PEDIATRICS Vol. 121 No. 3 March 2008, pp. 623-624 (doi:10.1542/peds.2007-3696)
COMMENTARY |
Let the Children Be Heard: Lessons From Studies of the Early Onset of Tobacco Addiction
a Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts
b Department of Social Medicine (Emeritus), Harvard Medical School, Boston, Massachusetts
Because smokers die, on average, a decade younger than nonsmokers, and smoking kills between one third and one half of those who start,1 it is important that all physicians become cognizant of the hazards related to the early onset of smoking.
When one of us (Dr Richmond) assumed the post of Surgeon General in 1977, it was accepted that addiction to nicotine was caused by years of daily smoking. It was assumed that anyone who experienced nicotine withdrawal had to smoke at least 5 times per day to keep it in abeyance. Given this, it was assumed that addiction did not begin until a person smoked 5 cigarettes daily, and anyone smoking less than this did not experience withdrawal and was not addicted.2 Because novice smokers typically take 2 to 3 years to reach 5 daily cigarettes,3 it was assumed that prolonged regular daily smoking was a prerequisite for dependence. Through the end of the century, the onset of dependence was envisioned as a creeping, protracted, erosion-like process, the product of tens of thousands of doses of nicotine.4
It was intriguing, therefore, when 1 of our (Dr DiFranza's) teenaged pediatric patients volunteered a history of failing at several attempts to quit smoking within a few weeks of trying her first cigarette.5 Another girl described unpleasant nicotine withdrawal symptoms despite having smoked only 1 or 2 cigarettes a few days a week for 2 months. She, too, had failed in her quit attempts. These initial cases turned out to be quite typical.3 Among youth who develop dependence, 10% report symptoms after their very first cigarette, and 25% have symptoms within 2 weeks.3 Through 20 000 individual interviews with adolescents3,6 and surveys from 100 000 youth,7 we have documented how dependence develops.8 Contrary to the perceived wisdom,4 withdrawal symptoms typically appear before the onset of daily smoking and almost always before smoking progresses to 5 cigarettes per day.9 Animal experiments have confirmed that nicotine induces enduring neurophysiologic adaptations in the brain from the first dose.10
The history of science is replete with stories of landmark discoveries that initially were disparaged or ignored because they contradicted strongly held beliefs.11 The data documenting that symptoms of dependence emerge rapidly, and typically when youths are smoking only 1 or 2 cigarettes per week,3 disproved the universally accepted theory that prolonged daily smoking is a prerequisite for dependence.2 When these data were presented at the annual meeting of the Society for Research on Nicotine and Tobacco in 2000, those in attendance could not accept what they had heard, suggesting that the children must have been smoking more than they admitted or that they were overreporting symptoms, exaggerating symptoms, espousing culturally derived expectations about symptoms, or responding to nonverbally communicated performance expectations from the interviewers. Each of these alternate interpretations of the data have been refuted in subsequent studies, and the initial discovery has been replicated independently many times.6,7,12,13
Nevertheless, because the data provided by the children contradict the current paradigm, many have suggested that children cannot be trusted to tell the truth about nicotine dependence. Through decades of research, the reliability of symptom accounts obtained from adult smokers had never been questioned, but when the histories obtained from thousands upon thousands of children contradicted the prevailing view, they have been treated as having little scientific value.14 Some authors have written as if this rapidly expanding body of literature does not exist, claiming that the nature of nicotine dependence in youth is something about which we know nothing.15 Although we should remain cognizant of the limitations of adolescent self-report data, we also should know when to believe them.
We now understand that nicotine dependence typically develops during childhood or adolescence. However, the official definitions of dependence were all issued at a time when the prevailing belief was that teens were not addicted.16 Moreover, these definitions were not constructed on an evidence base but, rather, represented proclamations reflecting theoretical assumptions concerning the nature of dependence in adults. In another double standard, these hypothetical constructs of dependence have never been subjected to the scientific skepticism that has been applied so conscientiously to the children's data that contradict them.
Those who ignore the children's data have embarked on their own effort to learn how and when nicotine dependence develops.17 Their strategy is to determine when young smokers first fit hypothetical adult criteria. We believe this strategy will not produce a description of the natural history of what is primarily a disease of pediatric onset; rather, it will produce a description of how children come to fulfill an adult's vision of what it means to be addicted. We believe that a more promising approach is to take what children teach us about the essential nature of dependence and apply that evidence base to develop an understanding of dependence in adults. This strategy has already borne fruit.18–20
Science can only advance if we are willing to discard our beliefs when the facts do not support them. Through the gracious cooperation of the tens of thousands of children who volunteered as research subjects, we now have a basic understanding of how and when nicotine dependence begins. Because 80% of smokers initiate smoking before 18 years of age,21 we should take this new information and translate it into more effective prevention programs.
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FOOTNOTES |
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Accepted Dec 14, 2007.
Address correspondence to Joseph R. DiFranza, MD, University of Massachusetts Medical School, Department of Family Medicine and Community Health, 55 Lake Ave, Worcester, MA 01655. E-mail: difranzj{at}ummhc.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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