title: An evaluation of a clinical approach to staging tobacco addiction.
abstract: OBJECTIVE
  To determine whether adolescents' symptom reports are consistent with the developmental sequence of tobacco addiction and whether the sequential appearance of these symptoms signifies increasing addiction.
  
  
  METHODS
  An anonymous survey was administered to 349 tobacco users in grades 9 through 12 in Florida. The combinations of withdrawal symptoms reported were examined to determine whether they were consistent with the developmental sequence described by case reports (wanting, then craving, then needing). Dependence was measured by several validated measures, including the Hooked on Nicotine Checklist, the Autonomy Over Tobacco Scale, and the modified Fagerström Tolerance Questionnaire.
  
  
  RESULTS
  The combinations of withdrawal symptoms reported by 99.4% of subjects were consistent with case reports stating that wanting, craving, and needing develop in that sequence. Across the stages, from wanting to needing, higher stages were associated with significant increases in the strength of addiction as measured by the Hooked on Nicotine Checklist, the Autonomy Over Tobacco Scale, the modified Fagerström Tolerance Questionnaire, and all other measures.
  
  
  CONCLUSIONS
  Our data confirmed that withdrawal symptoms develop in an orderly sequence, as proposed, and indicate that each progressive step along the sequence of wanting, craving, and needing represents a substantial increase in tobacco addiction. This provides the foundation for a clinical approach to staging the progression of tobacco addiction.
authors.affiliation: Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA 01655, USA. joseph.difranza@umassmemorial.org
authors.forename: Joseph R
authors.initials: JR
authors.lastname: DiFranza
authors.forename: Michael
authors.initials: M
authors.lastname: Sweet
authors.forename: Judith
authors.initials: J
authors.lastname: Savageau
authors.forename: W W Sanouri
authors.initials: WW
authors.lastname: Ursprung
mesh_terms: D000293:Adolescent; D005260:Female; D006801:Humans; D008297:Male; D012720:Severity of Illness Index; D014029:Tobacco Use Disorder / Q000175:diagnosis*