The developmental sequence of tobacco withdrawal symptoms of wanting, craving and needing
Highlights
► Abstinence from tobacco provokes characteristic symptoms of wanting, craving and needing. ► These symptoms develop in a set sequence of wanting, craving and needing over the clinical course. ► These symptoms recur in the same sequence during acute episodes of abstinence. ► These observations suggest that physiologic dependence develops in a characteristic sequence.
Introduction
Case series are instrumental in determining the clinical course of diseases (Yin, 2009). We published the first case series describing the symptoms of tobacco addiction in 2010 (DiFranza et al., 2010). Our primary discovery was that the symptoms of withdrawal appear to evolve through a characteristic sequence. Initially, the only symptom experienced during abstinence may be a mild desire to smoke that many smokers call ‘wanting’. Wanting is short-lived and easily ignored and does not intrude upon their thoughts (DiFranza et al., 2010). With continued use, smokers may develop a more intense and intrusive desire to smoke that many call ‘craving’. Craving is more persistent and harder to ignore: it interrupts their concentration. Later in the clinical course, the desire to smoke that is prompted by withdrawal may intensify to a point where it is impossible to ignore (DiFranza et al., 2010). Smokers cannot concentrate on anything other than their urgent need to smoke, and feel they need a cigarette just to feel, think and function normally again. Many smokers refer to this symptom as ‘needing’ a cigarette. Needing is distinguished qualitatively from craving by its unremitting urgency and the fact that it cannot be ignored.
Some smokers reported that early in their clinical course, when abstinent they experienced only wanting. Later, wanting would be followed by craving, and ultimately wanting and craving would be followed by needing. The sequence of symptom presentation during a single episode of abstinence (wanting, craving, then needing) appeared to recapitulate the sequence in which these symptoms evolved over the clinical course (wanting, craving, then needing). One limitation of this first case series was that this sequence was recognized post hoc during the data analysis, and subjects had not been asked if their symptoms followed this pattern. A second limitation is that subjects were not provided specific definitions for terms, so it is not entirely clear that subjects were all using the terms wanting, craving and needing to indicate the same experiences.
Kozlowski warned that smokers are not consistent in their use of the word craving, and recommended that terms with “precise and explicit specification” be used (Kozlowski et al., 1989, Kozlowski and Wilkinson, 1987). Accordingly, we developed specific operational definitions for the terms wanting, craving and needing. Objectives for the current study were (1) to determine if our operational definitions are valid descriptions of symptoms, and (2) to determine if smokers share a common experience concerning the sequence of symptom presentation over the clinical course, and during acute episodes of abstinence.
Section snippets
Subjects
Subjects were recruited online through Craigslist and word of mouth to a targeted enrollment of 25. Subjects had to be at least 14 years old and currently smoking at least one cigarette per month. Subjects received $20 for participating.
Interview protocol
A confidential semi-structured interview was conducted with each subject, in person or by phone, by medical interviewers (S.U. and L.B.) who obtained informed consent. The interviewers were trained by rehearsing the interview with volunteers while being observed
Subjects
The 25 subjects were 16–52 years of age (mean 24.5, SD 7.5), 56% female, 12% black, 16% Hispanic, and 72% non-Hispanic white. The mean age of smoking initiation was 14.9 years (range 7–20; SD 3.0). The mean duration of smoking was 10.9 years (SD 10.9). Subjects smoked an average of 28.5 days per month (range 22–30; SD 2.9); 7 were nondaily smokers, but of these, 2 smoked 29 days per month. The average daily cigarette consumption was 10.5 (range 2–20; SD 5.7). The mean AUTOS score was 20.0 (range
Discussion
Our first 50 case histories suggested that symptoms of withdrawal present in a set sequence over the clinical course: first wanting, then craving, and finally needing. Our 25 new cases support this developmental sequence. Additional support comes from a cross-sectional study of 349 adolescent smokers (DiFranza et al. , 2011a). Subjects were asked about their recent experiences with wanting, craving and needing using the same operational definitions as the current study. Combinations of symptoms
Conclusion
The current study provides support for the following observations: (1) abstinence from tobacco provokes characteristic symptoms of wanting, craving and needing that are widely endorsed by smokers as symptoms they have experienced; (2) these symptoms develop in a set sequence of wanting, craving and needing in all, or nearly all, smokers over their clinical course; (3) these symptoms recur in the same sequence during episodes of abstinence; (4) stress-induced urges to smoke are not relieved by
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