Assessment of nicotine dependence among adolescent and young adult smokers: A comparison of measures

Introduction

Tobacco use often starts in adolescence, yet assessment of dependence among adolescent smokers remains a challenge, particularly given the potential discord between self-reports of smoking behavior and actual use. We could find no prior study, among adolescents, that directly compares the association between objective biomarkers of tobacco exposure (e.g., cotinine) and multiple measures of dependence. This study examined the concurrent validity of two common dependence measures: the Fagerström Test for Nicotine Dependence (FTND) and the Hooked on Nicotine Checklist (HONC). We further examined the FTND by removing the one item on cigarettes smoked per day.

Methods

Based within a parent clinical trial for adolescent smoking cessation, eligible participants were 12–21 years old, smoking ≥ 5 cigarettes per day on average, and with urine cotinine > 100 ng/ml at baseline. Results are based on participants who completed each measure and who provided a urine cotinine sample at baseline (N = 73).

Results

Results showed that the FTND was associated with cotinine (p < 0.001; R² = 0.25), and that this relationship held true for the revised FTND as well (p < 0.001; R² = 0.18). However, the HONC was only marginally associated with cotinine (p = 0.06; R² = 0.09).

Discussion

Our results suggest that the FTND may be better associated with actual smoking behavior in adolescents as compared to the HONC. Pending replication, our data provide caution with regard to assessment of nicotine dependence at least among established adolescent smokers who have more entrenched smoking behavior.     

Alcohol use as a signal for sensitivity to nicotine dependence among recent onset smokers

Objective

This study evaluated the association between alcohol use, abuse and dependence and cigarette smoking to determine whether alcohol may signal greater sensitivity to nicotine dependence at very low levels of smoking.

Method

Data were drawn from five annual National Surveys on Drug Use and Health and included individuals age 12 to 21 who reported first exposure to smoking within the past two years and smoking at least once in the past month.

Results

Both alcohol abuse and alcohol dependence were associated with increased likelihood of symptoms that seem to tap tolerance for nicotine. These included items such as “the amount you smoke has increased”; “needing to smoke a lot more now in order to be satisfied”; and “smoking much more before starting to feel anything”. Alcohol dependence, but not abuse was associated with the remaining symptoms, “after not smoking for a while, needing to smoke to feel less restless and irritable”; “craving cigarettes after not smoking for a while”; and “worrying about running out of cigarettes”. All associations were not better accounted for by either alcohol use or amount smoked.

Conclusion

If causally associated, treatment of alcohol-use disorders may prevent or reduce the early emergence of nicotine dependence symptoms among new smokers, very early in the smoking uptake process. If instead alcohol disorders are a signal of sensitivity for nicotine dependence best accounted for by a third variable, then adolescents with alcohol dependence and/or abuse during early exposures to smoking represents an important subgroup that may benefit from interventions directly targeting this association.     

Association of parental smoking history with nicotine dependence, smoking rate, and psychological cofactors in adult smokers

Family history is a powerful predictor of variation in risk of common diseases and conditions because it can represent the influence of both shared genes and shared environments. To investigate the relationship of parental smoking history with nicotine dependence and smoking rate, as well as with known psychological cofactors for smoking (depression, anxiety, alcoholism, disordered eating), we studied smoking adults who provided smoking history for both parents. We found that having two ever-smoking parents, in comparison to zero or one, was associated with higher nicotine dependence scores, cigarettes per day, and levels of anxiety in participant, with a trend for depression. Participants whose mothers smoked during pregnancy had significantly higher scores on nicotine dependence, smoking rate, and disordered eating than participants with either ever-smoking mothers who did not smoke during pregnancy or never-smoking mothers. These findings suggest that family history of smoking may be a key determinant of interindividual variation in smoking behavior, nicotine dependence, and psychological cofactors among smokers.     

Major depression among adolescent smokers undergoing treatment for nicotine dependence

This is the first study to examine the prevalence and effects of major depression (MDD) in a sample of adolescent smokers (N = 211) undergoing treatment for nicotine dependence. We assessed MDD at baseline and end of treatment with the mood disorders portion of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Eleven percent of participants reported a history of MDD (6% of males and 21% of females). Study variables did not distinguish those with and without a history of MDD. End of treatment abstinence rates and relapse rates were similar in both groups. Two participants (1%), both female, experienced onset of MDD during the treatment. The findings provide further evidence that MDD is a comparatively common disorder among children and adolescents and that clinicians should monitor and be prepared to respond to depression that may emerge during the treatment of nicotine-dependent adolescents.     

Association of secondhand smoke exposure with nicotine dependence among Black smokers

Introduction

Exposure to secondhand smoke (SHS) is influenced by norms and regulations, socioeconomic status and immediate personal interactions. SHS exposure may occur in various settings, including the living space, workplace, and other social environments. This study examines the association between exposure to SHS and nicotine dependence among current smokers.

Methods

A cross-sectional sample of 246 Black (60% male and 40% female) current smokers age 40 and older, from Baltimore, Maryland and Washington, D.C, responded to an interviewer-administered questionnaire. We examined nicotine dependence using clinical guidelines based on the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (2000). We performed multivariate logistic regression to assess the association between SHS and nicotine dependence.

Results

SHS exposure in the current home environment and exposure in settings outside the home, as well as difficulty to quit smoking and heaviness of smoking, were associated with nicotine dependence. After adjustment for age, gender, education, income, employment status, current alcohol consumption, history of marijuana use, and number of cigarettes smoked per day; exposure to SHS at home only, and in both current home environment and other settings, continued to be associated with clinically-defined nicotine dependence (OR = 2.25; 95% CI 1.05, 4.86 vs. OR = 2.31; 95% CI 1.03, 5.18), respectively.

Discussion

These findings highlight the relative importance of examining SHS exposure in personal (residential and automobile) and public (workplace and outdoor) settings by current smokers. Promotion of smoke-free environments may reduce the prevalence of nicotine dependence among current smokers.     

The relationship between self-efficacy and nicotine withdrawal severity among adult smokers

Cigarette smokers who have low confidence in their ability to resist temptations to smoke or to quit smoking altogether (i.e., low quitting-related self-efficacy) are more likely to relapse during an attempt to quit smoking. Therefore, it is important to understand what factors influence quitting-related self-efficacy, especially during early abstinence when relapse is most likely to occur. Social cognitive theory suggests two competing hypotheses: (1) negative emotional and physiological states, such as those associated with the nicotine withdrawal syndrome, will reduce self-efficacy related to smoking cessation; and (2) low self-efficacy will increase an individual's susceptibility to arousal, such as the negative emotions and physiological responses associated with nicotine withdrawal. The current preliminary study prospectively examined the association between nicotine withdrawal severity and self-efficacy in 21 adult, heavy smokers (23.8% female) at three time points during the first 48?h of abstinence from smoking cigarettes. Results indicated that withdrawal severity did not predict self-efficacy. Instead, self-efficacy after 24?h of abstinence showed a trend toward predicting withdrawal severity at 48?h of abstinence. Findings suggest the possibility that low self-efficacy may be associated with an increase in nicotine withdrawal severity, and also suggest the presence of a dynamic relationship between self-efficacy and nicotine withdrawal.     

The relationship between nicotine dependence scores and biomarkers of exposure in adult cigarette smokers

Background: Tobacco dependence is a multidimensional phenomenon. The Fagerström Test for Nicotine Dependence (FTND) is a widely administered six-item questionnaire used as a measure of nicotine dependence. It has been suggested that this test may not represent the entire spectrum of factors related to dependence. Also the relationship of this test with biomarkers of exposure to cigarette smoke has not been extensively studied. Methods: Data from a multi-center, cross-sectional, ambulatory study of US adult smokers (the Total Exposure Study, TES) was analyzed. The FTND score and a number of additional questions related to smoking behavior, from an adult smoker questionnaire (ASQ) completed by 3585 adult smokers in the TES were analyzed. The 24-h urine nicotine equivalents, serum cotinine and blood carboxyhemoglobin were measured as biomarkers of exposure (BOE) to nicotine and carbon monoxide. Cigarette butts returned were collected during the 24-h urine collection period. Results: The FTND showed moderate correlations with BOE, while selected questions from ASQ although statistically significant, had weaker correlations. FTND scores showed substantially weaker correlations without the question about cigarettes smoked per day (CPD). CPD and time to first cigarette (TTFC) had the most impact on BOE. Conclusion: Additional questions from ASQ did not appear to contribute towards refining the FTND test. The correlation of the FTND scores with nicotine and carbon monoxide seems to be primarily driven by CPD. CPD and TTFC were the most important factors correlating with exposure.     

The relationship between impulsivity,risk-taking propensity and nicotine dependence among older adolescent smokers

Impulsivity and risk-taking propensity are neurobehavioral traits that reliably distinguish between smoking and non-smoking adults. However, how these traits relate to smoking quantity and nicotine dependence among older adolescent smokers is unclear. The current study examined impulsivity and risk-taking propensity in relation to smoking behavior and nicotine dependence among current older adolescent smokers (age 16–20 years; N = 107). Participants completed the Barratt Impulsiveness Scale‐11 (BIS-11), the Balloon Analogue Risk Task (BART), and self-report measures of smoking behavior and nicotine dependence. Results indicated a significant positive relationship between nicotine dependence and the Attention subscale (β = .20, t = 2.07, p < .05) and the Non-planning subscale (β = .19, t = 1.92, p < .06) of the BIS-11. Contrary to expectation, the results also indicated a significant negative relationship between performance on the BART and nicotine dependence (β = − .19, t = − 2.18, p < .05), such that greater risk-taking propensity was associated with less dependence. These data suggest that impulsivity and risk-taking propensity are related to older adolescent smoking but are separable traits with distinguishable associations with nicotine dependence among adolescents. These findings support the notion that impulsivity is related to heightened nicotine dependence, but suggest that the relationship between risk-taking propensity and nicotine dependence is more ambiguous and warrants further investigation.     

Predictors of 6-month tobacco abstinence among 1224 cigarette smokers treated for nicotine dependence

This study examined baseline characteristics associated with abstinence from tobacco 6 months after treatment for nicotine dependence. A total of 1224 cigarette smokers (619 females, 605 males) receiving clinical services for treatment of nicotine dependence between January 1, 1995 and June 30, 1997 were studied. The intervention involves a 45-min consultation with a nicotine dependence counselor. A treatment plan individualized to the patient's needs is then developed. The main outcome measure was the self-reported 7-day point prevalence abstinence from tobacco obtained by telephone interview 6-months after the consultation. A bootstrap resampling methodology for predictor variable selection was used to identify a set of multivariate predictors of 6-month tobacco abstinence. Five variables were multivariately associated with tobacco abstinence: male gender, no current psychiatric diagnosis, higher stage of change, longest duration of previous abstinence from tobacco of <1 or > or =30 days, and Fagerstr?m Test for Nicotine Dependence (FTND) score of < or =5. Assessment of these variables may be useful clinically by assisting health care providers in tailoring nicotine dependence interventions to enhance outcomes.     

Nicotine dependence and attempts to quit or cut down among young adult smokers

AIMS: To describe tobacco smoking behaviours, attempts to cut down or quit, and estimate the prevalence of DSM-IV nicotine dependence among young adult smokers. To relate these findings to population demand for national Quitline services. METHODS: Confidential interviews were conducted during the assessment of the Dunedin Multidisciplinary Health and Development Study birth cohort at age 26 years. Current smokers who had smoked daily for at least one month during the twelve months before interview were asked questions to identify nicotine dependence, based on DSM-IV criteria. RESULTS: Overall, 40% (n = 386) of the cohort followed up were current smokers who met the twelve month daily smoking criterion, one third of whom fulfilled DSM-IV criteria for nicotine dependence. The mean number of attempts to quit or cut down in the past year was 1.2. Assuming that each attempt represents a potential call to the Quitline, more than 5500 calls per month might be anticipated from the 25-29 year age group and in excess of 40 000 from the total New Zealand population, eighteen years and older. CONCLUSIONS: Results indicate that many young adult smokers are potential users of smoking cessation services and many are nicotine dependent. In order to satisfy this reservoir of need and reduce the population burden of ill-health and premature death due to tobacco smoking, resources should continue to be provided to support and enhance tobacco control programmes with proven effectiveness in helping smokers to quit.     

Slower nicotine metabolism among postmenopausal Polish smokers

Background

A non-invasive phenotypic indicator of the rate of nicotine metabolism is nicotine metabolite ratio (NMR) defined as a ratio of two major metabolites of nicotine – trans-3′-hydroxycotinine/cotinine. The rate of nicotine metabolism has important clinical implications for the likelihood of successful quitting with nicotine replacement therapy (NRT). We conducted a study to measure NMR among Polish smokers.

Carbon monoxide feedback in a motivational decision support system for nicotine dependence among smokers with severe mental illnesses

Health concerns are common reasons for wanting to quit smoking among smokers with mental illnesses. Motivational interventions have used feedback from a carbon monoxide monitor to increase awareness of health concerns, but this device is not commonly available. Whether brief motivational interventions can be effective without this feedback is unknown. Using a randomized controlled trial, this study tested the effect of carbon monoxide feedback within a brief, multi-component, computerized motivational intervention among 124 smokers with schizophrenia or mood disorders. The main outcome was initiating cessation treatment over two months. Although participants in the carbon monoxide group increased their knowledge about the carbon monoxide, (χ² = 6.97, df = 1, p = .008), the main and secondary outcomes did not differ significantly between groups. Overall, 32% of participants initiated treatment. This study suggests that a computerized motivational decision support system can lead users to initiate cessation treatment, and that carbon monoxide feedback is not a necessary component.     

The absence of DSM-IV nicotine dependence in moderate-to-heavy daily smokers

BACKGROUND: Current theoretical models of nicotine dependence assume a close relationship between use and dependence; however, previous data suggest that many daily smokers fail to develop nicotine dependence. OBJECTIVES: To determine what percentage of daily smokers fail to meet DSM-IV criteria for nicotine dependence within their lifetime, how non-dependence relates to duration and quantity of cigarette use, and whether other tobacco use and/or specific dependence criteria differentiate never-dependent and dependent smokers. METHODS: Cross-sectional data collected via personal interview from a nationally representative sample of 8213 past year daily smokers were analyzed. RESULTS: Approximately 39.4% of daily smokers never reached nicotine dependence. While the probability of remaining non-dependent decreased with smoking quantity and duration since the onset of daily smoking, a substantial portion of individuals (37.7%) who reported smoking >or=10 cigarettes per day and began smoking daily >or=10 years prior, remained never nicotine dependent. CONCLUSIONS: The absence of nicotine dependence in heavy daily smokers may result from limitations in the measurement of dependence and/or nicotine exposure. Alternatively, some individuals may be relatively resistant to becoming nicotine dependent despite extensive use. The latter explanation would have important implications for understanding the nature of nicotine dependence.     

Nicotine dependence as a moderator of a quitline-based message framing intervention

High nicotine dependence is a reliable predictor of difficulty quitting smoking and remaining smoke-free. Evidence also suggests that the effectiveness of various smoking cessation treatments may vary by nicotine dependence level. Nicotine dependence, as assessed by Heaviness of Smoking Index baseline total scores, was evaluated as a potential moderator of a message-framing intervention provided through the New York State Smokers' Quitline (free telephone based service). Smokers were exposed to either gain-framed (n=810) or standard-care (n=1222) counseling and printed materials. Those smoking 10 or more cigarettes per day and medically eligible were also offered a free 2-week supply of nicotine patches, gum, or lozenge. Smokers were contacted for follow-up interviews at 3 months by an independent survey group. There was no interaction of nicotine dependence scores and message condition on the likelihood of achieving 7-day point prevalence smoking abstinence at the 3-month follow-up contact. Among continuing smokers at the 3-month follow-up, smokers who reported higher nicotine dependence scores were more likely to report smoking more cigarettes per day and this effect was greater in response to standard-care messages than gain-framed messages. Smokers with higher dependence scores who received standard-care messages also were less likely to report use of nicotine medications compared with less dependent smokers, while there was no difference in those who received gain-framed messages. These findings lend support to prior research demonstrating nicotine dependence heterogeneity in response to message framing interventions and suggest that gain-framed messages may result in less variable smoking outcomes than standard-care messages.     

Smoking outcome expectancies in young adult female smokers: individual differences and associations with nicotine dependence in a genetically informative sample

Outcome expectancy is a central construct in models of addiction. Several outcome expectancies associated with smoking cigarettes have been identified, and studies suggest that individual differences in smoking expectancies are related to important aspects of tobacco use, including levels of smoking, nicotine dependence and smoking cessation. In the present study, we used a novel analytic method, exploratory structural equation modeling (ESEM), to quantify smoking expectancies from a subset of items adapted from the Smoking Consequences Questionnaire (SCQ; Brandon and Baker, 1991) and SCQ-Adult (Copeland et al., 1995). In our sample of 1262 monozygotic and dizygotic young adult, female twins who were regular smokers, we quantified six smoking expectancy factors similar to those reported in previous studies. These included Negative Affect Reduction, Boredom Reduction, Weight Control, Taste Manipulation, Craving/Addiction and Stimulation-state Enhancement. We used genetic model-fitting to examine the extent to which individual differences in the expectancies were influenced by latent genetic, shared environmental and non-shared environmental factors. We also examined the validity of the expectancy factors by examining their associations with nicotine dependence (ND) before and after adjusting for comorbid diagnoses of drug dependence and alcohol use disorder. Results of the validity analysis indicated that all of the expectancies were associated with ND after covariate adjustment. Although we lacked the statistical power to distinguish between genetic and shared environmental sources of variance, our results suggest that smoking outcome expectancies aggregate in families, but the majority of variance in these expectancies is due to environmental factors specific to the individual.     

Using an item response model to examine the nicotine dependence construct as characterized by the HONC and the mFTQ among adolescent smokers

Despite efforts to operationalize the nicotine dependence syndrome among adolescents, little is known regarding the relative severity of dependence symptoms assessed by different measures. The current study utilized a nonparametric item response model to assess the unidimensionality of the nicotine dependence construct and relative severity of dependence symptoms characterized by the Hooked on Nicotine Checklist (HONC) and the modified Fagerström Questionnaire (mFTQ) in a sample of 109 adolescent smokers (58% female) participating in a prospective investigation of smoking self-change efforts. It was hypothesized that symptoms assessed by the HONC would be associated with lower levels of nicotine dependence severity than symptoms assessed with the mFTQ. Results indicated that HONC and mFTQ items could be linked to a single latent construct. Most HONC items captured variability at the lower range and mFTQ items made discriminations at the middle and higher end of the dependence severity continuum. Findings suggest the HONC and mFTQ may provide complementary information in assessing nicotine dependence levels in adolescent regular smokers and have implications for symptoms expression in youth.     

Measuring nicotine dependence among smokeless tobacco users

The objective of this study was to assess the concurrent validity of the FTQ-ST and the DIS-IV diagnosis of nicotine dependence among 68 adult ST users enrolled in a randomized, controlled clinical trial of bupropion SR. FTQ-ST scores were not found to differ between those with and without a current DIS-IV diagnosis of nicotine dependence (7.4+/-2.1 vs. 6.8+/-2.8, P=0.325). For all possible FTQ-ST cutoff scores, the observed agreement between the FTQ-ST and the DIS-IV was not found to be different from that expected due to chance. FTQ-ST total scores were positively correlated with serum cotinine (Spearman's r=0.40, P<0.001), amount of tobacco used (r=0.51 and r=0.41 for average dips/chews per day; average tins/pouches per week, respectively, P<0.001), and a reduced likelihood of abstinence at 3 months (OR=0.76, 95% C.I. 0.61-0.96; P=0.019). Participants meeting DIS-IV criteria had lower cotinine concentrations than those without this diagnosis (411+/-263 ng/ml vs. 493+/-246 ng/ml; P=0.042). Poor concordance was observed between the FTQ-ST and the DIS-IV in the assessment of nicotine dependence in ST users.     

Physical dependence and attributions of addiction among cigarette smokers

Examination of the attitudes and attributions of cigarette smokers has differentiated smokers who believe their behavior is a "sickness" from those who believe they are "hooked." Among other things, the hooked smoker, more than the sick one, believes they are addicted and their chances of stopping smoking are poor. If there is a causal association between the attribution of addiction and perceived prospects of change, as this suggests, it could mean treatment and preventative programs stressing the addictive nature of cigarettes may be counterproductive. However, the present study, using a survey of 105 male and female smokers from the general population, suggests the attribution of addiction is related to a smoker's estimate of their chances of stopping only through a common association that each of these measures has with actual (not necessarily perceived) physical dependence. Caution is needed in the application of cognitive research when related physical measures have not been included in the research design.     

Nicotine dependence,internalizing symptoms,mood variability and daily tobacco use among young adult smokers

IntroductionCigarette use among young adults continues to rise. As young adults transition to college and assume other adult roles and responsibilities, they are at risk for the development of mental health problems and for the progression of substance use problems. Previous studies suggest that individual differences in negative and positive mood contribute to cigarette use in established college-aged smokers, but less is known whether fluctuations in mood influence daily cigarette use, controlling for trait levels of internalizing symptoms and nicotine dependence.MethodsData for this study came from a sample of college students (N = 39, 59% female, mean age 20.4 years) who reported regular cigarette use and participated in a 21-day ecological momentary assessment (EMA) study assessing within-individual variation in cigarette use and mood.ResultsA three-level hierarchical linear model accounting for the structure of 1896 occasions of cigarette use nested within days and individuals indicated that within-individual variability in positive mood was associated with cigarette use at each occasion, after taking into account baseline levels of nicotine dependence and internalizing problems.ConclusionsDaily shifts in positive moods are importantly associated with consuming cigarettes throughout the day.     

Effects of nicotine on cooperative responding among abstinent male smokers

The effects of nicotine on human cooperative responding in abstinent male smokers were examined. During episodes occurring at random times through a session, concurrently available cooperative and independent responses were maintained by points exchangeable for money. Cooperative responses simultaneously added points to counters marked "Your Earnings" and "Other's Earnings" only if the subject's and another person's responses ostensibly coincided. Independent responses added points only to the counter marked "Your Earnings". After the first daily session abstinent subjects smoked ad libitum, received either 0, 2 or 4mg nicotine gum or abstained from smoking. Increases from this first session in time allocated to the cooperative response option, proportion of cooperative responses and cooperative response rate were significantly greater following ad libitum smoking or acute administration of 4mg nicotine. No effects of nicotine abstinence were observed on independent response rate. These results suggest effects on sociability may maintain nicotine use and increase relapse risk in abstinent smokers.