Are there different "types" of smokers, for example casual smokers versus chain smokers? Are there personality or physiological differences between types of smokers?

There are both casual smokers and chain smokers. For some, a couple of puffs can lead to an addiction. Some highly addicted smokers find it almost impossible to quit while others can make the decision to quit and never miss it.

There is no consistent evidence that supports the finding that there are specific psychological or biological traits that are linked with smoking. We do know that children of parents who smoke or did smoke are at higher risk of nicotine dependence than children whose family members do not smoke.

Psychological Traits

Although some studies point to certain personality traits that contribute to the tendency to become dependent on tobacco, the influence of the social environment and culture must also be taken into consideration. Some researchers have noted that smoking is frequently associated with drug and alcohol use, lack of physical exercise, poor nutrition, anxiety, depression, risky behaviors such as not using seat belts in automobiles, and failure to follow preventive guidelines in terms of lifestyle. These behavioral traits have been considered factors that may contribute to nicotine dependence. However, there is insufficient evidence about the relationship between personality traits and smoking. Other personality patterns that have been loosely connected to smokers are hostility, aggression, and violence.

Biological Differences

Recently, scientists have identified a single genetic variant that not only contributes to a smoker's addiction but also increases the risk of developing lung cancer. Four different teams of scientists from different parts of the world reached the same conclusion—that a genetic variant on chromosome 15 is associated both with heavy smoking and a susceptibility to lung cancer. Scientists also found that smokers who inherit these genetic variations from both parents have an 80% greater chance of becoming addicted to nicotine and at some point developing lung cancer.

What screening tools are used to diagnose addictive smokers?

A number of screening tools have been developed. One is a modification of the alcohol screening tool known as CAGE. CAGE is an acronym for four simple questions:

Cut down: Have you ever felt the need to cut down or control your smoking but had difficulty doing so?

Annoyed: Do you ever get annoyed or angry with people who criticize your smoking or tell you that you ought to quit?

Guilt: Have you ever felt guilty about your smoking or about something you did while smoking?

Eye-opener: Do you ever smoke within half an hour of waking up?

Another screening tool is an outline for the DSM-IV diagnosis of substance dependence. It is called the Four C's test:

Compulsion—the intensity with which the desire to use tobacco overwhelms your thoughts, feelings, and judgment.

Control—the degree to which you can or cannot control tobacco use once you start using.

Cutting down—the effects of reducing tobacco intake, that is, withdrawal symptoms.

Consequences—denial or acceptance of the damage caused by tobacco use.

Table 6 shows the Fagerstrom Test, which is a standard instrument to assess the intensity of physical addiction.

Table 6 modified Fagerström test for Nicotine dependence

modified Fagerström test for Nicotine dependence

Scoring: 7 to 10 points = highly dependent; 4 to 6 points = moderately dependent; less than 4 points = minimally dependent.

Adapted with permission from Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom test for nicotine dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991;86:1119-1127.

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