Hooked from the first cigarette

Although we were all taught in medical school that tolerance precedes and causes addiction, addiction must be present before dependence-related tolerance can develop.

Nicotine leaves an indelible mark

To test this dependence-related tolerance hypothesis, my colleagues and I surveyed 2000 people who were smoking in public places, including the areas outside of our hospital’s entrance. We asked about their longest period of abstinence, how much they smoked before quitting, and how much they smoked at various times after resuming smoking. By plotting these data on a graph, we were able to see that dependence-related tolerance has 2 components, one reversible and the other permanent (irreversible).^24,25

The permanent component can cut the duration of a cigarette’s effect to half its original length, then to a quarter, to an eighth, a sixteenth, a thirty-second, a sixty-fourth and so on.

The reversible component reduces what is left by about half again.

So if we consider only the permanent component, it would cut the duration of effect from, say, four weeks to two weeks (one “cut”), then from two weeks to one week (second cut), from one week to 3.5 days (third cut), and so on. On top of this, the reversible component halves it again.

After 3 months of abstinence, then, the reversible component of tolerance disappears (temporarily) and a relapsed pack a day smoker will be happy—for a time—smoking a half-pack (10 cigarettes) per day. But then the reversible component kicks in and they’re back to smoking a pack a day.

The take-home message? Long-term smokers’ brains will never return to the days when their addiction could be satisfied with one cigarette per month because of the permanent component of tolerance.

How to help light smokers like your young patient

The fact that loss of autonomy over tobacco can occur after 1 cigarette helps explain the clinical observation that it is difficult for even non-daily smokers to stop smoking completely.

Helping a 14-year-old patient like the one in the opener to quit smoking requires that you not underestimate your patient’s need for advice about cessation. Unfortunately, none of the medications for smoking cessation, such as varenicline or bupropion, have been approved for this purpose in patients under the age of 18.

As a result, you’ll need to help young patients formulate a quit plan, just as you would with an adult heavy smoker. Give them the “Hooked On Nicotine Checklist.” The answers will help you both to tailor the quit plan to the obstacles they face. You’ll also need to provide young patients with anticipatory guidance about what they can expect from nicotine withdrawal.

Don’t wait for adolescents to broach the subject

Early intervention requires that you ask patients who are 10 years of age or older about smoking (TABLE 2). Be sure to take advantage of teachable moments and tell young patients just how addictive smoking can be—even if they’ve only smoked 1 or 2 cigarettes.

TABLE 2
The 5 A’s of smoking cessation²⁶

Your conversation might go like this:

The first cigarette you smoke changes your brain and may cause you to develop a craving for nicotine that could be hard to resist. The only sure way to avoid addiction is to never smoke that first cigarette.

If you are already smoking and you have a craving for a cigarette every once in a while, that is a sure sign of addiction. The sooner you quit, the better your chances of succeeding. Now let’s work on a quit plan that will help you do that.

Correspondence
Joseph R. DiFranza, MD, Department of Family Medicine and Community Health, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655; difranzj@ummhc.org.