Tob Control 11:228-235 doi:10.1136/tc.11.3.228
  • Research paper

Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study

  1. J R DiFranza1,
  2. J A Savageau1,
  3. N A Rigotti2,
  4. K Fletcher1,
  5. J K Ockene1,
  6. A D McNeill3,
  7. M Coleman1,
  8. C Wood1
  1. 1University of Massachusetts Medical School, Worcester, Massachusetts, USA
  2. 2Harvard Medical School, Massachusetts, USA
  3. 3University of London, London, UK
  1. Correspondence to:
 Joseph R DiFranza MD, Department of Family Medicine and Community Health, University of Massachusetts Medical School, 55 Lake Avenue, Worcester, Massachusetts 01655, USA;
  • Received 27 September 2001
  • Accepted 11 March 2002
  • Revised 28 January 2002


Objective: To determine if there is a minimum duration, frequency or quantity of tobacco use required to develop symptoms of dependence.

Design and setting: A retrospective/prospective longitudinal study of the natural history of tobacco dependence employing individual interviews conducted three times annually in two urban school systems over 30 months. Detailed histories of tobacco use were obtained including dates, duration, frequency, quantity, patterns of use, types of tobacco, and symptoms of dependence.

Participants: A cohort of 679 seventh grade students (age 12–13 years).

Main outcome measures: The report of any of 11 symptoms of dependence.

Results: Among 332 subjects who had used tobacco, 40% reported symptoms, with a median latency from the onset of monthly smoking of 21 days for girls and 183 days for boys. The median frequency of use at the onset of symptoms was two cigarettes, one day per week. The report of one or more symptoms predicted continued smoking through the end of follow up (odds ratio (OR) 44, 95% confidence interval (CI) 17 to 114, p < 0.001).

Conclusions: Symptoms of tobacco dependence commonly develop rapidly after the onset of intermittent smoking, although individuals differ widely in this regard. Girls tend to develop symptoms faster. There does not appear to be a minimum nicotine dose or duration of use as a prerequisite for symptoms to appear. The development of a single symptom strongly predicted continued use, supporting the theory that the loss of autonomy over tobacco use begins with the first symptom of dependence.


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