[Two of the authors respond:]
Nicotine addiction in children and adolescents is not the old mantra; it is a new mantra that has emerged over the last 5 years with accumulating evidence that novice smokers can experience symptoms of nicotine dependence early in the smoking onset process. Indeed, until recently, it was generally believed that young people could experiment with cigarettes without experiencing cravings or withdrawal symptoms. Our analysis documents that classic symptoms of dependence, such as cravings and symptoms of withdrawal, occur rapidly after the first puff, before the development of tolerance (i.e., the disappearance of the initial adverse effects, such as nausea and dizziness) and well before regular weekly or daily cigarette use.1
We agree with Preston that our paper did not incorporate perceived social benefits of smoking into the description of the natural course of smoking onset. However, current conceptualizations of dependence do take into account the fact that young people weigh the benefits of smoking early in the preparation and experimentation phases of smoking. Future studies on the natural course of onset should perhaps incorporate the evolution of perceived benefits in relation to the appearance of symptoms of dependence and intention to quit.
We agree that our finding that mental addiction can occur even before the first puff may reflect the fact that some people are more susceptible or attracted to smoking because of perceived benefits. However, the onset of mental addiction was closely aligned in many of our subjects with the onset of physical addiction; in reality, it may be impossible to distinguish mental addiction from physical addiction.
For every smoker who quits without experiencing withdrawal symptoms, there are many more who relapse. Randomized controlled trials demonstrate that relief of withdrawal symptoms through nicotine replacement therapy doubles quit rates, providing empirical evidence for the role of nicotine in dependence.2,3 One could argue that underestimating the biological underpinnings of dependence, and instead relying solely on the notion that dependence is psychological, may underlie the failure of many quit attempts. Smokers who fail in their attempt to quit smoking may become even more disempowered when they are blamed for not having enough willpower to quit.
REFERENCES
- 1.Gervais A, O'Loughlin J, Meshefedjian G, et al. Milestones in the natural course of onset of cigarette use among adolescents. CMAJ 2006;175(3):255-61. [DOI] [PMC free article] [PubMed]
- 2.Fiore MC, Bailey WC, Cohen SJ, et al. Recommendations regarding specific pharmacotherapies: first-line medications. In: Treating tobacco use and dependence. Rockville (MD): US Department of Health and Human Services; 2000. p. 72-90. Available: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.section.7838 (accessed 2007 Jan 22).
- 3.Silagy C, Lancaster T, Stead L, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004;(3):CD000146.pub2. [DOI] [PubMed]