Elsevier

Drug and Alcohol Dependence

Volume 91, Issue 1, 2 November 2007, Pages 26-39
Drug and Alcohol Dependence

On the development of nicotine dependence in adolescence

https://doi.org/10.1016/j.drugalcdep.2007.04.011Get rights and content

Abstract

Little is known about the natural history of drug dependence. This article describes the development and predictors of DSM-IV nicotine dependence in adolescence when tobacco use is initiated. In a two-stage design, a survey was administered to 6th–10th graders in the Chicago Public Schools to select a cohort of adolescents. Household interviews were conducted with adolescents five times and with one parent (predominantly mothers) three times over 2 years. The analytical sample includes 353 youths, who started using tobacco within 12 months preceding Wave 1 or between Waves 1–5. Survival analysis estimated latency to individual DSM-IV nicotine dependence criteria and the full dependence syndrome. Twenty-five percent of youths experienced the syndrome within 23 months of tobacco use onset. Tolerance, impaired control and withdrawal were experienced most frequently. Youths who developed full dependence experienced their first symptom faster after tobacco use onset than those who experienced only one criterion through the end of the observation period. Cox proportional hazards models estimated the importance of time-constant and time-varying sociodemographic, tobacco and other drug use, parental and peer smoking, social psychological and biological risk factors for experiencing the first criterion and the full syndrome. Pleasant initial sensitivity to tobacco and number of cigarettes smoked the prior month predicted both outcomes. Parental dependence predicted the full syndrome. Significant covariates were generally the same across gender and racial/ethnic subgroups. The predictive significance of the initial smoking experience and parental dependence highlight the potential importance of genetic factors in the etiology of nicotine dependence.

Introduction

Most of our knowledge about substance dependence derives from clinical studies of individuals in treatment or epidemiological studies of the general adult population. The majority are cross-sectional studies in which individuals are identified much after they have become dependent. Identifying the period of risk for onset of dependence and understanding the nature of the transition from onset to dependence is crucial to the development of prevention and intervention programs. Tobacco use provides a useful model for the developmental study of the transition to drug dependence, since many drugs of abuse share the same neurobiological processes (Hyman et al., 2006). Smoking onset takes place in adolescence; initiation is mostly complete by the late teens, with 90% of smokers reporting that they first tried smoking by the age of 18; early onset is related to chronic use and nicotine dependence in adulthood; and tobacco is the most addictive of recreational substances, with the exception of heroin (Breslau et al., 1993a, Breslau and Peterson, 1996, Chabrol et al., 2000, Chassin et al., 1996, Flint and Novotny, 1998, Giovino, 1999, Giovino et al., 1995, Johnson et al., 2004, Kandel, 2003, Kandel and Chen, 2000, Kandel and Yamaguchi, 1993; Substance Abuse and Mental Health Services Administration, 2005).

Prospective longitudinal data are needed starting in adolescence to study the developmental course of nicotine dependence. Adolescents experience symptoms of nicotine dependence (Centers for Disease Control, 1994; Colby et al., 2000, DiFranza et al., 2000, DiFranza et al., 2002, Fergusson et al., 1996, Kandel et al., 2005, Karp et al., 2006, McNeill et al., 1986, Nelson and Wittchen, 1998, O’Loughlin et al., 2002, O’Loughlin et al., 2003, O’Loughlin et al., 2004, Prokhorov et al., 1998, Prokhorov et al., 2001, Prokhorov et al., 2005, Rojas et al., 1998, Sledjeski et al., 2007, Stanton, 1995), although crude rates of dependence are lower among adolescents than adults (Andreski and Breslau, 1993, Anthony et al., 1994, Heishman et al., 1997, Kandel, 2003, Kandel et al., 1997, Kandel and Chen, 2000). Age-specific comparisons based on cross-sectional samples document that rates increase rapidly throughout adolescence up to age 18 when they stabilize (Kandel, 2003, Nelson and Wittchen, 1998).

In contrast to cigarette smoking, relatively little research has been conducted on the natural history of nicotine dependence and its predictors. Most prospective studies have not measured dependence, have not followed youths at closely enough spaced intervals to obtain adequate data on patterns of behavior and their predictors, have not assessed the timing and latency of the transition from experimental to dependent smoking, nor have they examined subgroup differences, in particular race/ethnic differences (Chassin et al., 1996, Choi et al., 1997, Fergusson et al., 1996, McNeill, 1991, Stanton, 1995, Stanton et al., 1991). Three recent exceptions include the 3-year follow-up by DiFranza et al., 2000, DiFranza et al., 2002 in two small Massachusetts cities of 7th graders contacted every 3 months, the 6-year follow-up by O’Loughlin et al. (Gervais et al., 2006, Karp et al., 2005, Karp et al., 2006, O’Loughlin et al., 2004) in Canada with a similar design of a cohort of 7th graders contacted every 3 months, and the 4-year annual follow-up of 9th graders in Northern Virginia by Audrain-McGovern et al., 2004a, Audrain-McGovern et al., 2004b, Audrain-McGovern et al., 2007. In each study, dependence was measured differently. DiFranza et al., 2000, DiFranza et al., 2002 used the HONC (Wheeler et al., 2004), O’Loughlin et al. (2002) the HONC and an ICD-10 based measure, Audrain-McGovern et al. (2007) used the mFTQ (Prokhorov et al., 1998). These studies have also focused on different aspects of the transition to nicotine dependence. DiFranza et al. (2002) examined latency from the onset of monthly smoking, defined as having smoked on two or more days within a 2-month period, to the onset of the first symptom of HONC dependence while O’Loughlin and colleagues (Gervais et al., 2006) examined the latency from the onset of the first cigarette puffed to the first onset of selected ICD-10 dependence symptoms as well as full dependence. Both Karp et al. (2006) and Audrain-McGovern et al. (2007) examined predictors of full dependence.

Latency from onset of smoking to dependence varies across studies, reflecting in part the different definitions of onset of smoking. DiFranza et al. (2002) reported that 50% of youths experienced their first HONC symptom within 54 days of the onset of monthly smoking, which occurred on average 486 days after the onset of smoking (DiFranza et al., 2002, p. 2). O’Loughlin and her colleagues (Gervais et al., 2006), who applied survival methods to determine the latency to various smoking behaviors after the first cigarette puffed, found that 25% of adolescent smokers experienced withdrawal within 11 months and full nicotine dependence within 40.6 months. The subjective experiences of “mental” and “physical” addiction were reported within a much shorter period of time, on average 2.5 months for mental addiction and 5.4 months for physical addiction.

In 2000, in a comprehensive review of cross-sectional and longitudinal studies, Mayhew et al. (2000) concluded that very few factors have been identified as unique predictors of transitions to onset, experimental smoking, regular smoking, or dependence. Since then, several studies have examined predictors of dependence in adolescence and early adulthood. We only consider prospective studies of adolescents that restricted their analyses to samples of smokers to ensure that predictors are unique to dependence and do not characterize smoking more generally. Thus, we do not review studies where those dependent were compared to all those not dependent, including subjects who never smoked (Elkins et al., 2006, Fergusson et al., 1996, Patton et al., 2005).

Factors identified as constituting risks for nicotine dependence in adolescence, once having smoked, include sociodemographic characteristics; history and extensiveness of smoking; other substance use; exposure to smokers in the proximate social environment, i.e., parents and peers; individual characteristics, such as psychiatric disorders, delinquency, and novelty seeking; and biological factors, such as initial sensitivity to nicotine, exposure to prenatal smoking, nicotine metabolism, in addition to genetic vulnerability.

Rates of nicotine dependence are higher among whites than minorities and among females than males among adolescents (Andreski and Breslau, 1993, Breslau et al., 1994, Breslau et al., 2001; DiFranza et al., 2002, Kandel, 2003, Kandel and Chen, 2000, Kandel et al., 1997, O’Loughlin et al., 2002) and young adults (Hu et al., 2006). In a sample of young adults, higher education, school enrollment and part-time employment were associated with lower rates of lifetime dependence (Hu et al., 2006).

Extensiveness of use predicts the onset and progression of dependence, and is associated with higher rates of dependence (Audrain-McGovern et al., 2007, Kandel and Chen, 2000, Karp et al., 2006, O’Loughlin et al., 2002, O’Loughlin et al., 2003). Earlier age at onset of smoking a whole cigarette (Audrain-McGovern et al., 2007, Breslau et al., 1994) and a shorter latency between onset and daily smoking are associated with higher rates of lifetime dependence (Hu et al., 2006). Use of substances other than tobacco, in particular marijuana, increases the risk of nicotine dependence (Audrain-McGovern et al., 2007, Timberlake et al., 2006).

Besides extensiveness of smoking, the best documented feature of nicotine dependence is its comorbidity with psychiatric disorders, especially depressive mood, anxiety, disruptive and personality disorders (Dierker et al., 2001, DiFranza et al., 2004b, Isensee et al., 2003, O’Loughlin et al., 2002, Rojas et al., 1998, Sonntag et al., 2000). This association among adolescents replicates findings among adults (Breslau et al., 1991, Breslau et al., 1993b, Breslau et al., 1994, Breslau et al., 2004, John et al., 2004, Kendler et al., 1993, Kessler, 2004). Less conventional behavior, such as delinquency, and personality factors, such as neuroticism and novelty seeking, are associated with higher rates of lifetime and current dependence (Breslau et al., 1994, Hu et al., 2006).

The association between parental smoking and child nicotine dependence is inconsistent across studies. Two studies reported that offspring had an increased risk of becoming regular smokers or nicotine dependent from adolescence to early adulthood when their mothers had ever smoked, had ever been daily smokers or dependent on nicotine (Hu et al., 2006, Lieb et al., 2003), although Lieb et al. (2003) found no association between maternal dependence with child dependence at baseline. Audrain-McGovern et al. (2007) found no association between household (parents and siblings) smoking and child dependence. In the absence of genetic assessment, parental dependence may index a genetic liability as well as a role model for smoking. As regards peers, association with smoking peers increases the risk of dependence (Audrain-McGovern et al., 2007, Hu et al., 2006).

Physiological factors also constitute important risk factors. A critical risk for nicotine dependence may derive from individual differences in sensitivity to nicotine resulting from genetic influences or intrauterine environmental exposure (Eissenberg and Balster, 2000, Madden et al., 1999, Perkins et al., 1996, Pomerleau, 1995, Pomerleau et al., 1998). The most sensitive individuals, who initially experience more positive or both more positive and negative effects, may be most likely to become dependent. They are more sensitive to the reinforcing effects of nicotine and develop tolerance more rapidly (Pomerleau et al., 1998). Several studies have now confirmed that initial pleasant smoking experiences are associated with subsequent dependence in adolescence (Audrain-McGovern et al., 2007, DiFranza et al., 2004a, Hu et al., 2006). However, DiFranza et al. (2004a) also found that the negative experience of nausea increased subsequent dependence, although other negative experiences, such as coughing and bad taste, reduced the risk of dependence. The initial sensitivity model is supported by genetic, biobehavioral human, and animal studies (Collins and Marks, 1991, Marks et al., 1991, Niaura et al., 2001, Overstreet, 1995, West and Russell, 1988).

Another risk factor may be prenatal maternal smoking, which predicts offspring nicotine dependence in adolescence (Lieb et al., 2003) and adulthood (Buka et al., 2003). Prenatal exposure may have direct effects expressed as an induced biological vulnerability to the addictive properties of nicotine (Abreu-Villaca et al., 2004, Benwell et al., 1988, Collins and Marks, 1989) and indirect effects manifested through nicotine induced behavioral problems during childhood, e.g., hyperactivity, conduct disorder (Fergusson et al., 1998, Fried, 1989, Griesler et al., 1998, Milberger et al., 1996, Orlebeke et al., 1997, Richardson and Tizabi, 1994, Vaglenova et al., 2004, Wakschlag et al., 1997, Weissman et al., 1999, Williams et al., 1998). These behaviors are well-documented risk factors for delinquency and substance use (Moffitt, 1993), particularly smoking (Barkley et al., 1990, Brown et al., 1996, Kollins et al., 2005, Lynskey and Fergusson, 1995) and nicotine dependence (Breslau et al., 1993a, Storr et al., 2004). Other biological factors, such as nicotine metabolism and genetic vulnerability, which constitute risk factors for dependence are not investigated in our study and are not discussed further.

This study describes the development of nicotine dependence in adolescence at the criterion and syndrome levels as defined by DSM-IV, as well as the risk factors for the transition to dependence following onset of tobacco use. We address three questions: (1) What is the time lag between the onset of tobacco use and the onset of individual criteria and the full syndrome of nicotine dependence in adolescence? (2) Does latency vary in different gender and racial/ethnic subgroups? (3) What factors affect the rates of transition to dependence? The analyses are based on a longitudinal cohort of recent adolescent tobacco users drawn from a school sample with closely spaced assessments, measures of tobacco use and symptoms of nicotine dependence, and putative risk and protective factors. These factors cover sociodemographic, social-psychological, parental and peer smoking, and biological domains. We have also examined level of pubertal development, a factor associated with smoking that has not been examined for dependence. Early pubertal development is positively associated with earlier smoking onset and higher rates of experimental and daily smoking, particularly among females (Bratberg et al., 2005, Harrell et al., 1998, Lanza and Collins, 2002, Martin et al., 2002, Wilson et al., 1994). The restriction to an analytical sample of smokers allows for the identification of risk and protective factors specific to nicotine dependence.

We tested the following hypotheses. The rate of transition from experimental smoking to nicotine dependence in adolescence will be higher among: (1) females than males; (2) whites than minorities; (3) those with high initial sensitivity to tobacco; (4) those who smoke extensively; (5) those who use other substances; (6) those with high levels of depression, anxiety and conduct problems; (7) those with a nicotine dependent parent; (8) those exposed to prenatal maternal smoking; (9) those at a higher stage of pubertal development.

Section snippets

Sample

The analyses are based on five waves of interviews with a subsample from a multi-ethnic longitudinal cohort of 1039 6th–10th graders from the Chicago Public Schools (CPS) and one of their parents, preferably mothers. A two-stage design was implemented to select efficiently the target sample for follow-up. In Phase I (spring 2003), 15,763 students in grades 6–10 were sampled from 43 public schools in the CPS. The sample was designed to provide approximately equal numbers of adolescents among the

Descriptive analyses

At Wave 1, adolescents in the analytical sample were on average 14.0 years old (S.D. = 1.3), range 11–17 years; 42.7% were male, 57.3% were female. The racial/ethnic distribution was non-Hispanic white (29.1%), non-Hispanic African American (26.8%) and Hispanic (44.1%). The overwhelming majority of youths had smoked cigarettes (95.7%). Other products used were cigars (36.9%), smokeless tobacco (3.9%), kreteks (3.1%), pipes (3.2%) and bidis (1.9%). The average age of tobacco use onset was 14.3

Conclusion

We have presented novel findings regarding the development of nicotine dependence and the factors associated with the transition to dependence in adolescence, the period in the life cycle of initiation to tobacco use. A school-based sample of young adolescents, who reported in school having started to use tobacco within the prior 12 months, were interviewed in their homes five times over 2 years at 6 month intervals; one parent, predominantly mothers, was interviewed three times. More than half

Acknowledgments

This research was partially supported by research grants DA12697 from NIDA/NCI and ALF CU51672301A1 from the American Legacy Foundation (Denise Kandel, principal investigator), and a Research Scientist Award (DA00081) from the National Institute on Drug Abuse to Denise Kandel. The authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Portions of this paper were presented at the 12th Annual Meeting of

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