How does Nicotine Addiction Start?

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.