1. Measures of Addiction Joseph R DiFranza, MD
Department of Family Medicine and Community Health
University of Massachusetts Medical School

3. The Stages of Physical Addiction What does it measure?
The progression through the 4 stages of physical addiction

4. Stages of Physical Addiction
Most advanced symptom
Abstinence does not trigger a desire to smoke
Wanting
Craving
Needing
Duration NA
Transient
More persistent
Unremitting
Salience
Easily ignored
Difficult to ignore
Impossible to ignore
Intrudes on thoughts No
Yes
Sense of urgency
Prevents normal functioning
Dysphoric experience

5. Measure of Stage of Physical Addiction
This describes me…
not at all
a little
pretty well
very well
If I go too long without smoking the first thing I will notice is a mild desire to smoke that I can ignore.
If I go too long without smoking, the desire for a cigarette becomes so strong that it is hard to ignore and it interrupts my thinking.
If I go too long without smoking I just can’t function right, and I know I will have to smoke just to feel normal again.

8. The Stages of Physical Addiction Psychometrics
Discriminates across all other measures of nicotine dependence
Correlates with brain structural changes (r= -.85)

9. The dorsal anterior cingulate gyrus- the location of maximal correlation between FA and Stage of Physical Addiction

10. Structural connectivity increases between the dorsal anterior cingulate and prefrontal cortex with advancing Stage of Addiction.

18. The Stages of Physical Addiction Pros and Cons
Very easily assessed and scored
A physiological measure that correlates with brain structure
Demonstrates concurrent validity with dozens of measures
It is not subject to cultural bias
Can be used with children and adults
Can be used with all types of tobacco

20. The Autonomy Over Tobacco Scale What does it measure?
Three aspects of addiction that contribute to a loss of autonomy
Withdrawal
Psychological Dependence
Cue-Induced Urges to Use Tobacco
It measures current symptoms only, so it can be used after cessation.

21. The Autonomy Over Tobacco Scale
Withdrawal
When I go too long without a cigarette, I get impatient.
When I go too long without a cigarette, I get strong urges that are hard to get rid of.
When I go too long without a cigarette, I lose my temper more easily.
When I go too long without a cigarette, I get nervous or anxious.
Psychological Dependence
I rely on smoking to focus my attention.
I rely on smoking to take my mind off being bored.
I rely on smoking to deal with stress.
I would go crazy if I couldn’t smoke.
Cue-Induced Urges to Smoke
When I feel stressed, I want a cigarette.
When I see other people smoking, I want a cigarette.
When I smell cigarette smoke, I want a cigarette.
After eating, I want a cigarette.

22. The Autonomy Over Tobacco Scale
Response options
Describes me not at all (0)
Describes me a little (1)
Describes me pretty well (2)
Describes me very well (3)
Scoring options
Add up total score (0-36)
Score items dichotomously (0-12)

23. The Autonomy Over Tobacco Scale Psychometrics
Excellent internal consistency
Total scale α = .94
Withdrawal α = .93
Psychological Dependence α = .77
Cue-Induced Urges α = .81
Correlates with
FTND r = .70
HONC r = .84
Smoking days per month r = .68
Latency to wanting r = .56
Validated for children and adults
Predictive validity in cessation study

24. The Autonomy Over Tobacco Scale Pros and Cons
Easily administered and scored
Reliable subscales
Symptom based, so it can be used in all cultures
Can be used with all forms of tobacco
Can be used with children and adults
The only measure that can be used after cessation
Useful for counseling before and after quit date
Does not diagnose addiction

25. The Latency to Needing a Cigarette What does it measure?
“After you have smoked a cigarette, how long can you go before you need to smoke again?”
I don’t feel a regular need to smoke
More than four weeks
four weeks
three weeks
two weeks
one week
six days
five days
four days
three days
two days
one day
less than one day (how many hours?)
less than an hour (how many minutes?)

26. The Latency to Withdrawal Psychometrics
Test-retest reliability is excellent (r = .85)
LTNC correlates with
Total AUTOS score, r = -.60
Cue-Induced Craving, r = -.64
Psychological Dependence, r = -.43
Withdrawal, r = -.57
Pleasure, r = -.39
LTNC varies moderately with daily cigarette consumption -.53, -.53, -.53

27. The Latency to Needing a Cigarette
Mean LTNC was 243 hours for subjects with <100 cigarette lifetime consumption
Mean LTNC was 2 hours for subjects with >100 lifetime consumption

28. The Latency to Withdrawal Pros and Cons
Very short and reliable
Relatively easily scored
Continuous measure
If they have a Latency, they are addicted.
Physiologic measure
Applicable to all forms of tobacco
Can be used in children and adults

29. Pleasure From Smoking
“How much pleasure do you get from smoking a cigarette?”
Likert scale zero = none, 9 = a great deal
Adolescent smokers mean pleasure = 5.7, 6.9
Adult smokers mean pleasure = 5.9
Test-retest reliability r =

30. Pleasure From Smoking Pleasure correlates with Withdrawal, r = .75
Psychological Dependence, r = .79
Cue-Induced Craving, r = .84
Proportion of time smoking out of need, r = .45
Latency to Needing a Cigarette, r = -.39

31. The Hooked on Nicotine Checklist What does it measure?
10 symptoms that make quitting more difficult

32. Hooked on Nicotine Checklist
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?

33. Hooked on Nicotine Checklist
When you haven't smoked for a while do you…
7) find it hard to concentrate?
8) feel more irritable?
9) feel a strong need or urge to smoke?
10) feel nervous, restless or anxious?

34. The Hooked on Nicotine Checklist Psychometrics
Excellent internal consistency α =
Excellent retest reliability (intraclass correlation = 0.88)
Excellent predictive validity: a HONC symptom increased the risk of daily smoking: OR= 83.
Correlates with
smoking frequency, r = .70
FTND, r = .71
AUTOS, r = .84

35. The Hooked on Nicotine Checklist Pros and Cons
Easy to administer and score (dichotomous or continuous)
Provides a cut-off score
Very sensitive
Measures only symptoms, not behavior
Free of age and cultural bias, valid for kids and adults
Can be used for all forms of tobacco
Measures lifetime incidence, cannot be used after cessation

36. The Fagerström Test for Nicotine Dependence What does it measure?
Severity of nicotine dependence
Does not diagnose dependence
No consensus on what it measures
Indirect behavioral measure of withdrawal and the Latency to Withdrawal

37. The Fagerström Test for Nicotine Dependence
1. How soon after you wake up do you smoke your first cigarette?
After 60 minutes (0)
31-60 minutes (1)
6-30 minutes (2)
Within 5 minutes (3)
2. Do you find it difficult to refrain from smoking in places where it is forbidden?
No (0)
Yes (1)
3. Which cigarette would you hate most to give up?
The first in the morning (1)
Any other (0)
4. How many cigarettes per day do you smoke?
10 or less (0)
11-20 (1)
21-30 (2)
31 or more (3)
5. Do you smoke more frequently during the first hours after awakening than during the rest of the day?
6. Do you smoke even if you are so ill that you are in bed most of the day?

38. The Fagerström Test for Nicotine Dependence Psychometrics
α = .73 (compared to .92 for HONC and .93 for AUTOS in the same sample)
Test-retest, r =
Correlates with
AUTOS, r = .70
HONC, r = .71
Changes in brain structure, r = -.52, r = -.58, and r = -.64 (compared to -.85 for Stage of Physical Addiction)
Latency to Needing a Cigarette, r = .45
Smoking days per month, r = .59

39. The Fagerström Test for Nicotine Dependence Pros and Cons
Short
Easily scored
Widely used
Provides discrimination at high levels of dependence
Cons
Insensitive to low levels of dependence
No cut off score- does not diagnose dependence
Based entirely on behavior which lends to cultural bias
Not valid for children
Not valid for nondaily smokers
For current smokers only

40. The Diagnostic and Statistical Manual What does it measure?
A diagnosis of nicotine dependence

41. The Diagnostic and Statistical Manual
Unsuccessful efforts to cut down or quit
Use despite harm
Withdrawal
Tolerance
Use in greater amounts or longer than intended
A great deal of time spent using
Social, occupational or recreational activities given up.

42. The Diagnostic and Statistical Manual
Literature review of 169 articles
No validity to a three-criteria diagnostic threshold
No validity to a four-symptom withdrawal threshold
Predictive validity was poor
It correlates poorly to modestly with all other measures of dependence and behavior

43. The Diagnostic and Statistical Manual Psychometrics
Adequate to excellent retest reliability
Unacceptable internal reliability
Unacceptable sensitivity (In one study DSM diagnosed only two thirds of smokers who had six of more failed quit attempts.)
Correlates poorly with self-diagnosed addiction, r = .48

44. The Diagnostic and Statistical Manual Pros and Cons
It provides a “diagnosis” based on completely arbitrary criteria with no established connection with the pathophysiology
Lengthy and difficult to administer
Very subjective criteria

45. The International Classification of Diseases What does it measure?
A diagnosis of tobacco dependence

46. The International Classification of Diseases
A strong desire or compulsion to take the substance
Impaired capacity to control use
A physiological withdrawal state
Tolerance
Preoccupation with use (activities given up, time spent)
Persistent use despite harm

47. The International Classification of Diseases Psychometrics
Literature search-2010
No psychometric data on the official instrument
No data supporting
Diagnostic validity
Predictive validity
3 symptom diagnostic threshold
2 symptom withdrawal threshold

48. The International Classification of Diseases Psychometrics
Does not correlate strongly with
Self-rated addiction, r = .58
Self-rated difficulty quitting, r = .57
Daily cigarette consumption, r = .22
Time to first morning cigarette, r = -.06

49. The International Classification of Diseases Pros and Cons
Lengthy to administer
It provides a “diagnosis” based on completely arbitrary criteria with no established connection with the pathophysiology

50. Summary Brief Valid and Reliable All forms of tobacco
Children and adults
After cessation
No cultural bias
Stages √
LTNC
AUTOS
HONC
FTND
DSM-IV
ICD-10
Pleasure