Initial Puff Starts to Trigger Nicotine Addiction

MONTREAL, July 31 -- The first puff on a cigarette may be enough to trigger the start of nicotine dependence, which grows stronger with every additional puff, according to investigators here.

Nicotine addiction has been considered a slow process, with adolescents sneaking a puff or two occasionally over the course of a year or more. But Jennifer O'Loughlin, Ph.D., and colleagues at McGill University and at the city's Public Health Agency found that the process is much quicker.

As soon as a month and half after lighting up their first cigarette, 25% of adolescent smokers are likely to advance from puffing to inhaling, they reported in the Aug. 1 issue of the Canadian Medical Association Journal. Moreover, a number of key addiction milestones such as cravings and physical addiction are evident in less than five months.

The authors followed 1,293 seventh grade students prospectively every three to four months for five years. One hundred and eighty-one girls and 130 boys initiated smoking during the follow-up.

The natural history of nicotine addiction, according to the authors, begins with the first puff followed by smoking a whole cigarette and reported mental addiction followed by "cravings, self-reported physical addiction, monthly smoking, withdrawal symptoms, tolerance, lifetime consumption of 100 cigarettes, weekly smoking, and daily smoking."

But conversion to ICD-10 tobacco dependence "was a relatively late and infrequent occurrence."

Nonetheless, the authors contend that their data suggested that tobacco dependence begins with the first puff and warned that pre-teen smokers "may not recognize the symptoms they experience as related to nicotine dependence, and consequently they may view tobacco control messages as irrelevant."

Dr. O'Loughlin and colleagues said this adolescent ennui may be overcome by making students, parents and physicians aware that "symptoms of nicotine dependence can manifest long before regular smoking and that, once cravings are experienced, the likelihood of progression to daily use and tobacco dependence is greatly increased."

The authors cautioned that the natural history detailed here refers to adolescents who initiated smoking as school students. Smokers who start later in life may have a different pattern of progression. Moreover, they note that they relied on self reports, which may be subject to recall bias, a limitation that they attempted to control by collecting data every three months.

Jonathan D. Klein, M.D., director of the American Academy of Pediatrics, wrote in an editorial that the report by Dr. O'Loughlin and colleagues "should strengthen the resolve of public health authorities and local government to prevent children and youth from starting to smoke in the first place and to protect them against exposure to smoking, either in the form of second-hand smoke or pro-smoking imagery in the media."