6.13Addiction and the adolescent smoker

Last updated: May 2023 

Suggested citation: Hall, W., Gartner, C., Vittiglia., A., and Hanley-Jones, S. 6.13 Addiction and the adolescent smoker. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors].  Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from: https://www.tobaccoinaustralia.org.au/chapter-6-addiction/6-13-addiction-and-the-adolescent-smoker 

Most smokers begin smoking during adolescence.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.2,3 About three-quarters of teenagers who smoke regularly continue to smoke as adults. Among adults who are daily smokers, nearly all experience their first cigarette by the age of 18.4 Those who begin smoking as teenagers are more likely to progress to heavier smoking and dependence than those who start smoking at a later age.5 Adolescents who smoke are also more likely to develop a shorter ‘time to first cigarette soon after waking’ measure than those who initiate smoking later in life.6 These smoking patterns increase the risk of developing tobacco-related disease later in life.1

The sensitisation-homeostasis model was developed to explain nicotine addiction among adolescents.7 The model suggests that, for adolescents, signs of tobacco addiction may occur more rapidly at lower or more intermittent levels of consumption.8-10 A common sign of tobacco addiction is the loss of autonomy, where smokers find cessation and quitting attempts to be unpleasant or difficult.11 A method to measure loss of autonomy is by using the Hooked on Nicotine Checklist (‘HONC’ – see Section 6.12). Research using the HONC has demonstrated that adolescents lose autonomy over their smoking soon after the onset of smoking.10,12-14 A large New Zealand study with participants aged 14 – 15 found that diminished autonomy can appear shortly after the onset of intermittent tobacco use, with 25% - 30% indicating diminished autonomy after just one cigarette.14 This study also found that diminished autonomy increases with increased frequency of tobacco use and with increasing lifetime use.14 A 2017 meta-analysis discovered that over two-thirds of people who try one cigarette become, at least temporarily, daily smokers, providing more robust evidence to support early intervention strategies to reduce experimentation among adolescents.15

Earlier US research using the HONC found that 40% of young smokers aged 12–13 (followed up over 30 months) reported symptoms of dependence.16 In those who reported one or more symptoms of dependence, 18% did so soon after their first use.16 Girls were more likely to report symptoms of dependence than boys, and experienced them sooner after starting smoking.16 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.17

Research in 2020, using a large nationally representative sample of US adolescents, found those aged 12–17 years old were 1.5 times more likely to develop a shorter ‘time to first tobacco cigarette soon after waking’ measure within six months of initiating smoking, compared to those who started smoking after the age of 18.  In adolescents who started smoking between the ages of 12 and 17, about 5.2% developed the habit of smoking shortly after waking up. For those who started smoking between the ages of 18 and 21, the percentage was lower, at around 3.7%.6

The immaturity of the adolescent brain may also contribute to the increased susceptibility of younger smokers to tobacco addiction, allowing nicotine to have more disruptive effects on brain function.7,11,18

An observational cohort study, spanning 2016 to 2021, explored the associations between the initiation of tobacco use in children and neurocognitive performance. The study found that children using tobacco scored lower on the Picture Vocabulary Tests and the crystallised cognition composite score, compared to their non-tobacco using counterparts. These results were consistent in both initial assessments and two-year follow-ups, indicating a potential decrease in cognitive performance related to tobacco use. Structural Magnetic Resonance Imaging (MRI) scans revealed a significant reduction in whole-brain measures—such as cortical area and volume—in children using tobacco compared to those not using. This trend was also observed at both the initial assessment and during follow-ups. The scans identified reduced cortical areas and volumes across multiple regions of the frontal, parietal, and temporal lobes. The study concluded that the initiation of tobacco use in late childhood could potentially lead to negative impacts on cognitive performance and brain structure.19

Even small amounts of tobacco smoking in adolescents has been linked to changes in the brain. According to longitudinal research in 2019, exposure to tobacco smoking in adolescents, even at low doses, or ‘light smoking’, was linked to a reduction in volume of the ventromedial prefrontal cortex (the area of the brain involved in processing information related to emotions and decision-making) as well as altered neuronal connectivity in the corpus callosum (potentially impacting communication between the brains two hemispheres). The research also indicated that nicotine, rather than other chemicals in cigarettes, may be linked to these changes, raising concerns about effects on brain function of use of nicotine containing e-cigarettes and other emerging products containing nicotine.20

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 6.14.

Relevant news and research

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1. US Department of Health and Human Services. Preventing Tobacco use among youth and young adults: A report of the Surgeon General. Atlanta GA: National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2012. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22876391.

2. Moolchan E, Parzynski C, Jaszyna-Gasior M, Collins C, Leff M, et al. 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. Ebrahimi Kalan M, Bahelah R, Bursac Z, Ben Taleb Z, DiFranza JR, et al. Predictors of nicotine dependence among adolescent waterpipe and cigarette smokers: A 6-year longitudinal analysis. Drug and Alcohol Dependence, 2020; 217:108346. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33075692

4. US Department of Health and Human Services, The health consequences of smoking--50 years of progress : A report of the Surgeon General.  Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf.

5. Dierker L, Swendsen J, Rose J, He J, and Merikangas K. Transitions to regular smoking and nicotine dependence in the Adolescent National Comorbidity Survey (NCS-A). Annals of Behavioral Medicine, 2012; 43(3):394-401. Available from: https://academic.oup.com/abm/article/43/3/394/4561581

6. Xue W, Lopez-Quintero C, and Anthony JC. 'Time to first tobacco cigarette soon after waking' occurs more often among underage newly incident smokers in the United States, 2004-2017. Addictive Behaviors, 2020; 111:106535. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32712495

7. 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

8. 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

9. O'Loughlin J, DiFranza J, Tyndale RF, Meshefedjian G, McMillan-Davey E, 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

10. Doubeni C, Reed G, and Difranza J. Early course of nicotine dependence in adolescent smokers. Pediatrics, 2010; 125(6):1127-33. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079339/

11. DiFranza JR, Savageau JA, Fletcher K, Ockene JK, Rigotti NA, 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: https://www.ncbi.nlm.nih.gov/pubmed/11929376

12. Ursprung WW and DiFranza JR. The loss of autonomy over smoking in relation to lifetime cigarette consumption. Addictive Behaviors, 2010; 35(1):14–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19717241

13. Prochaska JJ and Benowitz NL. The past, present, and future of nicotine addiction therapy. Annual Review of Medicine, 2016; 67:467-86. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5117107/

14. Scragg R, Wellman R, Laugesen M, and DiFranza J. Diminished autonomy over tobacco can appear with the first cigarettes. Addictive Behaviors, 2008; 33(5):689–98. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18207651

15. Birge M, Duffy S, Miler JA, and Hajek P. What proportion of people who try one cigarette become daily smokers? A meta-analysis of representative surveys. Nicotine & Tobacco Research, 2017:ntx243. Available from: http://dx.doi.org/10.1093/ntr/ntx243

16. DiFranza JR, Savageau JA, Rigotti NA, Fletcher K, Ockene JK, 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

17. 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

18. 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: https://www.ncbi.nlm.nih.gov/pubmed/12691267

19. Dai HD, Doucet GE, Wang Y, Puga T, Samson K, et al. Longitudinal assessments of neurocognitive performance and brain structure associated with initiation of Tobacco use in children, 2016 to 2021. JAMA Network Open, 2022; 5(8):e2225991. Available from: https://pubmed.ncbi.nlm.nih.gov/35947383/

20. Chaarani B, Kan KJ, Mackey S, Spechler PA, Potter A, et al. Low smoking exposure, the adolescent brain, and the modulating role of CHRNA5 polymorphisms. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31072760