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 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 18.3 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.4 These smoking patterns increase the risk of developing tobacco-related disease later in life.1
The sensitization-homeostasis model was developed to explain nicotine addiction among adolescents.5 The model suggests that, for adolescents, signs of tobacco addiction may occur more rapidly at lower or more intermittent levels of consumption.6-8 A common sign of tobacco addiction is the loss of autonomy, where smokers find cessation and quitting attempts to be unpleasant or difficult.9 A way 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.8, 10-12 A large study 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.12 This study also found that diminished autonomy increases with increased frequency of tobacco use and with increasing lifetime use.12 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.13
Earlier US research using the HONC, 40% of young smokers aged 12–13 (followed up over 30 months) reported symptoms of dependence.14 In those who reported one or more symptoms of dependence, 18% did so soon after their first use.14 Girls were more likely to report symptoms of dependence than boys, and experienced them sooner after starting smoking14 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.15
Another 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.5, 9, 16 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.
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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. 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.
4. 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: http://www.ncbi.nlm.nih.gov/pubmed/22160800
5. 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
6. 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
7. 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
8. 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/
9. 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
10. 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
11. Prochaska JJ and Benowitz NL. The past, present, and future of nicotine addiction therapy. Annu Rev Med, 2016; 67:467-86. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5117107/
12. 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
13. 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
14. 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
15. 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:
16. 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