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Sequencing of DSM-IV criteria of nicotine dependence


Denise B. Kandel, Columbia University, 1051 Riverside Drive, Unit 20, New York, NY 10032, USA. E-mail:


Aims  To determine whether there is a sequence in which adolescents experience symptoms of nicotine dependence (ND) as per the DSM-IV.

Design  A two-stage design was implemented to select a multi-ethnic target sample of adolescents from a school survey of 6th–10th graders from the Chicago Public Schools. The cohort was interviewed at home five times with structured computerized interviews at 6-month intervals over a 2-year period.

Participants  Subsample of new tobacco users (n = 353) who had started to use tobacco within 12 months prior to wave 1 or between waves 1 and 5.

Measurements and statistical methods  Monthly histories of DSM-IV symptoms of ND were obtained. Log-linear quasi-independence models were estimated to identify the fit of different cumulative models of progression among the four most prevalent dependence criteria (tolerance, impaired control, withdrawal, unsuccessful attempts to quit), indexed by specific symptoms, by gender and race/ethnicity.

Findings  Pathways varied slightly across groups. The proportions who could be classified in a progression pathway not by chance ranged from 50.7% to 68.8%. Overall, tolerance and impaired control appeared first and preceded withdrawal; impaired control preceded attempts to quit. For males, tolerance was experienced first, with withdrawal a minor path of entry; for females withdrawal was experienced last, tolerance and impaired control were experienced first. For African Americans, tolerance by itself was experienced first; for other groups an alternative path began with impaired control.

Conclusions  The prevalence and sequence of criteria of ND fit our understanding of the neuropharmacology of ND. The order among symptoms early in the process of dependence may differ from the severity order of symptoms among those who persist in smoking.