Development of a screening questionnaire for tobacco/nicotine dependence according to ICD-10, DSM-III-R, and DSM-IV.

A 10-item questionnaire (the Tobacco Dependence Screener; TDS) for screening of tobacco/nicotine dependence according to ICD-10, DSM-III-R, and DSM-IV was newly developed. The reliability and validity were assessed in three samples of smokers in Japan. A total of 58 male smokers completed the TDS and the Fagerstrom Tolerance Questionnaire (FTQ), and they were interviewed using the World Health Organization's Composite International Diagnostic Interview (Sample 1). A total of 118 male and 36 female smoking outpatients completed the TDS and the FTQ and provided a breath sample for carbon monoxide measurement (Sample 2). A total of 194 male smokers joined a health education program using a health risk appraisal (HRA) and reported their smoking status and completed the TDS 6 months after receiving the HRA results (Sample 3). The Cronbach's alpha coefficients for the TDS ranged from .74 to .81 among the samples, whereas those for the FTQ ranged from .41 to .64. Receiver operator characteristic analyses indicated that the TDS had a better screening performance for ICD-10, DSM-III-R, and DSM-IV diagnoses than did the FFQ. The TDS score significantly and positively correlated with the severity of the diagnoses, the carbon monoxide levels, number of cigarettes smoked per day, and years of smoking. The TDS score was significantly lower in those who quit smoking than in those who did not quit smoking after the HRA. It is suggested that the TDS is a reliable and useful screening questionnaire for tobacco/nicotine dependence according to ICD-10, DSM-III-R, and DSM-IV.     

Diagnostic concordance of DSM-III-R, DSM-IV, and ICD-10 inhalant use disorders

The diagnostic concordance of DSM-III-R, DSM-IV, and ICD-10 inhalant use disorders was assessed using the sample of lifetime inhalant users (n=76) participating in the DSM-IV Field Trial for Substance Use Disorders. Substantially smaller proportions of lifetime inhalant users met DSM-IV inhalant abuse or dependence criteria than met comparable DSM-III-R or ICD-10 criteria. DSM-III-R and ICD-10 performed similarly, although DSM-III-R tended to be more inclusive vis-à-vis diagnoses of inhalant dependence. Kappa coefficients indicated a moderate degree of concordance between the three nosologies for inhalant use disorder diagnosis rates. Inclusion of possible withdrawal symptomatology criteria (that are not normally included) in the DSM-IV and ICD-10 criteria sets for inhalant dependence exerted little effect on diagnosis rates.     

A multiple motive/multi-dimensional approach to measure smokeless tobacco dependence

Background

Unlike various research studies conducted to address dependence among smokers, only a few studies have examined smokeless tobacco (ST) dependence. The Fagerström Tolerance Questionnaire (FTQ) and Fagerström Test for Nicotine Dependence (FTND) based scales are the most widely used measures of nicotine dependence for both ST users and smokers. These scales were initially developed to measure physical dependence and tolerance and not to assess other salient dimensions of dependence such as craving, compulsion, or withdrawal, as defined by DSM-IV and ICD-10. The aim of this study is to develop and validate a multidimensional scale that has better content coverage, factor structure, and psychometric properties to measure dependence among ST users.

Methods

100 adult male smokeless tobacco users were recruited through email distribution lists and community referral. Participants completed three different nicotine dependence questionnaires and provided information related to their tobacco use and demographic characteristics. They also provided a saliva sample for cotinine measurement. In order to develop the new ST scale, subscales and items were selected based on correlation and factor analysis of the modified WISDM-68. Reliability and validity of the new scale, Oklahoma Scale for Smokeless Tobacco Dependence (OSSTD) were also assessed.

Results

The new ST scale identified seven latent constructs including 23 items to measure ST dependence. Internal consistency as measured by Cronbach's coefficient (α = 0.925) indicated better reliability of OSSTD than FTND-ST. Concurrent validity of OSSTD as evaluated by comparing it with dependence diagnosis and FTND-ST was affirmative. There was a significant correlation between the OSSTD total score and the cotinine levels and tobacco use characteristics among study participants.

Conclusion

OSSTD possesses better psychometric properties and provides an effective and efficient tool to measure ST dependence as a multidimensional construct.     

Nicotine dependence, psychological distress and personality traits as possible predictors of smoking cessation. Results of a double-blind study with nicotine patch

Aim

Nicotine replacement therapy (NRT) is an effective treatment for smokers who want to quit, however, the rates of successful quitting can be improved even more. In this context, nicotine dependence (assessed via the Fagerström Tolerance Questionnaire, FTQ), psychological distress (measured via the Symptom Rating Test, SRT), and personality traits (evaluated via the Adult Eysenck Personality Inventory, AEPI) were evaluated as possible predictors of smoking cessation.

Results

A total of 297 cigarette smokers were followed for one year as part of a NRT double-blind, parallel group, randomized trial. Baseline nicotine dependence (weeks 12 and 26: p < 0.05), AEPI neuroticism (weeks 12 and 52: p < 0.05), and AEPI psychoticism (weeks 12 and 52: p < 0.05) scores significantly influenced the outcome of smoking cessation during one-year of follow-up. An increase in psychological distress during follow-up was associated with a lower probability of quitting smoking (p = 0.000).

Conclusions

Nicotine dependence, neuroticism, psychoticism and, over time, psychological distress were the main factors influencing the long-term outcome (i.e., up to 12 months) of smoking cessation under NRT.     

Nicotine dependence and psychiatric and substance use comorbidities in a sample of American Indian male veterans

BackgroundAmerican Indians and Alaska Natives have the highest rates of nicotine dependence in the U.S. However, studies analyzing associations between nicotine dependence and psychiatric and substance use disorders in these groups have been limited.MethodsThis study analyzes the co-occurrence of current and lifetime DSM-III-R nicotine dependence with psychiatric and substance use disorders in a community sample of 480 American Indian male veterans.ResultsLifetime nicotine dependence (23.3%) was associated with all lifetime disorders studied, including alcohol use and drug use disorders, affective and anxiety disorders, PTSD, pathological gambling and antisocial personality disorder. Current nicotine dependence was present in 19% of the sample and significantly associated with current affective and gambling disorder.ConclusionsSubstantial co-morbidity exists between nicotine dependence and other substance abuse and psychiatric disorders among this sample of American Indian male veterans, particularly for lifetime diagnoses. Screening for all psychiatric disorders among American Indian/Alaska Native smokers may be warranted. Although these results are similar to those observed among the general U.S. population, unique risk factors exist among American Indians/Alaska Natives which may require further attention. Specific public health and clinical interventions to reduce the rate of nicotine dependence among American Indians/Alaska Natives are recommended.     

The Fagerstrom Test for Nicotine Dependence and the Diagnostic Interview Schedule: do they diagnose the same smokers?

Two common assessment tools for nicotine dependence are the Fagerstrom Test for Nicotine Dependence (FTND) and the Nicotine Dependence section of the Diagnostic Interview Schedule [(DIS)-III-R or -IV based on the Diagnostic and Statistical Manual (DSM)-III-R and -IV, respectively]. The FTND emphasizes morning smoking and overall "heaviness" of smoking. The DSM emphasizes adverse consequences, desire to cut down, and mood changes during withdrawal. We tested (1) how the DSM-III-R diagnosis of Nicotine Dependence is related to FTND score; and (2) how the (a) DSM-III-R or (b) elevated FTND score is related to longer smoking histories, greater psychiatric symptomatology, and tobacco liking scores. Retrospective chart reviews were conducted on 370 smokers, the majority (55.9%) of whom had a current DSM-III-R diagnosis of Substance Dependence other than nicotine. All subjects had completed the FTND, the DIS-III-R, the Symptom Checklist-90-Revised (SCL-90-R), and a survey on drug liking. Agreement statistics were calculated between the DSM-II-R diagnosis of Nicotine Dependence and various cutoff scores values that were assigned as thresholds for nicotine dependence on the FTND. At no cutoff score did the two instruments reliably agree; the highest kappa (at a cutoff of FTND > or = 7) was 0.205. At cutoffs above 5, the FTND diagnosed fewer cases than the DSM-III-R. Multiple regression analysis showed that DSM diagnosis was associated with greater psychiatric symptomatology on the SCL-90-R, while FTND scores were associated with greater tobacco liking. The FTND and the DSM-III-R appear to measure different aspects of the tobacco dependence process. Specifically, the FTND may provide a stronger measure of physical dependence, while the DSM may tap other domains such as awareness of dependence, behaviors resulting from that awareness, and psychiatric symptomatology. Disagreements between the FTND and the DSM are likely to become greater with the changes in the DSM-IV.     

Concordance between DSM-III-R and DSM-IV diagnoses of substance use disorders in adolescents

Except for cannabis and alcohol, concordance between DSM-III-R and DSM-IV substance use disorder diagnoses has not been reported in adolescents. We assessed a clinical sample of 102 adolescents using CIDI-SAM. Prevalence of either an abuse or dependence diagnosis was lower with DSM-IV than DSM-III-R except for cannabis and alcohol, and concordance rates were better for dependence than for abuse. For most substances, rates of DSM-IV withdrawal were lower than in DSM-III-R, but rates of DSM-IV physiological dependence remained high. Changes in DSM-IV criteria appear to have impacted diagnoses in these adolescents, particularly for the substances they use most--i.e. alcohol, tobacco, and cannabis.     

Smoking withdrawal, nicotine dependence and prepulse inhibition of the acoustic startle reflex

The present study examined the relationship between nicotine dependence as measured by the Fagerstrom Tolerance Questionnaire (FTQ) and prepulse inhibition (PPI) of the acoustic startle reflex measured after overnight smoking withdrawal in a non-clinical population of male smokers with no history of psychiatric disorders or drug/alcohol abuse. It was found that smokers who scored high (>median) on the FTQ showed significantly less PPI as compared to those scoring low (<median) on this scale. This finding further supports a role for nicotine in modulation of PPI, as has previously been found in rats and also in human beings. Received: 26 November 1997/Final version: 8 June 1998     

Concordance of different measures of nicotine dependence: two pilot studies

Two samples of adult daily smokers completed a structured interview to determine nicotine dependence according to generic (DSM-IV/ICD-10), Fagerstr?m [Fagerstr?m Tolerance Questionnaire (FTQ), Fagerstr?m Test for Nicotine Dependence (FTND), Heavy Smoking Index (HSI), and time to first cigarette after awakening (TFC)], consumption [e.g., cigarettes/day (CPD)], and self-rating (e.g., "how addicted are you") measures. One sample was a population-based sample of 43 smokers from the Vermont site of the DSM-IV field trial for substance use disorders. The other sample consisted of 50 smokers evenly distributed across a wide range of CPD to study biochemical markers of smokers. In the first study, DSM/ICD criteria were only slightly correlated with Fagerstr?m (r =.24-.35) and consumption (r =.06-0.33) criteria. Self-rating criteria were correlated moderately with most other criteria (r =.24-.60). In the second study, generic, Fagerstr?m, and self-rating criteria increased with increasing CPD up to 30 CPD but not thereafter. One interpretation of these results is that generic, Fagerstr?m, consumption, and self-rating criteria each tap different aspects of nicotine dependence.     

Validation of the modified Fagerström tolerance questionnaire with salivary cotinine among adolescents

This study was conducted to gain evidence of validity for a nicotine dependence measure for adolescent smokers. We hypothesized that the individual item responses and the total Fagerstr?m Tolerance Questionnaire (FTQ) score would be positively correlated with cotinine values. We examined the relationship between a seven-item modified FTQ and saliva continine among 131 adolescent volunteers in a smoking cessation program. As anticipated, the total FTQ score was related to saliva cotinine (r = .40, p < .01), as were six of the seven individual FTQ items (p < .05). Our findings provide preliminary evidence that the modified FTQ scale is valid and applicable to adolescent smokers.     

Nicotine dependence and withdrawal in alcoholic and nonalcoholic ever-smokers

We compared nicotine dependence and withdrawal in male alcoholic and control ever-smokers, controlling for relevant demographic and clinical variables. Alcoholics were more likely to meet criteria for moderate or severe nicotine dependence and endorse more nicotine dependence symptoms. Symptoms reported more frequently by alcoholics included: (a) using nicotine in larger amounts or over a longer time than intended; (b) continued use despite problems caused or exacerbated by nicotine; (c) marked tolerance; and (d) experiencing characteristic nicotine withdrawal symptoms. Alcoholics also smoked more heavily. Other than “headaches,” and “decreased heart rate,” alcoholics consistently endorsed nicotine withdrawal symptoms at a higher rate. After controlling for demographic and clinical variables and level of nicotine dependence, only “feel depressed” differed significantly between groups. Our research supports previous findings suggesting that nicotine dependence is more severe in those with a history of alcohol dependence. As a result, alcoholics may experience greater discomfort from nicotine withdrawal upon smoking cessation.     

The Accuracy and Trends of Smoking History Documentation in Electronic Medical Records in a Large Managed Care Organization

The accuracy of smoking history documentation in the electronic medical records was examined at a large managed care organization among 36,494 male members who self-reported smoking history in mailed surveys. The sensitivity of electronic smoking history documentation for ever-smoking status was 0.19 in years 2003–2005 (using ICD-9/CPT code only), 0.80 in 2006–2008 and 0.84 in 2009–2010 (combination of ICD-9/CPT codes and risk factor module used after 2006). The positive predictive value was 0.96, 0.90, and 0.95 in these periods, respectively. Among self-reported ever-smokers, increased healthcare utilization and smoking intensity/duration were associated with higher likelihood of having electronic smoking history documentation, while Asian race and Spanish language preference were associated with lower likelihood. These data suggest that enhanced efforts may be needed to screen for and document smoking among racial/ethnic minorities.     

Validity of retrospective assessments of nicotine dependence: a preliminary report

Information about levels of nicotine dependence in ex-smokers when they smoked, or in current smokers at an earlier date, is useful for clinical and research purposes. To estimate the accuracy of retrospective reports of dependence, 28 individuals who completed either the Fagerström Tolerance Questionnaire (FTQ) or Fagerström Test for Nicotine Dependence (FTND) in smoking cessation trials conducted 5 to 12 years earlier were asked to respond again to the same questions, thinking back to their smoking behavior just prior to their on-study quit attempt. Concordance and Kappa values for the items ranged from 50.0% to 95.0% and 0.00 to 0.92, respectively. The mean difference between the baseline and follow-up total scale scores was 0.05 for the FTQ and 0.38 for the FTND, and the correlation between these assessments was 0.62 for the FTQ (p<0.005) and 0.72 for the FTND (p<0.05). These preliminary results suggest that retrospectively assessed FTQ/FTND scale scores have acceptable reliability.     

Prevalence and correlates of tobacco use and nicotine dependence among psychiatric patients in India

Tobacco use among psychiatric patients in developing countries has not been well-investigated. To address this issue, we screened consecutive admissions to a major psychiatric hospital in southern India, and assessed the prevalence and correlates of tobacco use and nicotine dependence. Patients (n=988) provided information about their use of tobacco products, and participated in an interview that included the Fagerström Test for Nicotine Dependence as well as measures of other substance use. Three hundred and fifty-one patients (36%) reported current tobacco use, with 227 (65% of all users) reporting moderate to severe nicotine dependence. Current tobacco use as well as nicotine dependence were associated with male gender, a diagnosis of bipolar disorder, and risk of other substance use problems. The cultural context of these findings, and the implications for tobacco control among psychiatric patients, are discussed.     

吸烟者社会人口学等因素对尼古丁渴求程度影响的分析

目的:探讨吸烟者社会人口学等因素对尼古丁渴求程度的影响。方法:采用自评视觉模拟标尺(visualanalogscales)和自制调查表对符合DSM-Ⅳ尼古丁依赖诊断标准的211例吸烟者进行横断面现场调查。结果:经多元线性回归分析发现:女性较男性(P<0·05),50a以上较50a以下者(P<0·05),BMI>25·4组较BMI<22·6组(P<0·01),对尼古丁渴求程度小,具有显著的统计学意义。吸烟量与渴求程度呈剂量反应关系(P<0·001);吸烟深度与渴求程度之间存在着一种递进关系。结论:女性吸烟者较男性吸烟者对尼古丁的渴求程度小。吸烟量越大,吸烟吸得越深则对尼古丁的渴求程度越强;而年龄越大,身高体重指数越大者则对尼古丁的渴求程度越小。     

The association between cigarette smoking and DSM-IV nicotine dependence among first year college students

AIMS: This study was undertaken to evaluate the association between cigarette smoking behavior and DSM-IV nicotine dependence. DESIGN: Drawing on a sample of first year college students selected for representation across a continuum of smoking behavior, current DSM-IV nicotine dependence criteria were assessed among participants reporting any smoking in the preceding week on a web-based survey protocol. Logistic regression and receiver operator characteristic analyses were used to estimate the overall concordance between smoking and DSM-IV nicotine dependence. FINDINGS: Relationships were supported between both quantity and frequency of smoking in the past week and DSM-IV nicotine dependence showing higher prevalence of dependence at higher levels of use (p<0.05). While the highest prevalence of nicotine dependence was seen among those reporting the most frequent and heavy smoking, a substantial number of participants reporting daily and/or heavy smoking did not meet criteria for nicotine dependence. Conversely, nicotine dependence was seen among a subgroup of participants reporting relatively low levels of non-daily smoking. Diagnostic concordance was found to be moderate for both quantity and frequency and was not improved by combining information from these two indices. CONCLUSIONS: Aside from confirming DSM-IV nicotine dependence at relatively low levels of smoking, these results may be used to inform research aimed at identifying samples of nicotine dependent youth across the range of smoking levels.     

Does areca nut use lead to dependence?

BACKGROUND: The areca nut is consumed by approximately 10% of the world's population, and its consumption is associated with long-term health risks, with or without tobacco additives. However, it is not known whether its use is associated with a dependence syndrome, as is seen with other psychoactive substances. OBJECTIVE: To examine whether areca nut usage (with or without tobacco additives) could lead to the development of a dependence syndrome. METHODS: Three groups: [a] persons using areca nut preparations without tobacco additives [n=98]; [b] persons using areca nut preparations with tobacco additives [n=44]; and [c] 'Non-users' were systematically assessed using a checklist for the use of areca or areca+tobacco products, patterns of use, presence of a dependence syndrome in users, features of stimulant withdrawal and desired/beneficial effects. RESULTS: 38.8% and 40.8% of the 'areca' group satisfied definitions of current substance-dependence according to DSM-IV and ICD-10 criteria respectively. 79.5% of the areca+tobacco group satisfied criteria for current dependent use according to both DSM-IV and ICD-10 criteria. Both the groups reported a well-delineated withdrawal syndrome and similar attributions for desirable effects of use. CONCLUSION: Areca nut use by itself and more so with tobacco additives, is associated with the development of a dependence syndrome in a substantial numbers of users.     

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.     

On the development of nicotine dependence in adolescence

Little is known about the natural history of drug dependence. This article describes the development and predictors of DSM-IV nicotine dependence in adolescence when tobacco use is initiated. In a two-stage design, a survey was administered to 6th-10th graders in the Chicago Public Schools to select a cohort of adolescents. Household interviews were conducted with adolescents five times and with one parent (predominantly mothers) three times over 2 years. The analytical sample includes 353 youths, who started using tobacco within 12 months preceding Wave 1 or between Waves 1-5. Survival analysis estimated latency to individual DSM-IV nicotine dependence criteria and the full dependence syndrome. Twenty-five percent of youths experienced the syndrome within 23 months of tobacco use onset. Tolerance, impaired control and withdrawal were experienced most frequently. Youths who developed full dependence experienced their first symptom faster after tobacco use onset than those who experienced only one criterion through the end of the observation period. Cox proportional hazards models estimated the importance of time-constant and time-varying sociodemographic, tobacco and other drug use, parental and peer smoking, social psychological and biological risk factors for experiencing the first criterion and the full syndrome. Pleasant initial sensitivity to tobacco and number of cigarettes smoked the prior month predicted both outcomes. Parental dependence predicted the full syndrome. Significant covariates were generally the same across gender and racial/ethnic subgroups. The predictive significance of the initial smoking experience and parental dependence highlight the potential importance of genetic factors in the etiology of nicotine dependence.     

A review of the validity and reliability of smokeless tobacco dependence measures

Introduction

With the growing marketing of alternate tobacco products, advocacy of harm reduction, and smoke free air policies, an overall increase in Smokeless Tobacco (ST) use has been observed since the 1970s. Numerous studies have been published addressing nicotine dependence measures for smokers; however, research in the field of ST dependence measures is scarce.

Purpose

The aim of this study is to summarize the psychometric properties of ST dependence measures by evaluating the reliability and validity of these scales through peer review research.

Methods

A systematic literature search was conducted within the databases of PubMed and OVID Medline. Four publications reporting on the psychometric properties of ST dependence measures were identified; two regarding FTQ based scales, one regarding an FTND based scale, and one comparing two of these modified scales. A predefined set of criteria was used to assess the psychometric properties of these measures.

Results

ST dependence measures depend heavily on two underlying factors, heaviness of tobacco use and withdrawal. The internal consistency of the measures was low to moderate, Cronbach's α ranging from 0.30 to 0.52 Cotinine was used as criterion variable to validate the results of the dependence measures. Concurrent validity against DIS-IV-ND based diagnosis was not established for modified FTQ scale. Predictive validity of these ST dependence scales was measured as abstinence of ST use at three and six months. FTQ-ST was predictive of abstinence at three months however failed to predict six months abstinence.

Conclusion

FTQ and FTND based measures have inherited shortcomings and have limited psychometric properties. With ease of use and wide application in tobacco research, these measures provide preliminary foundation for studying ST dependence. However, the complexity of tobacco dependence requires a multidimensional measure with high validity and reliability for effective prevention care and for research purposes.