6.5 Measures of dependence

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6.0 Introduction

6.1 Defining nicotine as a drug of addiction

6.2 The physiological effects of nicotine

6.3 Psychoactive effects of nicotine

6.4 Influence of genetic factors on addiction

6.5 Measures of dependence

6.6 The association between addiction and socioeconomic status

6.7 Addiction and the adolescent smoker

6.8 Tobacco 'chippers'

6.9 Nicotine withdrawal syndrome

6.10 Nicotine and other drug use

6.11 Smokers' attitudes to and beliefs about addiction

Acknowledgments

References

Degree of tobacco dependence may be assessed by a range of diagnostic tools. Measurements of frequency and quantity of tobacco consumed, testing for biochemical markers (generally determined by the presence of cotinine, a by-product of nicotine metabolism, in the saliva) and questionnaires are all means of estimating extent of tobacco dependence.2

Several tests of psychological and physiological dependence, in the form of a questionnaire for smokers, have been developed,31 including the Fagerström Test for Nicotine Dependence15 (which evolved from the earlier Fagerström Tolerance Questionnaire32), the Cigarette Dependence Scales,33 the Nicotine Dependence Syndrome Scale,34 the Wisconsin Inventory of Smoking Dependence Motives,35 and instruments36, 37 based on the criteria for drug dependency given in the Diagnostic and Statistical Manual of Mental Disorders compiled by American Psychiatric Association, described in Section 6.1.

Of these, the most commonly used31 is the Fagerström Test for Nicotine Dependence.15 This instrument asks the smoker a set of questions, the answers to which are scored as shown in Table 6.2. The answers are added to find a single score. A score of six and above is seen as an indicator of high dependence.

Another recently developed system for assessing levels of addiction is the 'Hooked On Nicotine Checklist,' or HONC, which seeks to assess when the individual loses their control, or autonomy, over their use of tobacco use. Loss of autonomy is the point at which 'the sequelae of tobacco use, either physical or psychological, present a barrier to quitting.'38 p 399 The HONC was first devised specifically for younger smokers, due to the perception that some of the questions asked in the Fagerström Test are less relevant for youth. For example, most adolescents would not be able to smoke within minutes of waking in the morning, or if ill in bed, unless they were doing so with parental authority.38 More recent applications of the HONC suggest that it is also a useful instrument for measuring loss of autonomy over smoking in adults as well.39

The HONC poses 10 questions as shown in Table 6.3, the answers to which provide information by which degree of tobacco dependence can be measured:38, 40

Research applying the HONC criteria to dependency in young people has demonstrated that dependency on smoking may develop rapidly, even at low, sporadic levels of consumption.41 Some of these findings are discussed in Section 6.7 .