How does Nicotine Addiction Start? Data from the Year 10 Survey

Joseph R DiFranza, MDDepartment of Family Medicine and Community HealthUniversity of Massachusetts Medical School

How does Nicotine Addiction Start?Data from the Year 10 Survey

The Hound of the Baskervilles Arthur Conan Doyle-1902The more outr 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 HolmesThe girl who didnt read the text bookThe Development and Assessment of Nicotine Dependence in Youth (DANDY-1)681 7th year students were followed over 3 years

Addiction as a Loss of AutonomyFrom 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 Checklist1) Have you ever tried to quit, but couldnt? 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 Checklist4) 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 ChecklistWhen you haven't smoked for a while do you7) 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)Start: 0%AbstinentEnd: 72%Start: 60%SporadicEnd: 14%Start: 30%OccasionalEnd: 5%Start: 9%DailyEnd: 4%Start: 0%EscalatingEnd: 2%Start: 2%IntermittentEnd: 4%0.420.140.530.210.040.250.070.050.070.110.050.020.02Trajectory of Use Before HONC SymptomsTrajectory of Use After HONC SymptomsStart: 0%AbstinentEnd: 21%Start: 40%SporadicEnd: 6%Start: 46%OccasionalEnd: 15%Start: 14%DailyEnd: 22%Start: 0%EscalatingEnd: 26%Start: 0%IntermittentEnd: 10%0.150.130.440.360.200.270.460.160.230.180.290.100.150.060.140.050.03Nicotine Dependence in Teens StudyQuebecOngoing 13-year longitudinal cohortn=1293 grade 7 students (age 12-13) in 10 high schools

14We used Kaplan-Meier survival analysis to compute the cumulative probability of attaining each milestone according to time (months) from first puff

15We then mapped the sequence and timing of the 12 milestones, according to time at which the cumulative probability of attaining the milestone was 25%

Months to Cigarette Use Milestones 12 24 36 48 MonthsInhalation 2Whole cigarette 3 0Smokes monthly9Smokes weeklyLifetime 100 cigs19Smokes daily23Onset of ND Symptoms 12 24 36 48 MonthsInhalation 2Whole cigarette 3 0Smokes monthly9Withdrawal 12Smokes daily23Cravings5Smokes weeklyLifetime 100 cigs19ICD-10 Tobacco dependence 46 Tolerance 14DANDY 2 studyN=217 inhalers followed up to 4 years10% had lost autonomy within 2 days25% had lost autonomy within 30 days25% had lost autonomy by the time they were smoking 1 cigarette/monthStudents were smoking an average of 2 cigarettes/week when addiction started.ICD-10 dependence as early as 13 days

DANDY 2 studyAmong 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 SurveyThree consecutive annual surveys 2002-200424,995 current smokers

0102030405060708090100123 - 45 - 910 - 1920 - 99>100Lifetime Cigarette ConsumptionPercent with Diminished AutonomyGirlsBoysLoss of Autonomy in Relation to Smoking Frequency

0102030405060708090100123 - 45 - 910 -1920 - 99>100Lifetime Cigarette Consumption actual dataPercentProportion with Lost AutonomyProportion Abstinent 10th Year SurveySymptoms appear after one cigaretteThe process proceeds faster in girlsIt is well underway prior to daily useChicago Study35% of youth who had experienced a symptom of dependence had done so within one month of initiation.The First Case Series on Nicotine AddictionAbstinence provokes a desire to smoke in all addicted smokers.How would you describe this need to someone who has never smoked? WantingCravingNeedingWantingWanting is a mild transient desire to smoke that is easily ignored. Its like wanting some chocolate.CravingCraving is more intense than wanting and intrudes upon the persons 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.

CravingCraving is like being hungry, but instead of your stomach saying it, its your brainits just hungry, except for a cigarette. Ive felt, like, physical urges, like just craving them, but not like a mental thing. NeedingNeeding 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 cant get your mind off it.You really want one. You know you need it. You know youll feel normal after smoking, and you have to smoke to feel normal again. When addiction first developsNo withdrawal symptomsWanting Wanting and Craving Wanting, Craving, and NeedingClinical Staging of Nicotine AddictionStage 1 No withdrawal symptomsSmokers 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 cant function right, and I know I will have to smoke just to feel normal again.

34

35

36

37The Latency to WithdrawalA little light bulb goes off and its like, alright, time [to smoke]. The latency is the interval between smoking one cigarette and wanting, craving, or needing another.Latency-to-wantingLatency-to-cravingLatency-to-needingThe Latency to WithdrawalAt 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 WithdrawalAfter smoking for 6 weeks, a 16-year-old girl noticed a Latency to Withdrawal of 2 dayswhich shortened to 4 hours by age 16to 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 21 week (1 cig/wk)3.5 days (2 cig/wk)42 hours21 hours11.5 hours5.6 hours2.8 hours1.4 hours42 minutes (1 ppd) 21 minutes (2 ppd)

In adolescents smoking 2 cigs/wk increases the risk for heavy adult smoking 174 foldSummaryA 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.

Chart146668295

Frequency of SmokingPercentLoss of Autonomy

Sheet1Less than monthly46Monthly66Weekly82Daily95

Sheet1

Frequency of SmokingPercentLoss of Autonomy

Sheet2

Sheet3