title: Does progression through the stages of physical addiction indicate increasing overall addiction to tobacco?
abstract: BACKGROUND
  With physical addiction to tobacco, abstinence triggers a desire to smoke. As physical addiction advances, the desire to smoke changes in quality and intensity from wanting, to craving, to needing. A prior study in adolescents suggested that this progression signifies increasing addiction.
  
  
  OBJECTIVE
  We sought to determine if the sequential appearance of wanting, craving and needing provides an indication of the intensity of other markers of tobacco addiction including psychological and behavioral indicators.
  
  
  METHODS
  A web-based survey was completed by 422 smokers ages 18-78 years. Subjects were assigned to one of four qualitatively distinct stages of physical addiction based on their most advanced symptom: 1-none, 2-wanting, 3-craving, or 4-needing. Using linear Chi square and ANOVA, we determined if higher stages were associated with higher levels of tobacco addiction on more than a dozen measures.
  
  
  RESULTS
  16.8% of subjects were in stage 1, 26.1% in stage 2, 17.1% in stage 3 and 40.0% in stage 4. Each step up in stage was associated with higher levels of addiction as measured by the Fagerström Test for Nicotine Dependence, the Hooked on Nicotine Checklist, the Autonomy over Tobacco Scale, and higher levels of psychological dependence, duration of tobacco use, frequency of tobacco use, daily cigarette consumption, and 10 additional measures.
  
  
  CONCLUSIONS
  In this cross-sectional study, each sequential stage of physical addiction was associated with higher levels of every indicator of addiction. The data suggest that the stages of progression of physical addiction provide a global indication of the severity of tobacco addiction.
authors.affiliation: Department of Family Medicine and Community Health, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA. difranzj@ummhc.org
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Difranza
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Wellman
authors.forename: Judith A
authors.initials: JA
authors.lastname: Savageau
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016739:Behavior, Addictive / Q000453:epidemiology / Q000523:psychology*; D003430:Cross-Sectional Studies; D018450:Disease Progression; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012907:Smoking / Q000453:epidemiology / Q000523:psychology*; D014029:Tobacco Use Disorder / Q000453:epidemiology / Q000523:psychology*; D055815:Young Adult