6.7 Addiction and the adolescent smoker

Most smokers begin smoking during their teens.1 A person who smokes cigarettes in adolescence is more likely to progress to daily smoking and become addicted than someone who experiments with cigarettes in adulthood.2 About three-quarters of teenagers who smoke regularly continue to smoke as adults. Those who start smoking as teenagers smoke for longer and more heavily, on average, than those who start smoking at a later age.3 These smoking patterns increase the risk of developing tobacco-related disease later in life.1

Signs of tobacco addiction may occur more rapidly in adolescent smokers at lower or more intermittent levels of consumption.4–6 US research using the Hooked on Nicotine Checklist ('HONC'—see Section 6.5) has shown that adolescents lose autonomy over their smoking on average within two months of the onset of smoking. The median amount of smoking at which symptoms of dependency were reported was two cigarettes per day, smoked on one day per week. Those adolescent smokers who smoked only occasionally were less likely to develop any HONC symptoms and were more easily able to quit smoking. The frequency of smoking increased after one or more symptoms of dependency were reported. Although smokers may have recognised the emergence of dependence symptoms and attempted to quit, they found quitting more difficult than those who did not smoke regularly.7

In US research using the HONC, 40% of young smokers aged 12–13 (followed up over 30 months) reported symptoms of dependence.8 In those who reported inhaling tobacco smoke, 58% reported symptoms of dependence. In those who reported one or more symptoms of dependence, 18% did so soon after their first use, 33% did so when smoking once monthly, 49% when smoking weekly, and 70% did so before they started smoking daily.8 Girls were more likely to report symptoms of dependence than boys, and experienced them sooner after starting smoking (21 days for girls compared to 183 days for boys).8 Adolescents who experienced nausea, dizziness or relaxation when they initially smoked a cigarette were much more likely to develop a HONC symptom than those who did not.7 Other US research shows that younger smokers (aged 10–18) are twice as likely to report that 'it's really hard to quit' than older smokers (aged 19–22) who smoke the same amount.9

One hypothesis to explain the younger smokers' increased susceptibility to tobacco addiction is the greater immaturity of the adolescent brain, which allows nicotine to have more disruptive effects on brain function.3, 10, 11 There is a significant gap between the reality of adolescent addiction to nicotine and young smokers' beliefs about their ability to control their use of the substance. This is discussed in Section 6.11.

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1. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/1994/index.htm/

2. Moolchan E, Parzynski C, Jaszyna-Gasior M, Collins C, Leff M and Zimmerman D. A link between adolescent nicotine metabolism and smoking topography. Cancer Epidemiology, Biomarkers and Prevention 2009;18(5):1578–83. Available from: http://cebp.aacrjournals.org/cgi/content/full/18/5/1578

3. Sargent J and DiFranza J. Tobacco control for clinicians who treat adolescents. CA: A Cancer Journal for Clinicians 2003;53(2):102–23. Available from: http://caonline.amcancersoc.org/cgi/reprint/53/2/102

4. McNeill AD. The development of dependence on smoking in children. British Journal of Addiction 1991;86(5):589–92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1859924

5. O'Loughlin J, DiFranza J, Tyndale RF, Meshefedjian G, McMillan-Davey E, Clarke PB, et al. Nicotine-dependence symptoms are associated with smoking frequency in adolescents. American Journal of Preventive Medicine 2003;25(3):219–25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14507528

6. Doubeni C, Reed G and Difranza J. Early course of nicotine dependence in adolescent smokers. Pediatrics 2010;125(6):1127–33. Available from: http://pediatrics.aappublications.org/cgi/reprint/peds.2009-0238v1

7. Wellman R, DiFranza J, Savageau J and Dussault G. Short term patterns of early smoking acquisition. Tobacco Control 2004;13(3):251–7. Available from: http://tobaccocontrol.bmj.com/cgi/reprint/13/3/251.pdf

8. DiFranza JR, Savageau JA, Rigotti NA, Fletcher K, Ockene JK, McNeill AD, et al. Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study. Tobacco Control 2002;11(3):228–35. Available from: http://tc.bmjjournals.com/cgi/content/abstract/11/3/228

9. Barker D. Reasons for tobacco use and symptoms of nicotine withdrawal among adolescent and young adult tobacco users - United States, 1993. Morbidity and Mortality Weekly Reports 1994;43(41):745–50. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/00032964.htm

10. DiFranza J and Wellman R. A sensitisation-homeostasis model of nicotine craving, withdrawal and tolerance: integrating the clinical and basic science literature. Nicotine and Tobacco Research 2005;7(1):9–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15804674

11. DiFranza JR, Savageau JA, Fletcher K, Ockene JK, Rigotti NA, McNeill AD, et al. Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study. Archives of Pediatrics and Adolescent Medicine 2002;156(4):397–403. Available from: http://archpedi.ama-assn.org/cgi/content/full/156/4/397

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