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The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire

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Abstract

We examine and refine the Fagerström Tolerance Questionnaire (FTQ: Fagerström, 1978). The relation between each FTQ item and biochemical measures of heaviness of smoking was examined in 254 smokers. We found that the nicotine rating item and the inhalation item were unrelated to any of our biochemical measures and these two items were primary contributors to psychometric deficiencies in the FTQ. We also found that a revised scoring of time to the first cigarette of the day (TTF) and number of cigarettes smoked per day (CPD) improved the scale. We present a revision of the FTQ: the Fagerström Test for Nicotine Dependence (FTND).
British Journal of Addiction (1991) 86, 1119-1127
RESEARCH REPORT
The Fagerstrom Test for Nicotine Dependence:
a revision of the Fagerstrom Tolerance
Questionnaire
TODD F. HEATHERTON,! LYNN T. KOZLOWSKI,^
RICHARD C. FRECKER3 & KARL-OLOV FAGERSTROM^
^Department of
Psychology,
Harvard University, 33 Kirkland Street, Cambridge, MA 02138,
USA,^Program in Behavioral Health, Pennsylvania State University, University Park, PA
16802, USA, ^Addiction Research Foundation, 33 Russell Street, Toronto, Ontario M5S 2S1,
Canada & ^Pharmacia Leo
Therapeutics
AB, Box 941, S-251 09
Helsingborg,
Sweden
Abstract
We examine and refine the Pagerstrom Tolerance Questionnaire (PTQ Pagerstrom, 1978). The relation
between
each PTQ item and biochemical measures of heaviness of smoking was examined in 254
smokers.
We
found that the nicotine rating item and the inhalation item were unrelated to any of our
biochemical measures
and these two items
were
primary contributors to psychometric
deficiencies
in the PTQ. We also found that a
revised
scoring
of time to the first
cigarette
of the day (TTP) and number of
cigarettes
smoked per day (CPD)
improved the
scale.
We
present a revision of the PTQ: the
Pagerstrom
Test for Nicotine Dependence (PTND).
Introduction
The FTQ was developed in 1978 to provide a short,
convenient self-report measure of dependency on
nicotine (Fagerstrom, 1978). The eight items were
derived from theoretical notions of reliance on
nicotine (see Fagerstrom and Schneider [1989] for a
current version of the FTQ). A review of the
literature by Fagerstrom and Schneider (1989)
found that 14 of 16 different data sets relating
biochemical markers to the FTQ found statistically
significant correlations. Carbon monoxide and nico-
tine may yield stronger correlations than nicotine,
perhaps because the nicotine measures are more
variable due to the relatively short plasma half-life
of nicotine.
Use of the FTQ has been questioned because of
perceived psychometric deficiencies, including a
multifactorial structure, low levels of reliability and
poor item selection (Heatherton et ai, 1989; Lich-
tenstein
&
Mermelstein, 1986; Lombardo, Hughes &
Fross,
1988; Pomerleau, Majchrezak & Pomerleau,
1989;
Pomerleau et ai, 1990). For example, Licht-
enstein & Mermelstein (1986) found that the FTQ
was multifactorial, with only one of the factors
contributing significantly to the explanation of
variance; this factor consisted of two items: 'time to
the first cigarette of the day' (TTF) and 'average
daily consumption of cigarettes' (CPD). Further,
Lichtenstein & Mermelstein (1986) found that the
FTQ has low internal consistency (coefficient
alpha=0.55 for one sample, and 0.51 for the other),
as was also found by Pomerleau et
al.
(1990; 0.58 for
one of their samples and 0.41 for a different
sample). Since some of the FTQ items correlate as
highly with biochemical and behavioural measures
(if not more highly) as the total score (Lichtenstein
1119
1120 Todd F. Heatherton et al.
& Mermelstein, 1986), it is possible that some items
add little but error variance to the total scores.
Time to the first
cigarette
of the day (TTF). Time
to the first cigarette of the day is theoretically
important to the prediction of nicotine dependence
(Heatherton et al, 1989; Kozlowski, Director &
Harford, 1981). Due to the relatively short half-life
of nicotine, dependent smokers have depleted
plasma levels of nicotine upon arising. These
smokers are likely to experience discomfort unless
they quickly have their first cigarette. TTF has been
found to be an excellent predictor of biochemical
measures (cotinine, nicotine and carbon monoxide;
Heatherton et al, 1989) and also predictive of
successful smoking cessation (Kabat & Wynder,
1987;
Kozlowski et al, 1981). Heatherton et al
(1989) found that a four category scoring of TTF
(<5,
6-30, 31-60, 61-I-) was superior to the two
category scoring method used in the FTQ (<30 vs
>30) for predicting biochemical indices of
smoking.
Cigarettes per day. The number of cigarettes
smoked per day is a face valid measure of depen-
dence on nicotine, and early studies assumed that
dependence was a direct function of smoking rate
(Brantmark, Ohlin & Westling, 1973). CPD has
been shown to relate to disease risk (e.g. USPHS,
1979) and to exposure to tobacco constituents
(Kozlowski & Herling, 1988; Hill, Haley
&
Wynder,
1983).
However, although CPD has been found to
predict abstinence in some studies (e.g. Hall et al,
1984) it has not predicted abstinence in others (e.g.
Fagerstrom, 1982b).
The FTQ uses three categories for CPD
(1-15,
16-25,
26+) which may be inappropriate because it
categorizes those who smoke 20 cigarettes per day
with those who smoke 25 cigarettes per day. This
categorization format may obscure the digit bias in
self-reported cigarette consumption between those
who purchase packages of 2O's versus 25's (Kozlow-
ski,
1986; Kozlowski, Heatherton & Ferrence,
1989).
Nicotine
yield.
Standard tar and nicotine yields do
not provide very good estimates of what smokers are
getting from their cigarettes (e.g. Kozlowski,
Frecker & Lei, 1982; Maron & Fortmann, 1987)
since all cigarettes can be subject to so-called
compensatory smoking (i.e. more intensive smoking
to compensate for reduced standard tar and nicotine
yields) (e.g. Rickert & Robinson,
1981;
Fagerstrom,
1982a; Robinson, Young & Rickert, 1981). Thus,
machine-rated yields for cigarettes may tell us little
about dependence; it is the obtained yield that is
important.
Further, some smokers may be unsure of nicotine
yield, especially in countries—such as the
USA—where cigarette manufacturers do not publi-
cize yield rate on packages (Kozlowski & Heather-
ton, 1990). A study on awareness of tar yields
conducted in the UK found that reporting of tar
categories is not particularly accurate, except for the
lowest tar group (Peach, Shah & Morris, 1986).
Inhalation. The FTQ has three levels for inhala-
tion (not inhale, inhale sometimes and always
inhale). This item has been criticized on the grounds
that it may not discriminate degrees of dependency
because almost everyone always inhales. Hughes,
Gust & Pechacek (1987) found that 95% of 1006
smokers inhaled and Pomerleau et al (1990) found
93.3%
of their sample (of 150) always inhales.
Thus,
almost every smoker obtains two points
towards dependence from this one measure, and
therefore the question may not be very useful.
However, dependence on tobacco relies on the
smoker inhaling the smoke from the cigarette; it is
important to ensure that smokers are actually
obtaining a dose from their cigarettes to count them
as dependent smokers. In general, smokers are able
to report accurately whether they inhale or not
(Herling & Kozlowski, 1988), although it does not
seem that smokers are accurate in estimating the
'depth' of their inhalations (Stepney, 1982).
Other questions. The remaining FTQ questions
derive from theoretical notions about the behavior
of high dependent smokers. They are face valid
measures of difficulty refraining from smoking
(where forbidden or if ill) and increased smoking in
the morning. These items have received the least
empirical attention, and their concurrent validity is
largely unknown. However, whereas measures like
CPD are highly related to physiological measures of
smoking, these other questions may be more impor-
tant as behavioral indices. That is, the smoking
behavior of highly dependent smokers may indeed
be different from that of low dependent smokers,
independent of physiological indices. Such beha-
viors may be particularly important to the issue of
smoking cessation.
The FagerstrSm Test for Nicotine Dependence 1121
HSI as an alternative measure
Since two of the FTQ questions account for the
majority of variance in total scores, TTF and CPD
(Lichtenstein & Mermelstein, 1986), Heatherton et
al. (1989) proposed that these two items alone
might serve as an alternative to the FTQ. For
example, these two questions are more closely
related to measures of dependence and withdrawal
than are the other FTQ items (Heatherton et al.,
1989).
Further, as discussed in the preceding
section, the FTQ scoring method for TTF and CPD
may also inadvertently limit the predictive power of
these constructs. Heatherton et al. (1989) developed
a Heaviness of Smoking Index (HSI) which consists
simply of TTF and CPD. However, these are scored
differently in the HSI than in the FTQ, with the
HSI having four categories for both TTF (<5,
6-30, 31-60,
61
+ ) and CPD (1-10,11-20, 21-30,
30+) and the FTQ having only two TTF categories
and three CPD categories. We present data in the
current study which compares the predictive abili-
ties of the FTQ and the short form HSI.
The overall goal of this project was to examine
the best way to use and score items from the FTQ in
order to predict biochemical measures of heaviness
of smoking and to develop an improved version of
the scale, to be called the Fagerstrom Test for
Nicotine Dependence (FTND).' To this end we
administered questions about smoking behaviors
and obtained saliva samples from visitors to the
Ontario Science Centre.
naire, all subjects were asked "At present, how long
after waking do you wait before having your first
cigarette (in minutes)?" and "How many cigarettes
do you smoke per day at present?" in addition to
completing the intact FTQ.
Respondents were recruited at the Ontario Sci-
ence Centre by means of a large sign announcing 'A
Study of Smoking Habits'. No mention was made of
smoking abstinence and all subjects were unpaid
volunteers who participated between 10.00 a.m. and
3.30 p.m. Subjects provided a breath sample for CO
testing and a saliva sample for salivary cotinine (a
stable metabolite of nicotine; Abrams et al., 1987;
Jarvis et al., 1987; Kozlowski & Herling, 1988) and
salivary nicotine testing. Subjects placed a cotton
dental roll inside their cheek and allowed it to
collect saliva while they filled out the question-
naires. Subjects then placed the dental roll directly
into a sealed red-top vacutainer. The experimenter
then transferred the dental roll to an empty syringe
and attempted to extract as much saliva as possible
back into the red-top vacutainer. Subjects who did
not appear to provide a sample containing at least
1.0 mg of saliva were asked to provide an additional
sample. The salivary extracts were analyzed in a
pressurized clean air laboratory at the Addiction
Research Foundation, using capillary-column gas
chromotography Qacob, Wilson & Benowitz, 1981).
Unfortunately, insufficient saliva samples for 8
subjects were obtained and they are not therefore
included in those analyses of saliva nicotine or
cotinine.
Methods
Subjects
Our sample consisted of 254 adult visitors to the
Ontario Science Centre. Subjects ranged in age from
17-77 (M=33.5, Standard Deviation (SD) = 12.7),
with Ul being male and 143 being female. Subjects
smoked an average of 20.7 cigarettes per day (range
3-75,
SD
= 10.5) and smoked their first cigarette of
the day, on average, at 47.2 minutes (range 0-720,
SD=86.8). The average FTQ score for this sample
was 5.2 (SD= 1.9).
Procedure
Questionnaires on various aspects of smoking were
administered to all subjects. Within this question
'We preferred the name FagerstrSm Test of Nicotine Dependence
(FTND) to the Fagerstrom Tolerance Questionnaire because the
latter was deemed too imprecise.
Results
FTQ
1:
TTF
The FTQ measure of TTF consists of two categ-
ories (within 30 minutes=68.5% vs. greater than 30
minutes=31.5%).^ There were considerable differ-
ences between later and early smokers on the
biochemical indices. As may be seen in Table
1,
both
the log transformations' and raw data values for CO
and salivary cotinine differ between those who have
their first cigarette of the day within 30 minutes and
those who delay their first cigarette for more than 30
minutes. The HSI scoring method uncovers differ-
ences within each of the FTQ groups. For example.
^These numbers refer to the percentage of subjects selecting this
response.
'Logarithmic transformation were used because of the disparate
cell sizes and heterogeneity of variance. This issue was especially
relevant for TTF measures.
1122 Todd F. Heatherton et al.
Table 1. TTF
measures scored
by FTQ and HSI methods on biochemical measures
Measure
CO
SD
Log CO
SD
Cotinine
SD
Log Cotinine
SD
Cell n's
FTQ
>30
13.1
7.1
1.10
0.23
193.0
101.8
2.22
0.28
75
Scale
<30
23.4
9.3
1.35
0.18
336.0
152.2
2.48
0.23
169
61
+
11.3=
6.1
1.04
0.22
157.4'
92.9
2.13
0.26
30
HSI
31-60
14.5=
7.5
1.14
0.22
219.7'
100.0
2.28
0.27
45
Scale
6-30
22.0
9.0
1.33
0.18
320.4
155.1
2.45
0.24
116
<5
26.5
9.2
1.41
0.16
367.9
142.2
2.53
0.20
53
Means within FTQ and HSI sharing common subscripts are not significantly different.
(Fisher's test,p<0.05).
there were significant differences between those
who had their first cigarette of the day within 5
minutes and those who waited more than 5 minutes
but not more than 30 minutes in CO, salivary
cotinine and nicotine. There were similar differ-
ences between the other HSI categories, suggesting
that it may be profitable to use finer distinctions of
TTF than those used in the FTQ.
FTQ
2:
forbidden
cigarettes
The second FTQ question asks smokers whether it
is difficult to refrain from smoking in places where
it is forbidden (no=71.3% vs.
yes
=
28.7%).
Those
individuals who report difficulties are assessed one
point. Smokers who found it difficult to refrain from
smoking in places where it was forbidden did not
differ from those who did not find it difficult in
salivary cotinine (301.7 ±155.5 ng/ml vs.
287.9 ± 152.9,/)=ns). Logarithmic transformation
did not alter this result. These groups did differ,
however, in CO level, with those who have difficulty
refraining having higher CO values (22.7 ± 10.4
ppm) than those who do not report difficulties
(19.1 ±9.5 ppm, £244=2.6,/XO.Ol).
FTQ 3: which
cigarette
would you most hate to give
up?
Those checking that they would most hate to give
up the first cigarette of the morning (11.0%) are
given one point whereas those who say any other
cigarene are given zero points (89.0%). These
groups did not differ on any biochemical measures.
Logarithmic transformations did not change the
results.
FTQ
4:
CPD
The FTQ has three categories of CPD, with zero
points awarded for 1-15 (36.6%), one point
awarded for 16-25 (44.9%) and two points
awarded for 26 or more (18.5%). This method of
scoring produced significant effects for all of the
dependent measures. Post-hoc tests revealed signi-
ficant differences between all pairwise means for
CO,
but not for cotinine (16-25 vs.
26
+ ,p=as).
Logarithmic transformations did not affect these
outcomes. The lack of significant differences be-
tween the two heaviest smoking groups may be
due to the inappropriate grouping of those who
smoke 20 cigarettes per day with those who smoke
25 cigarettes per day. The HSI scoring method
uncovered significant differences between these
two groups in CO, cotinine, and nicotine. Thus,
although either scoring method revealed many
between group differences, the FTQ method may
group 20 and 25's together inappropriately. Such a
finding supports the recommendations of the US
Department of Health and Human Services
(1988).
FTQ 5: smoke more in the morning
Individuals who report smoking more in the
morning than during the rest of the day (21.3%)
obtain one point on the FTQ, whereas individuals
who do not report smoking more in the morning
(78.7%) do not receive any points. These groups
differed on CO (24.2 ±9.9 vs. 19.1 ±9.6,
t244=3.48, p<0.0006) and salivary cotinine
(343.7± 143.9 vs. 277.9±
153.3,
r244=2.78,
/X0.006).
The
Fagerstrom
Test for Nicotine Dependence 1123
FTQ 6: smoke if ill
Individuals who report smoking if they are so ill that
they spend most of the day in bed (29.9%) receive
one point on the FTQ whereas no points are
awarded to individuals who do not report doing so
(70.1%).
Those who smoke when ill were heavier
smokers: CO (23.5 ±9.7 vs.
18.8
±9.6,
r246
= 3.55,
/)<0.0005), and salivary cotinine (340.7 ± 145.8 vs.
271.3±
152.3,
t246
= 3.31,/)<0.002).
FTQ 7: nicotine yield
The FTQ has three categories for nicotine yield,
corresponding roughly to low yield (0
points-38.6%), medium yield (1 point-39.4%) and
high yield (2 points-22.0%). An analysis of variance
revealed no differences between these groups on any
dependent measure. To further investigate the
relation between nicotine yield, we conducted
simple regression and polynomial regression using
FTQ nicotine category and actual nicotine values to
predict all dependent measures. There was no
significant relation between nicotine rating and any
dependent measure.
FTQ 8: inhale
Only one smoker of our sample of 254 adults
reported not inhaling their cigarettes (0.4%,
FTQ=O points). Therefore we included that person
with those who said they sometimes inhaled (7.2%,
FTQ=1 point) to examine whether they differed
from those who report always inhaling
(92.5%,
FTQ=2 points). There were no biochemical differ-
ences between the two groups.
Individual item summary
An examination of the proportions of individuals
obtaining points for each question reveals that very
few individuals gain points from FTQ items two
(trouble refraining, 28.7%), three (most hate to give
up morning cigarette, 11.0%), five (smoking more
in the morning than the rest of the day, 21.3%), and
item six (smoke when ill, 29.9%). In contrast, the
vast majority of subjects gained points for inhalation
(99.6%),
and most subjects got points for nicotine
yield (62.4%), CPD (63.4%) and TTF (68.5%).
TTF,
CPD, smoking more in the morning,
trouble refraining when forbidden, and smoking
when ill appeared to have the greatest between
group differences in biochemical measures. The
other three questions uncovered no biochemical
differences. Further, it was clear that the HSI
scoring method for CPD and TTF uncovered
differences in biochemical that were obscured by the
FTQ scoring method.
FTQ whole scale vs. HSI measures
The results for the individual item analysis
prompted us to construct a number of models to try
to come up with the best way to score the FTQ (how
to score each item, how many items to include). We
report the results for eight models only, including
the best five models (models four to eight).'' These
models are summarized below:
Model One FTQ
1,2,3,4,5,6,7,8
Model Two FTQ
1,2,3,5,6,8(R)
Model Three FTQ 1,4
Model Four FTND: HSI TTF, CPD; FTQ
2,3,5,6
Model Five HSI TTF, CPD; FTQ 5,6
Model Six HSI TTF, CPD; FTQ 5
Model Seven HSI TTF, CPD; FTQ 6
Model Eight HSI TTF, CPD
Note that the inhalation question has been revised in
model two. This revised scoring gives one point for
always inhaling and zero points for sometimes or
never inhaling. The remainder of the items are
scored as in the original FTQ whereas the HSI TTF
and CPD items are scored into four categories.
Model Eight corresponds to the HSI scale devel-
oped by Heatherton et al. (1989) and consists only
of TTF and CPD whereas Model Four is the
revision of the FTQ scale which we recommend (i.e.
it is the FTND).
We conducted a series of regression analyses
using the various models to predict each of the
biochemical measures. The proportion of variance
explained for each dependent measure can be found
in Table 2. An examination reveals that any
modification of the FTQ improves the predictive
ability on all dependent measures. Further, M-4, M-
6 and M-8 appear to be the best models, which
suggests that the HSI scoring of TTF and CPD is
important for the best models. The HSI scale
(Heatherton et al., 1989) was most frequently the
best predictor, occasionally improved by FTQ item
5 or 6.
'Models 1 to 3 were included to show the results for the original
FTQ scorings.
1124 Todd F. Heatherton et al.
Items
CO
Log CO
Cotinine
Log cotinine
Table 2. Comparing the adjusted
R^
for the various models
M-1
23.9
25.5
17.5
18.5
M-2
26.8
29.9
19.8
23.6
M-3
29.4
33.2
21.6
25.6
Model
M-4
28.4
31.9
21.0
24.6
M-5
30.1
34.1
24.2
28.5
M-6
32.1
36.6
25.6
30.0
M-7
29.6
33.8
24.2
28.2
M-8
31.4
36.1
25.6
29.5
Index:
Model 1 FTQ:
1,2,3,4,5,6,7,8
Model 3 FTQ 1,4
Model 5 HSI TTF, CPD; FTQ 5,6
Model 7 HSI TTF, CPD; FTQ 6
Model 2 FTQ
1,4,5,6,8(R)
Model 4 FTND: HSI TTF CPD; FTQ 2,3,5,6
Model 6 HSI TTF, CPD: FTQ 5
Model 8 HSI TTF, CPD
Internal
consistency.
One of the major complaints
about the FTQ is its low levels of internal
consistency. This may be due partially to the
relatively few number of items in the FTQ, since
measures of internal consistency are dependent on
test length. The average reported reliability for the
FTQ is 0.51 (see our earlier citations), which is
below traditional standards. In the current study,
coefficient alpha for the FTQ was computed to be
0.48 (which is close to previous findings), whereas it
was 0.61 for the FTND (Model 4 from above). This
is a considerable improvement considering that
fewer items usually leads to lower reliability.
Factor structure. Lichtenstein & Mermelstein
(1986) conducted a principal components analysis
of the FTQ and discovered that the scale was
multifactorial. However, they found that only the
first factor explained a significant proportion of
variance (20%) and consisted of only two items
(TTF and CPD), raising the possibility that the
FTQ items might not form a unitary set. We
conducted an iterated principal axes factor analysis
on the eight FTQ items and found that, in fact, they
do not form a homogenous set. For example, the
MSA (measure of sampling adequacy; cf. Kaiser,
1974) values for FTQ nicotine and inhalation
ratings were under 0.60, indicating an unacceptable
ratio of inter-item correlation to partial correlation
coefficients (total scale mean MSA=0.65, a value
described by Kaiser as mediocre). This factor
analysis revealed two factors: Morning smoking
(TTF,
smoking more in the morning, hate to give
up morning cigarette) and cigarette consumption
(CPD,
smoke if ill, trouble refraining). FTQ
nicotine rating and inhalation did not load on either
factor (loadings were less than 0.15). Thus, our
analysis leads to similar conclusions as those
reached by Lichtenstein & Mermelstein.
We then conducted an iterated principal axes
factor analysis of the FTND items and found that
all of the items loaded on a single factor, with only
FTND item 3 ('hate to give up morning cigarette')
loading less than 0.30 (loading=0.23). A second
factor did not have an eigenvalue over 1.0 and
consisted only of FTND item 3 (loading=0.34).
The overall MSA value was 0.70, considered within
the acceptable 'real world' range by Kaiser (1974).
Thus,
we are satisfied that the FTND items form a
homogenous set.
Discussion
Our exploration of the FTQ scale has revealed that
for the large part, the FTQ is a valid measure of
heaviness of smoking as measured by biochemical
indices. The precise scoring of the FTQ items
affected the overall sensitivity of the scale, with
modifications of TTF and CPD appearing to be
most important. We must stress, however, that we
have no information on the relationship of FTQ or
FTND or HSI to the ability to give up smoking in
either the short or long run. Further research is
needed to determine how these items and scorings
relate to the key behavioral issue of smoking
cessation. The current research has some limitations
(i.e.
a select sample), and these results may not
extend to more representative populations.
We conclude that the FTQ is a useful tool for
identifying individuals who have the greatest con-
centration of tobacco products and who therefore
might be at greater risk for disease. However,
modifications of FTQ scoring can improve the
scale's overall quality (Pomerleau et al, 1989,
1990).
Pomerleau et al (1990) looked at the ability
of different components of the FTQ to predict
cotinine levels and suggested that none of the
subscales provided consistent improvement over
FTQ scores. We find that revisions of the scoring of
The Fagerstrom Test for Nicotine Dependence 1125
Table 3. Items and scoring for
Fagerstrom
Test for Nicotine Dependence (FTND)
Questions
1.
2.
3.
4.
5.
6.
How soon after you wake up do you
smoke your first cigarette
Do you find it difficult to refrain from
smoking in places where it is forbidden
e.g. in church, at the library, in cinema, etc.?
Which cigarette would you hate most to
give up?
How many cigarettes/day do you smoke?
Do you smoke more frequently during the
first hours after waking than during the
rest of the day?
Do you smoke if you are so ill that you
are in bed most of the day?
Answers
Within 5 minutes
6-30 minutes
31-60 minutes
After 60 minutes
Yes
No
The first one in the
morning
All others
10 or less
11-20
21-30
31 or more
Yes
No
Yes
No
Points
3
2
1
0
1
0
1
0
0
1
2
3
1
0
1
0
' Permission to use this scale for other than research purposes should be obtained from
K. O. Fagerstrom
the most important questions on the FTQ (TTF &
CPD) and the omission of inhalation and nicotine
rating provide both higher face and predictive
ability than the FTQ.
The present results indicate that the inhalation
question adds little to the FTQ. Even though people
need to inhale to gain a dose of nicotine, the
inhalation question did not receive overwhelming
support from the current study. One possible
explanation for this finding is that because very few
individuals fail to inhale, the between-group com-
parisons are not particularly powerful. Research has
shown that individuals can accurately estimate
whether they inhale or not (Herling & Kozlowski,
1988),
although it has yet to be shown how useful
these estimates are. The usefulness of the inhalation
item is also called into question because smokers
who do not inhale are unlikely to be seen in
treatment, which is where the majority of research
that uses the FTQ takes place. Considering these
problems together, it seemed prudent to eliminate
the inhalation question in any revision of the FTQ.
Similarly, the validity of the nicotine rating item
was also not supported by the present analysis. We
examined numerous methods of scoring nicotine
ratings and tried many different types of statistical
analyses; all of our efforts were met with failure.
The major problem with nicotine yield is that the
machine ratings correspond rather poorly with the
resultant yield of a smoked cigarette. Because
compensatory smoking methods can render any low
yield cigarette a high yield cigarette (Fagerstrom,
1982a; Kozlowski et al, 1989) individual differ-
ences in smoking style exert a greater influence on
nicotine obtained than the machine-rated nicotine
yield.
Fagerstrom acknowledged early that the FTQ
might be improved by modification, and our goal
was to arrive at such modifications. We propose a
revised scoring for the FTQ, called the Fagerstrom
Test for Nicotine Dependence (FTND). The
FTND can be found in Table 3.
The FTND consists of six of the original items
(nicotine rating and inhalation have been elimi-
nated) with revised scoring for two of the items
(TTF and CPD). Although the other items did not
add appreciably to the prediction of biochemical
levels,
they may relate to the behavioral issue of
smoking cessation. Because we did not have any
measures of smoking cessation in the current study,
we consider this the highest priority for future
studies on the FTND. An additional reason for
choosing to keep some of the other FTQ items is
that they may be useful for patient-doctor discus-
sions about nicotine dependence. That is, the
behavioral measures (such as having difficulty
1126 Todd F. Heatherton
et al.
refraining from smoking
or
smoking when
ill) may
provide insight
for the
patient regarding their need
to smoke.
Both
TTF and CPD are
modified
in the
FTND
according
to the HSI
scoring method (Heatherton et
al, 1989).
In the
current study,
the HSI was
uniformally
the
best predictor
of
biochemical
mea-
sures. Thus, often
the HSI is an
acceptable replace-
ment
for the
full-scale FTND.'
We
advise,
how-
ever, using
the
full-scale FTND when issues
of
smoking cessation
are
relevant, and until direct tests
are available
of
the relative merits
of
the two scales.
In summary,
the
FTND corrects some
of the
psychometric
and
conceptual problems
of
the
FTQ.
The FTND
has
acceptable levels
of
internal consis-
tency,
and is
closely related
to
biochemical indices
of heaviness
of
smoking.
The HSI
method
of
using
only
CPD and TTF
also received considerable
support from
the
current analysis. When time
or
resources
are
limited,
it
might
be
most profitable
to
ask
and
score only these
two
items. Further, future
work
is
needed which compares directly the HSI
and
FTND, especially
as
they relate
to
smoking cessa-
tion. Thus, future
use of
the revised FTND should
help
us
refine
our
knowledge
of
the dependency
oh
tobacco
and the
means
of
measuring
it.
Acknowledgements
We thank Marilyn Pope, Renate Kraskins,
and
Helma Nolte
for
their assistance with this project.
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... They were selected from among patients who had undergone initial examination but had not yet begun treatment at the SC outpatient departments at the National Hospital Organization (NHO) facilities or from among outpatients who had missed their SC treatment for at least one year after their last treatment. The inclusion criteria were as follows: (1) depressive tendency with a score between 39 and 59 on the self-rating depression scale (SDS) test [20][21][22] (questionnaire test for depression assessment); (2) nicotine dependence score of at least 5 on the Fagerstrom Test for Nicotine Dependence (FTND) [23][24][25]; (3) not currently undergoing pharmacotherapy at a department of psychiatry or taking psychosomatic medicine; and (4) age 20-80 years at the time of obtaining consent. Patients with a score of 53 or more on the SDS test or those clinically judged to require consultation by their attending physician were referred to a department of psychiatry/psychosomatic medicine to check whether they required pharmacotherapy. ...
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