Let the Children Be Heard: Lessons From Studies of the Early Onset of Tobacco Addiction

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 … 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