6.12Measures of tobacco dependence

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Last updated: February 2018 Suggested citation: Hall, W., Gartner, C., and Vittiglia, A. 6.12 Measures of tobacco dependence. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from http://www.tobaccoinaustralia.org.au/chapter-6-addiction/6-12-measures-of-tobacco-dependence

A smoker’s degree of tobacco dependence may be assessed by a range of measures. These include the frequency and quantity of tobacco consumed, biochemical markers (such as levels of cotinine, a by-product of nicotine metabolism, in the saliva), and questionnaire measures of self-reported smoking behaviour.¹

Instruments used in clinical settings that assess whether a smoker satisfies the criteria for drug dependence  include the DSM-5 criteria, derived from the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association² and the ICD-10 classification from the International statistical classification of diseases of the World Health Organisation³ A summary of the diagnostic criteria of Tobacco Use Disorder is described in Section 6.1.

Tests of psychological and physiological dependence, in the form of a questionnaire for smokers,⁴ include the Fagerström Test for Nicotine Dependence⁵ (which evolved from the earlier Fagerström Tolerance Questionnaire⁶), the Cigarette Dependence Scales,⁷ the Nicotine Dependence Syndrome Scale,⁸ the Wisconsin Inventory of Smoking Dependence Motives,⁹ and the Autonomy over Tobacco Scale¹⁰

The most commonly used measure¹¹ is the Fagerström Test for Nicotine Dependence.^5, 12 This instrument asks the smoker a set of questions, the answers to which are scored as shown in Table 6.5.1 and added to give a total score: a score of six or more is seen as an indicator of high dependence.

Question	Answer	Score
How soon after you wake up do you smoke your first cigarette?	Within 5 minutes	3
	6–30 minutes	2
	31–60 minutes	1
	After 60 minutes	0
Do you find it difficult to refrain from smoking in places where it is forbidden?	Yes	1
	No	0
Which cigarette would you hate to give up most?	The first one in the morning	1
	All others	0
How many cigarettes per day do you smoke?	10 or less	0
	11–20	1
	21–30	2
	31 or more	3
Do you smoke more frequently during the first hours after waking than during the rest of the day?	Yes	1
	No	0
Do you smoke if you are so ill that you are in bed most of the day?	Yes	1
	No	0

Source: Heatherton et al 5 

Another, newer measure of levels of addiction is the ‘Hooked on Nicotine Checklist,’ or HONC, which assesses when the individual loses their control, or autonomy, over their use of tobacco use.¹³ Loss of autonomy is the point at which ‘the sequelae of tobacco use, either physical or psychological, present a barrier to quitting’ (p399).¹³ The HONC was originally devised for use with younger smokers for whom some of the questions in the Fagerström Test were much less relevant. 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 permission.¹³ Subsequent research suggests that the HONC is also useful for measuring loss of autonomy over smoking in adults.^14, 15

The HONC asks 10 questions to assess degree of tobacco dependence.^13, 16  

1. Have you ever tried to quit, but couldn’t?

2. Do you smoke now because it is really hard to quit?

3. Have you ever felt like you were addicted to tobacco?

4. Do you ever have strong cravings to smoke?

5. Have you ever felt like you really needed a cigarette?

6. Is it hard to keep from smoking in places where you are not supposed to, like school?

When you tried to stop smoking … (or, when you haven’t used tobacco for a while…)

7. Did you find it hard to concentrate because you couldn’t smoke?

8. Did you feel more irritable because you couldn’t smoke?

9. Did you feel a strong need or urge to smoke?

10. Did you feel nervous, restless, or anxious because you couldn’t smoke?

Research on the HONC in young people has found that dependence may develop rapidly, even at low, sporadic levels of consumption.¹³ Some of these findings are discussed in Section 6.13. 

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References

1. Royal College of Physicians of London. Nicotine addiction in britain. A report of the tobacco advisory group of the royal college of physicians. London: Royal College of Physicians of London, 2000.

2. American Psychiatric Association, Diagnostic and statistical manual of mental disorders.  5th ed Arlington, VA: American Psychiatry Association; 2013.

3. World Health Organization. International statistical classification of diseases and related health problems 10th revision (ICD-10). Geneva: WHO, 1990, updated 2008. Available from: http://www.who.int/classifications/icd/en/.

4. Piper M, McCarthy D, Bolt D, Smith S, Lerman C, et al. Assessing dimensions of nicotine dependence: An evaluation of the Nicotine Dependence Syndrome Scale (NDSS) and the Wisconsin Inventory of Smoking Dependence Motives (WISDM). Nicotine and Tobacco Research, 2008; 10(6):1009–20. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2614360/

5. Heatherton T, Kozlowski L, Frecker R, and Fagerström K. The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. British Journal of Addiction, 1991; 86(9):1119−27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1932883

6. Fagerstrom K. Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addictive Behaviors, 1978; 3(3−4):235−41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/735910

7. Etter J, Le Houezec J, and Perneger T. A self-administered questionnaire to measure dependence on cigarettes: The cigarette dependence scale. Neuropsychopharmacology, 2003; 28(2):359−70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12589389

8. Shiffman S, Waters A, and Hickcox M. The Nicotine Dependence Syndrome Scale: A multidimensional measure of nicotine dependence. Nicotine and Tobacco Research, 2004; 6(2):327−49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15203807

9. Piper M, Federman E, Piasecki T, Bolt D, Smith S, et al. A multiple motives approach to tobacco dependence:  The Wisconsin Inventory of Smoking Dependence Motives (WISDM-68). Journal of Consulting and Clinical Psychology, 2004; 72(2):139−54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15065950

10. DiFranza J, Wellman R, Ursprung W, and Sabiston C. The autonomy over smoking scale. Psychology of Addictive Behaviors, 2009; 23(4):656–65. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20025371

11. Piper M, McCarthy D, and Baker T. Assessing tobacco dependence: A guide to measure evaluation and selection. Nicotine and Tobacco Research, 2006; 8(3):339−51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16801292

12. Haddock CK, Lando H, Klesges RC, Talcott GW, and Renaud EA. A study of the psychometric and predictive properties of the Fagerström test for nicotine dependence in a population of young smokers. Nicotine and Tobacco Research, 1999; 1(1):59–66. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11072389

13. DiFranza JR, Savageau JA, Fletcher K, Ockene JK, Rigotti NA, et al. Measuring the loss of autonomy over nicotine use in adolescents: The DANDY (Development and Assessment of Nicotine Dependence in Youths) study. Archives of Pediatrics and Adolescent Medicine, 2002; 156(4):397–403. Available from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/191739

14. DiFranza JR, Savageau JA, Rigotti NA, Fletcher K, Ockene JK, et al. Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study. Tobacco Control, 2002; 11(3):228–35. Available from: http://tc.bmjjournals.com/cgi/content/abstract/11/3/228

15. Wellman R, DiFranza J, Savageau J, Godiwala S, Friedman K, et al. Measuring adults' loss of autonomy over nicotine use: The Hooked on Nicotine Checklist. Nicotine and Tobacco Research, 2005; 7(1):157−61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15804688

16. Sargent J and DiFranza J. Tobacco control for clinicians who treat adolescents. CA: A Cancer Journal for Clinicians, 2003; 53(2):102−23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12691267