Applied Evidence

Hooked from the first cigarette

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One cigarette may be all it takes to get hooked. A 10-point questionnaire can help you drive that point home to adolescents who occasionally light up



Practice recommendations
  • Teach adolescents that one cigarette is often all it takes to get hooked (C).
  • The “Hooked On Nicotine Checklist” is a self-assessment tool that may help motivate some adolescent smokers to quit (C).
  • Even adolescents who smoke only a few cigarettes per week may need your help with quitting (C).

Strength of recommendation (SOR)

  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented evidence, case series

A 14-year-old girl comes into your office for a routine sports physical. She has been your patient since birth, and has seen you every year or two for the usual childhood illnesses and health exams. Her history is unremarkable, except that when you ask her whether she’s ever smoked, she confides in you that she occasionally smokes a cigarette with her girlfriends—something, she says, her parents know nothing about.

She tells you that she began smoking 2 months ago, but doesn’t smoke much—only about 3 cigarettes a week. She denies using any other form of tobacco (eg, smokeless tobacco) and tells you that she has not experimented with drugs.

When you ask her whether she’s tried to stop smoking, she tells you that she has, but that she’s already failed at several attempts to quit. You question her further and uncover some signs and symptoms of nicotine addiction, including cravings and a feeling of irritability when she isn’t able to smoke.

“Am I addicted to nicotine?” she asks you. But before you get a chance to respond, she continues: “And how is that possible? I don’t even smoke that much!”

Hooked from the first cigarette?

You bet.

Very soon after that first cigarette, adolescents can experience a loss of autonomy over tobacco, and recent research indicates that this loss of autonomy may play a key role in nicotine addiction.1

The challenge we face, though, is that many young patients think there’s no harm in trying a cigarette once. After all, what could be the problem with that? But there is a big risk to smoking just once and family physicians need to drive this message home to adolescent patients. A 10-point checklist can help.

10 questions that can open an adolescent’s eyes

The “Hooked On Nicotine Checklist” (PATIENT HANDOUT) is an objective measure of a patient’s loss of autonomy and it can be a real eye opener for adolescents. Simply give it to your adolescent patients and ask them to answer the 10 questions with a Yes or No answer.

A Yes response to any of the 10 questions indicates a loss of autonomy. The number of Yes responses gives an indication of the severity of the dependence, and may help to motivate adolescent smokers to quit. (Seven is the mean for adult smokers.) A smoker loses full autonomy when the sequelae of tobacco use present an obstacle to quitting—that is, when quitting requires an effort or results in discomfort.

Studies find that one cigarette is all it takes

Studies on a cohort of 7th graders found that every symptom on this validated checklist1 had been experienced by at least one young person within weeks of starting to smoke, sometimes after the first cigarette.2,3 These results have been replicated many times.4-7

Three New Zealand national surveys involving 25,722 adolescent smokers who used this checklist revealed a loss of autonomy in 25% to 30% of young people who had smoked their one and only cigarette during the preceding month.6

In another study using Diagnostic and Statistical Manual of Mental Disorders-IV criteria, 35% of young people who had symptoms of dependence had been smoking for one month or less when the first symptom appeared,5 challenging the assumption that addiction requires years of smoking. These studies also challenge the belief that repetition is the force that causes addiction, as at least one quarter had symptoms after one cigarette.

Expert opinion has also held that people who smoke fewer than 5 cigarettes daily are rarely addicted. Research data, however, indicate that 50% of young people were hooked on tobacco prior to smoking at a rate of 2 cigarettes per week.3,7 These results have also been replicated.4-7 Loss of autonomy has been reported even prior to the onset of smoking once per month.4,8

Which adolescents are most vulnerable?

About one quarter of young people experience the FIRE (First-Inhalation-Relaxation-Experience), a sensation of relaxation the first time they inhale from a cigarette, and this sensation predicts continued smoking.9 FIRE is the strongest predictor of the progression to the loss of autonomy and a diagnosis of tobacco dependence.10 One study demonstrated that an alarming 91% of those with the FIRE subsequently lost autonomy.10 FIRE appears to be a symptom of the neurological events that trigger addiction with the first cigarette.10


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