"Withdrawal symptoms" in adolescents: a comparison of former smokers and never-smokers

The Role of Attention in Placebo and Nocebo Effects

BACKGROUND

Although some existing models propose that attention may be crucially implicated in placebo/nocebo effects, empirical research on this aspect remains limited and scattered.

PURPOSE

This systematic review aims to provide an inclusive overview of studies that have either directly manipulated or assessed attention within the context of placebo and nocebo procedures so to gain a synthetized picture of the role of this variable in placebo/nocebo effects. Importantly, only studies in which attention represented a mechanism or mediator of the placebo/nocebo response, and not a primary outcome, were included.

METHODS

A systematic search was conducted across multiple databases, including PubMed, Scopus, PsycINFO, Web of Science, and Embase, to identify peer-reviewed studies. These studies were subjected to methodological evaluation and eligibility criteria for inclusion.

RESULTS

We identified and classified 12 studies into three categories based on their focus: (i) those that directly assessed attention, (ii) those that directly manipulated participants' attention, and (iii) those that combined both a direct manipulation and assessment of attention. In all selected studies attention acted as a mechanism or mediator of the placebo/nocebo response, and was not considered a primary outcome of the placebo/nocebo manipulation.

CONCLUSIONS

The synthesis of the included studies reveals that the role of attention in placebo and nocebo effects is still a topic of debate, marked by variations in how attention is conceptualized and measured. Results suggest that attention has significant clinical implications, particularly in optimizing therapeutic efficacy by directing patients' focus toward signs of healing and away from indicators of illness or distress. To advance our understanding, future research should explore these attentional mechanisms, in conjunction with neurophysiological correlates.

Who mixes tobacco with cannabis and does mixing relate to nicotine dependence?

BACKGROUND

Cannabis users who mix tobacco with cannabis are exposed to nicotine in the tobacco. We identified characteristics of young adult cannabis users who mix and investigated whether mixing frequency is associated with nicotine dependence (ND).

METHODS

Data were collected in self-report questionnaires in 2017-20 from 788 young adults (44% male; mean (SD) age 30.6 (1.0) years) participating in a longitudinal investigation of the natural course of ND. Using multivariable logistic regression, we assessed whether any of 16 sociodemographic, lifestyle, psychosocial or other characteristics were associated with mixing among 313 past-year cannabis users. We also assessed whether mixing frequency was associated with ND among 289 past-year cannabis users who had ever smoked cigarettes controlling for age, sex, and other sources of nicotine (i.e., number of cigarettes smoked, other tobacco products, second-hand smoke exposure).

RESULTS

Of 788 participants, 40 % (n = 313) reported past-year cannabis use. Of these, 150 (48 %) reported mixing. Younger age, lower education and income, past-year cigarette use, use of other tobacco products and illicit drugs, poor coping skills and gambling were associated with mixing. Number of ICD-10 ND criteria endorsed was associated with mixing < weekly (b(95 % CI) = 0.3(0.02,0.7)) and weekly/daily (0.5(0.1,0.9)) after controlling for other sources of nicotine.

CONCLUSION

Mixing is associated with ND and therefore may threaten tobacco control efforts by rendering quitting cigarette smoking more difficult among smokers who mix tobacco with cannabis. Mixing tobacco with cannabis should be considered as an additional source of nicotine exposure in studies of ND in young people.

Smoking and incidence of insomnia: a systematic review and meta-analysis of cohort studies

OBJECTIVE

This study investigated the impact of smoking on the incidence of insomnia.

STUDY DESIGN

Systematic review and meta-analysis of cohort studies.

METHODS

PubMed, EMBASE, Web of Science, Cochrane Library, and OVID were searched through March 2020. Cohort studies reporting the effect of smoking on the incidence of insomnia were included. We quantitatively analyzed the basic framework and study characteristics and then pooled estimate effects with 95% confidence intervals (CIs) of outcomes of each included study using fixed-effects meta-analyses.

RESULTS

This systematic review included six cohort studies involving 12,445 participants. Quantitatively summarized results suggested that smoking could significantly increase the incidence of insomnia (odds ratio [OR]: 1.07, 95% CI: 1.02, 1.13). Regular smoking was significantly associated with the incidence of insomnia (OR = 1.07, 95% CI: 1.01, 1.13). As for occasional smokers and ex-smokers, the pooled analysis did not indicate a significant association (occasional smoker: OR = 2.09, 95% CI: 0.44, 9.95; ex-smoker; OR = 1.02, 95% CI: 0.67, 1.54). Subgroup analysis by age, gender ratio, and region showed a statistically significant relationship between smoking and the incidence of insomnia in specific groups.

CONCLUSIONS

Integrated longitudinal observational evidence identified smoking as a significant risk factor of insomnia. Considering the limited amount of available studies, more high-quality and prospective cohort studies of large sample sizes are needed to explore details of this association.

Does use of other tobacco products change when cigarette smoking status changes: A descriptive study of young adults

BACKGROUND

Whether polytobacco use or nicotine dependence (ND) change when cigarette smoking status changes in young adults is an understudied issue. Our objective was to describe use of other tobacco products (OTPs) and ND according to change in cigarette smoking status over four years in young adults.

METHODS

We drew data from a longitudinal study of 1294 adolescents age 12-13 at inception in 1999-2000 and followed into young adulthood. Among 790 participants with data at age 20 and 24, 22% had never smoked cigarettes; 37% were "sustained smokers"; 9% were "relapsers"; 10% had quit 1-3 years ago; and 22% had quit ≥4 years ago. We described past-year OTP (i.e., cigars/cigarillos, waterpipe, sundry tobacco products (i.e., pipe, bidis, chewing tobacco, snuff)) use and ND over 4 years in these groups.

RESULTS

At age 20, sustained smokers reported using a mean(SD) of 1.1(0.9) OTP in the past-year; relapsers reported 0.5(0.6); shorter-term quitters reported 0.9(0.7); longer-term quitters reported 0.3(0.6); and never smokers reported 0.2(0.4). There was no change in OTP use or ND in never smokers and longer-term quitters. Shorter-term quitters reduced the number of OTPs by -0.5(95% confidence interval: -0.7,-0.3) on average over 4 years; sustained smokers decreased by -0.2(-0.3,-0.1). Relapsers increased by 0.6(0.4,0.7) on average.

CONCLUSIONS

OTP use and ND were stable in early adulthood among never smokers, sustained smokers and longer-term quitters, but fluctuated in parallel with stopping and starting to smoke. Research is needed to ascertain the underpinnings of these fluctuations and whether they help or hinder cessation.

Type of e-liquid vaped, poly-nicotine use and nicotine dependence symptoms in young adult e-cigarette users: a descriptive study

BACKGROUND

Data are lacking on type of e-liquid vaped among e-cigarette users. Further, few studies assess all sources of nicotine used by e-cigarette users to assess whether poly-nicotine use relates to nicotine dependence (ND). The objectives were to describe young adult e-cigarette users by: (i) type of e-liquid vaped; (ii) poly-nicotine use; (iii) ND symptoms; and (iv) attempts to quit conventional cigarettes.

METHODS

Data were available in cycle 23 of a longitudinal investigation on the natural course of cigarette smoking and ND. A total of 775 young adults (44% male; mean (SD) age 30.5(1.0)) completed mailed self-report questionnaires in 2017-20.

RESULTS

Of 775 participants, 149 (19.2%) reported past-year e-cigarette use. Overall, 55.0% of e-cigarette users had used cannabis-containing e-liquid (31.5% vaped cannabis e-liquid exclusively); 50.4% used nicotine-containing e-liquid (23.5% vaped nicotine e-liquid exclusively); and 39.9% used e-liquid without nicotine (8.7% vaped e-liquid without nicotine exclusively). Most e-cigarette users (82.6%) used other nicotine-containing products including conventional cigarettes (72.5%); 60.8% reported ND symptoms, rising to 79.4% among those who vaped nicotine-containing e-liquid. Finally, 29.0% tried to quit conventional cigarettes using e-cigarettes in the past-year, but only 16.7% found them helpful.

CONCLUSIONS

E-cigarettes now appear to appeal to a broader market than smokers who want to quit. More than half of young adult e-cigarette users vaped cannabis-containing e-liquid in the past year while only one-quarter had used e-cigarettes to assist with cessation. Most e-cigarette users used multiple nicotine-containing substances (including combustible cigarettes) which were associated with reports of ND symptoms.

Acculturation-related predictors of very light smoking among Latinos in California and nationwide

The prevalence of light smoking has increased among Latinos. The purpose of this study was to identify demographic and acculturation-related factors associated with very light smoking, defined as smoking 1-5 cigarettes per day (CPD), among Latinos in California and nationwide. Latino smokers in the 2007-2008 National Health and Nutrition Examination Survey (NHANES) or the 2009 California Health Interview Survey (CHIS) were analyzed. Logistic regression assessed factors associated with very light smoking. Among NHANES smokers, those born in Mexico or who lived fewer years in the US were more likely to be very light smokers than 6+ CPD smokers. Among CHIS smokers, those born in Mexico, in another Spanish speaking country, or who spent smaller percentages of their life in the US were more likely to be very light smokers. Findings from this study can be used to design tobacco control media campaigns that include very light smokers.

Cohort Profile: The Nicotine Dependence in Teens (NDIT) Study

The Nicotine Dependence in Teens (NDIT) study is a prospective cohort investigation of 1294 students recruited in 1999-2000 from all grade 7 classes in a convenience sample of 10 high schools in Montreal, Canada. Its primary objectives were to study the natural course and determinants of cigarette smoking and nicotine dependence in novice smokers. The main source of data was self-report questionnaires administered in class at school every 3 months from grade 7 to grade 11 (1999-2005), for a total of 20 survey cycles during high school education. Questionnaires were also completed after graduation from high school in 2007-08 and 2011-12 (survey cycles 21 and 22, respectively) when participants were aged 20 and 24 years on average, respectively. In addition to its primary objectives, NDIT has embedded studies on obesity, blood pressure, physical activity, team sports, sedentary behaviour, diet, genetics, alcohol use, use of illicit drugs, second-hand smoke, gambling, sleep and mental health. Results to date are described in 58 publications, 20 manuscripts in preparation, 13 MSc and PhD theses and 111 conference presentations. Access to NDIT data is open to university-appointed or affiliated investigators and to masters, doctoral and postdoctoral students, through their primary supervisor (www.nditstudy.ca).

Predictors of nicotine dependence symptoms among never-smoking adolescents: a longitudinal analysis from the Nicotine Dependence in Teens Study

BACKGROUND

Recent cross-sectional studies suggest some adolescents who have never smoked cigarettes experience nicotine dependence (ND) symptoms and that exposure to second-hand smoke, social exposure to smoking, and alcohol use are plausible correlates. The aim of this study was to replicate and extend these findings by investigating possible predictors of ND symptoms longitudinally.

METHOD

Participants included 847 secondary school students who had never smoked cigarettes enrolled in the Nicotine Dependence in Teens Study. Adolescents completed self-report questionnaires measuring smoking status, ND symptoms, and risk factors for ND in smokers (i.e., socio-demographic indicators, social exposure to smoking, psychosocial indicators, and substance use) in 20 survey cycles from 7 to 11th grade. Generalized estimating equations, which account for repeated measures within individuals, were used to test the predictors of ND symptoms.

RESULTS

Consistent with previous research, 7.8% of never-smokers across all cycles endorsed at least one ND symptom. Younger age (p ≤ .001), country of birth (p ≤ .05), peer smoking (p ≤ .001), teacher smoking (p ≤ .05), depression (p ≤ .05), stress (p ≤ .001), lower self-esteem (p ≤ .05), impulsivity (p ≤ .05), and alcohol use (p ≤ .001) predicted greater ND symptoms in multivariable modeling.

CONCLUSIONS

Replicating previous cross-sectional findings, peer smoking and alcohol use predicted ND symptoms among never-smoking adolescents. Extending these findings, previous predictors only observed among ever-smokers, including socio-demographic and psychosocial indicators, also predicted ND symptoms. This longitudinal investigation demonstrated the temporal relation of the predictors preceding ND symptoms. Future research should consider longer prospective studies with younger children to capture early onset of ND symptoms and with longer follow-up to detect eventual smoking uptake.

Mindfulness training for smoking cessation: moderation of the relationship between craving and cigarette use

BACKGROUND

Smoking is the leading cause of preventable death in the US, while abstinence rates remain modest. Smoking has been shown to be perpetuated by operant conditioning, notably negative reinforcement (e.g., smoking to relieve negative affective states). Mindfulness training (MT) shows promise for smoking cessation, by potentially altering an individual's tendency to smoke in response to craving. The purpose of this study was to examine the effects of MT and mindfulness practice on the relationship between smoking and craving after receiving four weeks of MT.

METHODS

33 adults received MT as part of a randomized trial for smoking cessation. Individuals in the MT condition recorded formal and informal mindfulness practice during treatment using daily diaries.

RESULTS

Analyses showed that strong correlations between craving and smoking at baseline (r=0.582) were attenuated at the end of treatment (r=0.126). Mindfulness home practice significantly predicted cigarette use (formal: B=-1.21, p=0.007; informal: B=-1.52, p<0.0001) and informal practice moderated the relationship between craving and smoking at the end of treatment (B=0.52, p=0.03).

CONCLUSIONS

These findings suggest that MT may be effective as a treatment for smoking cessation and that informal mindfulness practice predicts a decoupling of the association between craving and smoking.

The nicotine withdrawal assessment for youth: initial instrument validation and psychometric properties

Within the field of adolescent tobacco use, there does not exist a consistently used and validated measure of adolescent nicotine withdrawal symptoms. The purpose of this study was to evaluate the psychometric properties of the Nicotine Withdrawal Assessment for Youth (N-WAY), a new measure of adolescent nicotine withdrawal symptoms. Smokers and nonsmokers, ranging from 13 to 19 years old, were administered the N-WAY and other smoking information questionnaires in order to examine its reliability and validity. The N-WAY demonstrated satisfactory test-retest reliability (r=0.74-88) and internal consistency (Cronbach's α=0.90-0.92). Its total symptom score accurately discriminated current smokers from nonsmokers. The N-WAY was demonstrated to measure a construct different than nicotine dependence symptoms while correlates of nicotine withdrawal symptoms, such as number of daily cigarettes smoked and prior quit attempts, accurately predicted total N-WAY symptom and impact scores. Preliminary results indicate the N-WAY is a reliable and valid assessment of adolescent nicotine withdrawal symptoms among current smokers.

The association between workplace smoking bans and self-perceived, work-related stress among smoking workers

Background

There is substantial empirical evidence on the benefits of smoking bans; however, the unintended consequences of this anti-smoking measure have received little attention. This paper examines whether workplace smoking bans (WSB's) are associated with higher self-perceived, work-related stress among smoking workers.

Methods

A longitudinal representative sample of 3,237 individuals from the Canadian National Population Health Survey from 2000 to 2008 is used. Work-related stress is derived from a 12-item job questionnaire. Two categories of WSB's, full and partial, are included in the analysis, with no ban being the reference category. Analysis also controls for individual socio-demographic characteristics, health status, provincial and occupational fixed-effects. We use fixed-effects linear regression to control for individual time-invariant confounders, both measured and unmeasured, which can affect the relationship between WSB's and work-related stress. To examine the heterogeneous effects of WSB's, the analysis is stratified by gender and age. We check the robustness of our results by re-estimating the baseline specification with the addition of different control variables and a separate analysis for non-smokers.

Results

Multivariate analysis reveals a positive and statistically significant association between full (β = 0.75, CI = 0.19-1.32) or partial (β = 0.69, CI = 0.12-1.26) WSB's, and the level of self-perceived, work-related stress among smoking workers compared to those with no WSB. We also find that this association varies by gender and age. In particular, WSB's are significantly associated with higher work stress only for males and young adults (aged 18-40). No statistically significant association is found between WSB's and the level of self-perceived work-related stress among non-smoking workers.

Conclusion

The results of this study do not imply that WSB's are the main determinant of self-perceived, work-related stress among smokers but provides suggestive evidence that these may be positively related.

Nicotine withdrawal symptoms in adolescent and adult twins

We examined the variation and heritability of DSM-IV nicotine withdrawal (NW) in adult and adolescent male and female twin cigarette smokers (who reported smoking 100 or more cigarettes lifetime). Telephone diagnostic interviews were completed with 3,112 Australian adult male and female smokers (53% women; age: 24-36) and 702 Missouri adolescent male and female smokers (59% girls; age: 15-21). No gender or cohort differences emerged in rates of meeting criteria for NW (44%). Latent class analyses found that NW symptoms were best conceptualized as a severity continuum (three levels in adults and two levels in adolescents). Across all groups, increasing NW severity was associated with difficulty quitting, impairment following cessation, heavy smoking, depression, anxiety, conduct disorder and problems with alcohol use. NW was also associated with seeking smoking cessation treatment and with smoking persistence in adults. The latent class structure of NW was equally heritable across adult and adolescent smokers with additive genetic influences accounting for 49% of the variance and the remaining 51% of variance accounted for by unique environmental influences. Overall, findings suggest remarkable similarity in the pattern and heritability of NW across adult and adolescent smokers, and highlight the important role of NW in psychiatric comorbidity and the process of smoking cessation across both age groups.

Attention-deficit/hyperactivity disorder confounds nicotine withdrawal self-report in adolescent smokers

Individuals with attention-deficit/hyperactivity disorder (ADHD) are more likely than those without ADHD to initiate smoking and develop nicotine dependence. Recent research indicates that adults with ADHD experience more severe nicotine withdrawal symptoms than those without ADHD. However, little is known about nicotine withdrawal in adolescent smokers with history of ADHD. Among a sample of 134 nicotine-dependent adolescents entering a smoking cessation research study, participants completed the Minnesota Nicotine Withdrawal Scale (MNWS) and lifetime diagnostic assessment for ADHD during the baseline visit. Responses on individual items and MNWS total score were compared between participants with and without history of ADHD. In addition, correlations between MNWS responses and current ADHD symptoms were investigated among participants with history of ADHD. Forty-eight participants (36%) met lifetime ADHD criteria. Adolescent smokers with history of ADHD scored significantly higher on MNWS than those without history of ADHD. Among participants with history of ADHD, responses on the MNWS difficulty concentrating, restlessness/impatience, and anxiety/nervousness items each correlated positively with several current ADHD symptoms. Treatment-seeking adolescent smokers with history of ADHD are more likely to endorse nicotine withdrawal symptoms than those without history of ADHD. However, it does not appear that the symptoms reported in this sample represent a valid "withdrawal syndrome," particularly because these smokers had not yet formally attempted to quit. Rather, the data likely reflect common features between ADHD and nicotine withdrawal. Smoking research, particularly among adolescents in whom ADHD is so common, should carefully consider the complex issue of comorbid ADHD and nicotine dependence.

Thwarting science by protecting the received wisdom on tobacco addiction from the scientific method

In their commentary, Dar and Frenk call into question the validity of all published data that describe the onset of nicotine addiction. They argue that the data that describe the early onset of nicotine addiction is so different from the conventional wisdom that it is irrelevant. In this rebuttal, the author argues that the conventional wisdom cannot withstand an application of the scientific method that requires that theories be tested and discarded when they are contradicted by data. The author examines the origins of the threshold theory that has represented the conventional wisdom concerning the onset of nicotine addiction for 4 decades. The major tenets of the threshold theory are presented as hypotheses followed by an examination of the relevant literature. Every tenet of the threshold theory is contradicted by all available relevant data and yet it remains the conventional wisdom. The author provides an evidence-based account of the natural history of nicotine addiction, including its onset and development as revealed by case histories, focus groups, and surveys involving tens of thousands of smokers. These peer-reviewed and replicated studies are the work of independent researchers from around the world using a variety of measures, and they provide a consistent and coherent clinical picture. The author argues that the scientific method demands that the fanciful conventional wisdom be discarded and replaced with the evidence-based description of nicotine addiction that is backed by data. The author charges that in their attempt to defend the conventional wisdom in the face of overwhelming data to the contrary, Dar and Frenk attempt to destroy the credibility of all who have produced these data. Dar and Frenk accuse other researchers of committing methodological errors and showing bias in the analysis of data when in fact Dar and Frenk commit several errors and reveal their bias by using a few outlying data points to misrepresent an entire body of research, and by grossly and consistently mischaracterizing the claims of those whose research they attack.

Nicotine withdrawal symptoms following a quit attempt: an ecological momentary assessment study among adolescents

INTRODUCTION

The present study describes growth curves of withdrawal symptoms among 138 daily smoking adolescents before, during, and after a quit attempt.

METHODS

Participants reported their levels of withdrawal symptoms (craving, negative affect, and hunger) three times a day over a period of 28 days: 1 week prior to and 3 weeks following a quit attempt.

RESULTS

All withdrawal symptoms were quite stable at a relatively low level during the 5 days prior to the quit day. At Day 8, withdrawal symptoms (especially craving) increased substantially. A significant decrease in symptoms was visible during the week following the quit day, and within 2 weeks postquit, both abstinent and relapsed adolescents had reverted to levels comparable to those during the prequit period. The course over time for craving and hunger were best described by a quadratic term, and a linear model best suited negative affect. Individual intercepts and slopes of the growth curves were used to predict abstinence during the last week of the study and at the 2-month follow-up. Analyses revealed that higher levels of craving at the beginning of the prequit week and on the target quit day (intercepts) decreased the odds of being abstinent during the last week of the study. In addition, the quadratic term for hunger predicted abstinence during the last week. Finally, among all three symptoms, none of the growth model characteristics predicted abstinence at follow-up.

DISCUSSION

The findings generally suggest that smoking cessation among daily smoking adolescents does not largely depend on how their withdrawal symptoms evolve over time after achieving abstinence.

Therapy for specific problems: youth tobacco cessation

Cigarette smoking is the leading cause of premature morbidity and mortality in the United States. The majority of children smoke their first cigarette in early adolescence, and many older teens have well-established dependence on nicotine. Efforts to promote and support smoking cessation among these youth smokers are critical. The available experimental studies of youth cessation interventions find that behavioral interventions increase the chances of youth smokers achieving successful cessation. Currently there is insufficient evidence for the effectiveness of pharmacological treatments with youth smokers. Many innovative studies have been compromised by challenges in recruiting sufficient numbers of youth, obtaining approval for waivers of parental consent, and high attrition in longitudinal studies. Key areas for future work include bridging the fields of adolescent development and treatment design, matching treatments to developmental trajectories of smoking behavior, better understanding treatment processes and treatment moderators, and building demand for evidence-based cessation treatments.

Effects of acute tobacco abstinence in adolescent smokers compared with nonsmokers

PURPOSE

Abstinence effects such as nicotine withdrawal and mood changes contribute to the maintenance of cigarette smoking in adult smokers, and emerging reports on adolescent smokers suggest they may experience similar subjective effects when deprived. This study aimed to prospectively document tobacco abstinence-induced changes during the first 48 hours of abstinence in adolescent smokers compared with nonsmokers, to distinguish effects distinct from typical adolescent lability.

METHODS

Fifty-seven adolescent smokers and 44 adolescent nonsmokers were assessed during a 48-hour inpatient session. Characteristic nicotine withdrawal symptoms, cravings for cigarettes, and mood symptoms were measured at 13 time points following initiation of abstinence.

RESULTS

The only abstinence-related effects observed were changes in craving for tobacco and feelings of anger. Tobacco craving increased and peaked quickly following initiation of abstinence and displayed a slight decrease toward the end of the 48-hour abstinence period, while anger symptoms peaked after a more prolonged abstinence. Overall, smokers' symptoms and cravings were positively associated with amount of daily smoking but not with reports of dependence or biological measures of extent of use.

CONCLUSIONS

We observed that among adolescent smokers, the primary effects associated with abstinence from cigarettes are relatively minimal, and include a heightened and persistent craving to smoke and increases in anger. Although smokers had greater negative mood symptoms compared with nonsmokers, the presence and severity of most of these symptoms appear to be minimally altered by abstinence and not associated with dependency or biological indicators of amount of tobacco use.

Preliminary examination of tobacco withdrawal in adolescent smokers during smoking cessation treatment

Tobacco withdrawal symptoms have been shown to play a significant role in mediating relapse to smoking in adult smokers; however, few prospective studies have examined the course of tobacco withdrawal symptoms over time and their connection to lapse in adolescent smokers. Withdrawal symptoms were assessed weekly for 4 weeks in a sample of adolescent smokers participating in a pilot cessation intervention. Adolescent smokers experienced an exacerbation in overall withdrawal symptoms, particularly of cravings and restlessness, although symptoms were generally mild. The course of symptoms was different for boys and girls: Girls generally experienced a peak and subsequent decline in symptoms early in the establishment of abstinence, whereas boys experienced a constant level of symptoms that did not decline over the 4 weeks. Finally, withdrawal symptoms experienced on quit day were not related to lapse to smoking during the course of treatment for either boys or girls. These results suggest that although withdrawal symptoms may be uncomfortable, they may not be the most salient to a lapse to smoking for adolescent smokers attempting to quit. These findings have direct implications for the design and implementation of treatment of nicotine dependence in adolescent smokers.

On the development of nicotine dependence in adolescence

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.

The epidemiology of tobacco use and dependence

Tobacco use continues to be a public health issue of great importance. Acute and critical care nurses in particular have a unique opportunity to become a cornerstone for the nation's tobacco control efforts through integration of prevention and cessation interventions as part of patient care. This article provides readers with a working knowledge of tobacco use and dependence as background reading for the subsequent articles presented in this special issue addressing tobacco cessation in acute and critical care settings.