ICD-10 dependence as early as 13 days
DANDY 2 study
 Among subjects who had ever puffed on a cigarette a HONC
symptom increased the risk of progressing to daily smoking:
OR=196.
 Among subjects who had inhaled a HONC symptom
increased the risk of daily smoking: OR= 83.
New Zealand 10th Year Survey
 Three consecutive annual surveys 2002-2004
 24,995 current smokers
Percent with Diminished Autonomy
100
90
80
70
60
Girls
50
Boys
40
30
20
10
0
1
2
3-4
5-9
10 - 19
Lifetime Cigarette Consumption
20 - 99
>100
Loss of Autonomy in Relation to Smoking
Frequency
100
90
80
70
60
Boys
50
Girls
40
30
20
10
0
Less than monthly
Monthly
Weekly
Daily
Loss of Autonomy
100
90
80
Percent
70
60
50
40
30
20
10
0
Less than
monthly
Monthly
Weekly
Frequency of Smoking
Daily
100
90
80
70
Percent
60
50
40
30
20
10
0
1
2
3-4
5-9
10 -19
20 - 99
Lifetime Cigarette Consumption – actual data
Proportion with Lost Autonomy
Proportion Abstinent
>100
10th Year Survey
 Symptoms appear after one cigarette
 The process proceeds faster in girls
 It is well underway prior to daily use
Chicago Study
 35% of youth who had experienced a symptom of
dependence had done so within one month of initiation.
The First Case Series on Nicotine Addiction
 Abstinence provokes a desire to smoke in all addicted
smokers.
 How would you describe this need to someone who has
never smoked?
 Wanting
 Craving
 Needing
Wanting
 Wanting is a mild transient desire to smoke that is easily
ignored.
 “It’s like wanting some chocolate.”
Craving
 Craving is more intense than wanting and intrudes upon the
person’s thoughts.
 It is more persistent and is difficult to ignore.
 “I feel like someone inside of me is really telling me to
smoke.”
 Craving “just, like, pops in your head, like someone is
sending you a message.”
Craving
 Craving is like “being hungry, but instead of your stomach
saying it, it’s your brain…it’s just hungry, except for a
cigarette.”
 “I’ve felt, like, physical urges, like just craving them, but not
like a mental thing.”
Needing
 Needing is an intense and urgent desire to smoke that is
impossible to ignore. The individual must smoke to restore a
normal mental or physical state.
 “Pretty urgent… you need it and you can’t get your mind off it.”
 “You really want one.You know you need it. You know you’ll feel
normal after smoking, and you have to smoke to feel normal
again.”
When addiction first develops
 No withdrawal symptoms
 Wanting
 Wanting and Craving
 Wanting, Craving, and Needing
Clinical Staging of Nicotine Addiction
 Stage 1 No withdrawal symptoms
 Smokers can remain abstinent indefinitely without withdrawal symptoms.
 Stage 2 Wanting
 “If I go too long without smoking the first thing I will notice is a mild desire to
smoke that I can ignore.”
 Stage 3 Craving
 “If I go too long without smoking, the desire for a cigarette becomes so strong
that it is hard to ignore and it interrupts my thinking.”
 Stage 4 Needing
 “If I go too long without smoking, I just can’t function right, and I know I will
have to smoke just to feel normal again.”
Mean Adolescent HONC Scores by Stage
10
9
8
Score
7
6
5
4
3
2
1
0
Stage 1
Stage 2
Stage 3
Stage 4
Mean Adult HONC Scores by Stage
10
9
8
Score
7
6
5
4
3
2
1
0
Stage 1
Stage 2
Stage 3
Stage 4
Days Smoked per Month
by Stage (adults)
Days smoked per month
30
25
20
15
10
5
0
Stage 1
Stage 2
Stage 3
Stage 4
Number of Cigarettes Smoked
on Smoking Days (adults)
cigarettes smoked per day
14
12
10
8
6
4
2
0
Stage 1
Stage 2
Stage 3
Stage 4
The Latency to Withdrawal
 “A little light bulb goes off and it’s like, alright, time [to




smoke].”
The latency is the interval between smoking one cigarette
and wanting, craving, or needing another.
Latency-to-wanting
Latency-to-craving
Latency-to-needing
The Latency to Withdrawal
 At the onset of addiction the latency-to-withdrawal may be
longer than a week.
 Repeated tobacco use causes the latencies to shrink.
 The shortening of the latency drives the escalation in
smoking.
The Latency to Withdrawal
 After smoking for 6 weeks, a 16-year-old girl noticed a





Latency to Withdrawal of 2 days
which shortened to 4 hours by age 16½
…to 2 hours by age 17,
…to 1.5 hours by age 18,
…to 1 hour by age 19,
…and to 30 to 45 minutes by age 21.
The Latency to Withdrawal - Factors of 2
1) 1 week (1 cig/wk)
2) 3.5 days (2 cig/wk)
3) 42 hours
4) 21 hours
5) 11.5 hours
6) 5.6 hours
7) 2.8 hours
8) 1.4 hours
9) 42 minutes (1 ppd)
10) 21 minutes (2 ppd)
 In adolescents smoking 2
cigs/wk increases the risk
for heavy adult smoking
174 fold
Summary
 A Loss of Autonomy marks the onset of addiction.
 The addiction process begins with the first cigarette and
progresses rapidly.
 Addiction develops through the same sequence of Wanting,
Craving, Needing in all smokers.
 The addiction process is well underway in intermittent
smokers.
 The shortening of the Latency to Withdrawal drives the
escalation of smoking and explains why early symptoms are
powerful indicators of prognosis.