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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.

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how does nicotine addiction start data from the year 10 survey

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 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 development and assessment of nicotine dependence in youth dandy 1
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
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
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 checklist1
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 checklist2
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 11
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 12
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%

Sporadic

End: 14%

Start: 30%

Occasional

End: 5%

Start: 9%

Daily

End: 4%

Start: 0%

Escalating

End: 2%

0.25

0.05

0.02

0.02

0.07

0.11

0.53

0.21

0.42

0.14

0.04

0.05

Start: 0%

Abstinent

End: 72%

Trajectory of Use Before HONC Symptoms
trajectory of use after honc symptoms

Start: 0%

Intermittent

End: 10%

0.03

0.16

0.14

0.15

0.10

Start: 40%

Sporadic

End: 6%

Start: 46%

Occasional

End: 15%

Start: 14%

Daily

End: 22%

Start: 0%

Escalating

End: 26%

0.27

0.46

0.29

0.05

0.18

0.23

0.44

0.06

0.36

0.15

0.20

0.13

Start: 0%

Abstinent

End: 21%

Trajectory of Use After HONC Symptoms
nicotine dependence in teens study
Nicotine Dependence in Teens Study
  • Quebec
  • Ongoing 13-year longitudinal cohort
  • n=1293 grade 7 students (age 12-13) in 10 high schools
months to cigarette use milestones
Months to Cigarette Use Milestones

12 243648 Months

0

Smokes daily

23

Smokes monthly

9

Smokes weekly

Lifetime 100 cigs

19

Whole cigarette

3

Inhalation

2

onset of nd symptoms
Onset of ND Symptoms

12 243648 Months

0

Tolerance

14

Cravings

5

Smokes daily

23

Withdrawal

12

ICD-10 Tobacco

dependence

46

Smokes monthly

9

Smokes weekly

Lifetime 100 cigs

19

Whole cigarette

3

Inhalation

2

dandy 2 study
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 study1
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 10 th year survey
New Zealand 10th Year Survey
  • Three consecutive annual surveys 2002-2004
  • 24,995 current smokers
slide21

100

90

80

70

60

Girls

50

Percent with Diminished Autonomy

Boys

40

30

20

10

0

1

2

3 - 4

5 - 9

10 - 19

20 - 99

>100

Lifetime Cigarette Consumption

slide24

100

90

80

70

60

50

Percent

40

30

20

10

0

1

2

3 - 4

5 - 9

10 -19

20 - 99

>100

Lifetime Cigarette Consumption – actual data

Proportion with Lost Autonomy

Proportion Abstinent

10 th year survey
10th Year Survey
  • Symptoms appear after one cigarette
  • The process proceeds faster in girls
  • It is well underway prior to daily use
chicago study
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
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
  • Wanting is a mild transient desire to smoke that is easily ignored.
  • “It’s like wanting some chocolate.”
craving
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.”
craving1
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
  • 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
When addiction first develops
  • No withdrawal symptoms
  • Wanting
  • Wanting and Craving
  • Wanting, Craving, and Needing
clinical staging of nicotine addiction
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.”
the latency to withdrawal
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 withdrawal1
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 withdrawal2
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
The Latency to Withdrawal - Factors of 2
  • 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)
  • In adolescents smoking 2 cigs/wk increases the risk for heavy adult smoking 174 fold
summary
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.