Philippe Boucher's Rendez-vous with . . . Joseph DiFranza
About the first results of the DANDY 1 study (Development and Assessment of Nicotine Dependence in Youths)
Rendez-vous with . . . Joseph DiFranza
Family physician and Professor of family medicine
University of Massachusetts Medical School
Worcester, Massachusetts, USA
By Philippe Boucher
Friday, May 10 2002
PB : Thank you Joseph for accepting our rendez-vous.
May I ask you to introduce yourself ?
Joseph DiFranza: Many in the tobacco control field are already familiar with my earlier research. I have 70 publications on tobacco over the past 20 years. I did some of the important work regarding Joe Camel. I have been conducting research on youth access for 15 years. I have written papers regarding the impact of ETS on children. For many years, I was focused solely on the advocacy side of tobacco control, but for the past several years I have been deeply involved in the hard science of nicotine addiction. Lately my time has been divided between my youth access work and my new interest in nicotine addiction. I have just been funded to conduct the DANDY2 study over a five year period to follow up on several of the issues discussed below.
Here is the Hooked On Nicotine Checklist (HONC):
Q1. The Archives of Pediatric adolescent medicine published in April the some results of your DANDY study (Development and Assessment of Nicotine Dependence in Youths). You propose a new approach to dependence based on the loss of autonomy. How is it different from the previous approaches?
11) Have you ever tried to quit, but couldn't?
2) Do you smoke now because it is really hard to quit?
3) Have you ever felt like you were addicted to tobacco?
4) Do you ever have strong cravings to smoke?
5) Have you ever felt like you really needed a cigarette?
6) Is it hard to keep from smoking in places where you are not supposed to, like school? When you tried to stop smoking...(or, when you haven't used tobacco for a while...) 7) did you find it hard to concentrate because you couldn't smoke?
8) did you feel more irritable because you couldn't smoke?
9) did you feel a strong need or urge to smoke?
10) did you feel nervous, restless or anxious because you couldn't smoke?
Joseph DiFranza: Traditional definitions of nicotine dependence focused on defining when nicotine dependence becomes a mental disorder. Our interest is in determining when nicotine dependence begins. I use a common sense approach. Dependence begins when a person can no longer freely give up tobacco. I do not think that we have to wait for evidence that tobacco use has caused disruption to a person's social functioning to say they are dependent. I think our traditional definitions of dependence are too strict. I have studied the history of these traditional definitions and have discovered that they are really no more than the product of a committee. They have their uses but they are not based on any "gold standard" of addiction. These definitions have blinded us to the possibility that dependence actually starts very quickly, long before tobacco use causes social disruption.
We have already published data indicating that symptoms of dependence typically begin within a few weeks of the onset of intermittent smoking. We will have several more papers out in the coming year presenting more data from the DANDY study.
Q2. You write that "the validity of the autonomy model can be tested by determining if a measure of lost autonomy is predictive of continued smoking or failed cessation". Can you explain how the Hooked on Nicotine Checklist (HONC) works?
Joseph DiFranza: The HONC has ten questions any one of which would indicate that quitting smoking will take more than a simple act of free will. If these symptoms really indicate that a person is hooked, then the presence of any of the symptoms should predict that the smoker will have a harder time quitting in the future. In our study, youths who developed one or more of the ten HONC symptoms were 29 times more likely to fail at their first attempt at quitting, 44 times more likely to still be smoking at the end of our study, and 58 times more likely to be smoking daily. We feel that this is strong proof that the autonomy theory is correct, that dependence begins when there is any obstacle to cessation. This is what most people call being hooked.
Q3. What is your assessment of the loss of autonomy among young smokers?
Joseph DiFranza: Youths become hooked, or dependent, on tobacco much more quickly than any one had previously imagined. It also takes much less tobacco to get hooked than we had thought. There does not appear to be any threshold of nicotine intake in terms of cigarettes per day for dependence to start. We hope to publish our data on the dose of nicotine required for dependence to start in the near future.
Q4. Did you find differences according to the sexes?
Joseph DiFranza: We have consistently seen that girls have higher HONC scores than boys. Girls also develop the HONC symptoms much quicker than boys. We haven't been able to figure out why.
Q5. What's next? How do you think the tobacco control advocates should incorporate those findings into their activities?
Joseph DiFranza: We are trying to determine why some youths seem resistant to dependence on nicotine. We want to figure out why some develop symptoms very quickly while others take a long time. Some develop symptoms at very low doses of nicotine, others seem to require more.
This information should be used in prevention programs. The HONC would be ideal as a self-assessment tool and could be used in pamphlets, posters, health curricula, etc. We should focus on teaching youths the "ten warning signs of addiction." Very few people know that the ten symptoms in the HONC are symptoms of nicotine dependence. We should also make an effort to explain to youths that they can get addicted with their first few cigarettes and that they do not have to be smoking every day to be addicted. If we can get them to recognize the signs of addiction earlier it should be easier for them to quit.
PB: Thank you Joseph for taking the time to be with us today.
P.S: Joseph had already been our guest for Rendez-vous 41, on August 6, 1999.
Rendez-vous is supported by a contract from the Robert Wood Johnson Foundation
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