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Joseph R DiFranza, MD Department of Family Medicine and Community Health University of Massachusetts Medical School How does Nicotine Addiction Start? Data from the Year 10 Survey Slide 2 The Hound of the Baskervilles Arthur Conan Doyle-1902 The 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 Holmes Slide 3 The girl who didnt read the text book Slide 4 The Development and Assessment of Nicotine Dependence in Youth (DANDY-1) 681 7 th year students were followed over 3 years Slide 5 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 Slide 6 Hooked on Nicotine Checklist 1) 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? Slide 7 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? Slide 8 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? Slide 9 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. Slide 10 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) Slide 11 Start: 0% Abstinent End: 72% Start: 60% Sporadic End: 14% Start: 30% Occasional End: 5% Start: 9% Daily End: 4% Start: 0% Escalating End: 2% Start: 2% Intermittent End: 4% 0.42 0.14 0.53 0.21 0.04 0.25 0.07 0.05 0.07 0.11 0.05 0.02 Trajectory of Use Before HONC Symptoms Slide 12 Trajectory of Use After HONC Symptoms Start: 0% Abstinent End: 21% Start : 40% Sporadic End: 6% Start: 46% Occasional End: 15% Start: 14% Daily End: 22% Start: 0% Escalating End: 26% Start: 0% Intermittent End: 10% 0.15 0.13 0.44 0.36 0.20 0.270.46 0.16 0.23 0.18 0.29 0.10 0.15 0.06 0.14 0.05 0.03 Slide 13 Nicotine Dependence in Teens Study Quebec Ongoing 13-year longitudinal cohort n=1293 grade 7 students (age 12-13) in 10 high schools Slide 14 Slide 15 Slide 16 Months to Cigarette Use Milestones 12 24 36 48 Months Inhalation 2 Whole cigarette 3 0 Smokes monthly 9 Smokes weekly Lifetime 100 cigs 19 Smokes daily 23 Slide 17 Onset of ND Symptoms 12 24 36 48 Months Inhalation 2 Whole cigarette 3 0 Smokes monthly 9 Withdrawal 12 Smokes daily 23 Cravings 5 Smokes weekly Lifetime 100 cigs 19 ICD-10 Tobacco dependence 46 Tolerance 14 Slide 18 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 Slide 19 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. Slide 20 New Zealand 10 th Year Survey Three consecutive annual surveys 2002-2004 24,995 current smokers Slide 21 0 10 20 30 40 50 60 70 80 90 100 123 - 45 - 910 - 1920 - 99>100 Lifetime Cigarette Consumption Percent with Diminished Autonomy Girls Boys Slide 22 Loss of Autonomy in Relation to Smoking Frequency Slide 23 Slide 24 0 10 20 30 40 50 60 70 80 90 100 123 - 45 - 910 -1920 - 99>100 Lifetime Cigarette Consumption actual data Percent Proportion with Lost AutonomyProportion Abstinent Slide 25 10 th Year Survey Symptoms appear after one cigarette The process proceeds faster in girls It is well underway prior to daily use Slide 26 Chicago Study 35% of youth who had experienced a symptom of dependence had done so within one month of initiation. Slide 27 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 Slide 28 Wanting Wanting is a mild transient desire to smoke that is easily ignored. Its like wanting some chocolate. Slide 29 Craving Craving 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. Slide 30 Craving Craving 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. Slide 31 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 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. Slide 32 When addiction first develops No withdrawal symptoms Wanting Wanting and Craving Wanting, Craving, and Needing Slide 33 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 cant function right, and I know I will have to smoke just to feel normal again. Slide 34 Slide 35 Slide 36 Slide 37 Slide 38 The Latency to Withdrawal A 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-wanting Latency-to-craving Latency-to-needing Slide 39 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. Slide 40 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 16 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. Slide 41 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 Slide 42 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.