Short CommunicationExploring brief measures of nicotine dependence for epidemiological surveys
Introduction
The Fagerström Test for Nicotine Dependence (FTND) is the most widely used instrument to establish and quantify nicotine dependence (Heatherton, Kozlowski, Frecker, & Fagerström, 1991). The importance of FTND is that it may help to predict the success at stopping smoking. The FTND has six items that provide a total score ranging between 0 and 10. Two items of the FTND, Item 4 (the number of cigarettes per day; scored between 0 and 3), and Item 1 (the time to the first cigarette of the day; scored between 0 and 3), may be the most important items to reflect dependence (Kozlowski, Porter, Orleans, Pope, & Heatherton, 1994). The combination of these two items has been called the Heavy Smoking Index (HSI) since Heatherton, Kozlowski, Frecker, Rickert, and Robinson (1989) demonstrated its validity in three samples of smokers studied by using biological measures of smoking. In spite of some psychometric problems Haddock et al., 1999, Kozlowski et al., 1994, Payne et al., 1994, Pomerleau et al., 1994, the FTND continues to be the most widely used instrument to measure nicotine dependence all over the world. Fagerström et al. (1996) proposed that a FTND score of 6 or higher identifies subjects with high nicotine dependence.
In the past, epidemiological surveys have focused on the prevalence of tobacco smoking. A more recent survey focused on nicotine dependence points out that there is a need for changing the focus of epidemiological surveys of the general population from tobacco smoking to nicotine dependence (Breslau, Johnson, Hiripi, & Kessler, 2001). In the past, attempts to establish measures of nicotine dependence have been limited to prevalences of heavy smoking, which is usually defined as consuming more than 20 to more than 30 cigarettes per day. Heavy smoking is considered a gross indicator of high nicotine dependence.
Certainly, new epidemiological surveys may require brief measures of nicotine dependence. Ideally, the FTND can be used in some surveys but six questions may be too lengthy for many other surveys including hundreds of other questions. This study explores the use of FTND Items 1 or 4 or the combination of both items as brief measures of high nicotine dependence. The cut-off point of 6 in the FTND for classifying individuals as those with and without high nicotine dependence is considered as the “gold standard.” This gold standard is compared with: (1) a dichotomous classification of Item 4 that is equivalent to heavy smoking (smoking more than 30 cigarettes or having a score of 3 in Item 4); (2) a dichotomous classification of Item 1 (having a score of 2 or higher or smoking within 30 min) that has been used in one epidemiological survey (Son, Markovitz, Winders, & Smith, 1997) but has never been studied; and (3) a dichotomous classification of the HSI or what is the same the combination of Items 1 and 4 (having a score of 4 or higher).
Several samples described before Aguilar et al., submitted for publication, Becoña & Vázquez, 1998, de Leon et al., in press, Gonzalez-Pinto et al., 1998, Jurado et al., submitted for publication are used to conduct these new analyses. The objective of this study is to analyze the kappas, percentage of disagreement, and sensibility/specificity of three brief definitions of high nicotine dependence by comparing with the gold standard, a score≥6 in the FTND. The three brief definitions of nicotine dependence are heavy smoking (score=3 in Item 4); high score in early smoking (score≥2 Item 1) and a high HSI score (score≥4 in the addition of Items 1 and 4).
Section snippets
Method
Five samples including 1462 current daily smokers with FTND scores were analyzed. The samples are described in Table 1 and were obtained by combining samples from several studies in the US and Spain. The sample included patients with severe mental illnesses (schizophrenia and mood disorders) who are known to have high levels of nicotine dependence. The diagnoses for the US patients were schizophrenia 74% (89/120) and mood disorders 26% (31/120), including major depression 7% (8/120) and bipolar
Results
Heavy smoking, a measure traditionally used in epidemiological surveys as a proxy measure for nicotine dependence, had a relatively good agreement with high FTND but had a low sensitivity (59% for combined sample, Table 2). There was a relatively high percentage of subjects with no heavy smoking but with high dependence measured by FTND. In the combined sample, 12% of the participants were highly dependent by FTND but were not heavy smokers (the range for the five samples was from 4% to 29%).
Discussion
Researchers planning an epidemiological survey including questions about smoking, but who are unable to include the six items from the FTND, may want to consider including only two items: Item 4, which measures the number of cigarettes smoked per day, and Item 1, which measures the time to the first cigarette of the day. A score≥4 from the addition of these two items appears to provide a good brief measure of high nicotine dependence. If the researchers decide to follow the traditional practice
Acknowledgements
Mr. Diaz is an Associate Instructor in Statistics at Universidad Nacional de Colombia. Mr. Diaz's salary was partly supported by a grant from the Kentucky Department of Mental Health and Mental Retardation (to Jose de Leon). Margaret T. Susce, R.N., M.L.T. helped in editing this article. Please see original publications for acknowledgments and a complete list of people who helped with data collection.
References (15)
- Aguilar, M. C., Gurpegui, M., Diaz, F. J., & de Leon, J. (submitted for publication). Complex interactions between...
- et al.
The Fagerström Test for Nicotine Dependence in a Spanish sample
Psychological Reports
(1998) - et al.
Nicotine dependence in the United States: Prevalence, trends and smoking persistence
Archives of General Psychiatry
(2001) - de Leon, J., Becoña, E., Gurpegui, M., Gonzalez-Pinto, A., & Diaz, F. J. (in press). The association between high...
- et al.
Nicotine dependence and initiation of smoking in schizophrenia and mood disorders
Schizophrenia Research
(2002) - et al.
Nicotine dependence versus smoking prevalence: Comparison among countries and categories of smokers
Tobacco Control
(1996) - et al.
Tobacco smoking and bipolar disorder
Journal of Clinical Psychiatry
(1998)
Cited by (82)
Item Response Theory analysis of Fagerström Test for Cigarette Dependence
2018, Addictive BehaviorsCitation Excerpt :Again, there are no studies in the literature on this issue and the result can be explained by the fact that the youngest smoke fewer cigarettes and wait longer before smoking their first cigarette of the day (Hammond, 2005). ROC analyses suggested a cut-off point of 6 for FTCD and of 4 for HSI to define heavy smokers, values which are consistent with the literature (Chabrol et al., 2005; de Leon et al., 2003; Diaz et al., 2005; Fagerström et al., 1996). ROC analyses also suggested a cut-off point of 3 for FTCD and of 1 for HIS to identify light smokers.
Evaluating the role of smokeless tobacco use indices as brief measures of dependence
2017, Addictive BehaviorsThe relationship of waterpipe use with cigarette smoking susceptibility and nicotine dependence: A cross-sectional study among Hong Kong adolescents
2017, Addictive BehaviorsCitation Excerpt :Those who answered “definitely no” to both questions were considered unsusceptible to cigarette smoking and otherwise as susceptible to smoking. Nicotine dependence was assessed by two items from the Heaviness of Smoking Index, including cigarette consumption per day and the time to first cigarette of waking (de Leon et al., 2003; Kozlowski, Porter, Orleans, Pope, & Heatherton, 1994). Cigarette consumption per day was measured by asking “During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?”
Warm Handoff Versus Fax Referral for Linking Hospitalized Smokers to Quitlines
2016, American Journal of Preventive MedicineRisky use and misuse of alcohol and cigarettes in psychiatric inpatients: A screening questionnaire study
2016, Comprehensive PsychiatryCitation Excerpt :Another common screening questionnaire is the Lübeck Alcohol Dependence and Abuse Screening Test (LAST) [30], which allows to detect patients with alcohol dependence or abuse. The value of the use of screening questionnaires to detect smoking and nicotine dependence has also been established [31]. The Fagerström Test for Nicotine Dependence (FTND) [32], developed as a revision of the Fagerström Tolerance Questionnaire, is the most widely used instrument to assess and quantify nicotine dependence all over the world [31].