So you think you are a social smoker…
Who are you kidding?
Joseph R DiFranza, MD
Department of Family Medicine and Community Health
University of Massachusetts Medical School
What is a social smoker?
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Fewer than 5 cigarettes per day
May not smoke everyday
No symptoms of addiction
The girl who didn’t read the text book
Addiction

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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 an obligation, a loss of autonomy.
The Loss of Autonomy


When quitting requires an effort or involves
discomfort
The Hooked on Nicotine Checklist
Hooked on Nicotine Checklist

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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

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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
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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?
Prospective study of adolescents

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25% had lost autonomy within 30 days
25% had lost autonomy by the time they were
smoking 1 cigarette/month
10% had lost autonomy within 2 days
Students were smoking an average of 2
cigarettes/week when addiction started.
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 20 - 99
Lifetime Cigarette Consumption
≥ 100
Loss of Autonomy
100
90
80
Percent
70
60
50
40
30
20
10
0
Less than
monthly
Monthly
Weekly
Frequency of Smoking
Daily
The clinical data indicate that…

One cigarette must rapidly change the brain.
The neuroscience shows…
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The nicotine from one cigarette occupies
88% of the brain’s nicotinic receptors.
One dose of nicotine triggers the transcription
of at least 168 genes in the brain.
One dose stimulates an increase in the
number of brain nicotine receptors over night.
One dose initiates drug sensitization.
% Change in Distance Travelled
(% of Day 1)
Nicotine-Induced Behavioral Sensitization
900
850
800
750
700
Average of Nicotine animals (n=4)
Average of Control animals (n=4)
650
600
550
500
450
400
350
300
250
200
150
100
50
1
2
3
Day
4
5
6
A
1
1
5
B
2
2
2
3
3
4
4
7
5
7
6
6
5
PFC
2 Acg
3 Acc
4 VP
7
5
HP
6 VTA
7
VC
5%
4%
3%
2%
1%
0
C
-1%
-2%
-3%
-4%
-5%
The neuroscience shows…

Four doses of nicotine are enough to
increase the density of dendrites in brain
regions involved in addiction.
Before…
18
After …
19
The First Case Series on Nicotine Addiction

In all addicted smokers withdrawal triggers a
desire to smoke that compels them to use
tobacco
The First Case Series on Nicotine Addiction

How would you describe this need to
someone who has never smoked?
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
Wanting
Craving
Needing
Wanting

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Wanting is a mild transient desire to smoke
that is easily ignored.
“It’s like wanting some chocolate.”
Craving

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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
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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
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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
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No withdrawal symptoms
Wanting
Wanting and Craving
Wanting, Craving, and Needing
Clinical Staging of Nicotine Addiction

Stage 1 No withdrawal symptoms

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Stage 2 Wanting
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“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

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Smokers can remain abstinent indefinitely without withdrawal
symptoms.
“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
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“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
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At the onset of addiction the latency-to-wanting
may be longer than a month.
Smokers do not realize they are having
withdrawal symptoms.
With a half of life of 2 hours in the blood, how
can nicotine keep withdrawal at bay for weeks?
The neuroscience shows…
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One dose of nicotine increases noradrenaline synthesis
for at least a month.
One dose lowers activation thresholds for a month.
One dose affects tyrosine hydroxylase activity for a
month.
One dose in adolescence has measurable effects on
behavior during adulthood.
The Latency to Withdrawal
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At the onset of addiction the latency-to-wanting
may be longer than a month.
With repeated tobacco use tolerance develops
causing the latencies to shrink.
The shortening of the latency drives the
escalation in tobacco use.
The Latency to Withdrawal
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After smoking for 6 weeks, a 16-year-old girl
noticed a latency-to-craving of 2 days
which shortened to 4 hours by age 161/2,
…to 2 hours by age 17,
…to 1.5 hours by age 18,
…to 1 hour by age 19,
…and to 30-45 minutes by age 21.
The Latency to Withdrawal-factors of 2
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
4 weeks
2 weeks
1 week (1 cig/wk)
3.5 days (2 cig/wk)
42 hours
21 hours
11.5 hours
5.6 hours
2.8 hours
1.4 hours
42 minutes (1 ppd)
21 minutes (2 ppd)
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At age 12, smoking 2 cigs/wk
increases the risk for heavy
adult smoking 174 fold
The Vicious Cycle
Tobacco use
Shortening
latencies
Neurological
adaptations
Symptoms of Wanting,
Craving, Needing
The Blind Men and the Elephant.
The Blind Men and the Elephant
- John Godfrey Saxe
And so these men of Indostan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong.
Though each was partly in the right,
They all were in the wrong!
The committee of blind researchers describe
the multiple domains of addiction.
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Craving
Withdrawal
Regularity of use
Spending too much time smoking
Giving up other activities in order to smoke
Smoking immediately upon arising from bed
Smoking more than intended
Tolerance
All of the so-called domains of nicotine addiction
are the same elephant: Wanting, Craving and
Needing and the Latency to Withdrawal.
The Latency-factors of 2
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
4 weeks
2 weeks
1 week (1 cig/wk)
3.5 days (2 cig/wk)
42 hours
21 hours (daily smoking)
11.5 hours
5.6 hours
2.8 hours
1.4 hours
42 minutes (1 ppd)
21 minutes (2 ppd)
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Bums cigarettes at parties
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Smokes only on weekends
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First time buying cigarettes
Smokes before work or school
Smokes upon awakening
Uses lunch break to smoke
Smoking in the bathroom

Smokes in middle of the night
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I am careful not to run out. I make sure I have
enough cigarettes for the next morning (adults)
100
90
% Endorsed
80
70
60
50
40
30
20
10
0
Stage 1
Stage 2
Stage 3
Stage 4
% Endorsed
To some degree I have to plan my schedule
around when I will be able to smoke (adults)
100
90
80
70
60
50
40
30
20
10
0
Stage 1
Stage 2
Stage 3
Stage 4
How the Latencies affect smokers’ behaviors

Required cigarettes and elective cigarettes
How can I miss you when you won’t go away?
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
4 weeks
2 weeks
1 week
3.5 days
42 hours
21 hours (1 cpd)
11.5 hours
5.6 hours
2.8 hours
1.4 hours
42 minutes
21 minutes
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A person who starts smoking one
cigarette per day will not experience
withdrawal until their latency shortens to
less than a day.
Asymptomatic addiction
Smokers are late to recognize addiction

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“I’m not addicted, I only smoke once a week
when I feel the urge.”
“I can’t be addicted because I don’t need to
smoke everyday.”
“I can’t be addicted because I never buy my
own cigarettes.”
Smokers don’t recognize their addiction until
stage 3 or 4, or when the latency shortens to
less than 24 hours.
Nondaily smokers relapse at the same
rate as daily smokers

Over 90% fail at their first attempt to quit
smoking.
Summary

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The neurological changes triggered by
nicotine begin with the first dose.
Symptoms of a compulsion to use tobacco
develop through 4 stages.
The shortening of the latency to withdrawal
drives the progression to daily smoking.
Most social smokers are addicted and don’t
know it.
So you think you are a social smoker…
Who are you kidding?
Joseph R DiFranza, MD
Department of Family Medicine and Community Health
University of Massachusetts Medical School