3The Stages of Physical Addiction What does it measure? The progression through the 4 stages of physical addiction
4Stages of Physical Addiction Most advanced symptomAbstinence does not trigger a desire to smokeWantingCravingNeedingDurationNATransientMore persistentUnremittingSalienceEasily ignoredDifficult to ignoreImpossible to ignoreIntrudes on thoughtsNoYesSense of urgencyPrevents normal functioningDysphoric experience
5Measure of Stage of Physical Addiction This describes me…not at alla littlepretty wellvery wellIf 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.
18The Stages of Physical Addiction Pros and Cons Very easily assessed and scoredA physiological measure that correlates with brain structureDemonstrates concurrent validity with dozens of measuresIt is not subject to cultural biasCan be used with children and adultsCan be used with all types of tobacco
20The Autonomy Over Tobacco Scale What does it measure? Three aspects of addiction that contribute to a loss of autonomyWithdrawalPsychological DependenceCue-Induced Urges to Use TobaccoIt measures current symptoms only, so it can be used after cessation.
21The Autonomy Over Tobacco Scale WithdrawalWhen 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 DependenceI 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 SmokeWhen 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.
22The Autonomy Over Tobacco Scale Response optionsDescribes me not at all (0)Describes me a little (1)Describes me pretty well (2)Describes me very well (3)Scoring optionsAdd up total score (0-36)Score items dichotomously (0-12)
23The Autonomy Over Tobacco Scale Psychometrics Excellent internal consistencyTotal scale α = .94Withdrawal α = .93Psychological Dependence α = .77Cue-Induced Urges α = .81Correlates withFTND r = .70HONC r = .84Smoking days per month r = .68Latency to wanting r = .56Validated for children and adultsPredictive validity in cessation study
24The Autonomy Over Tobacco Scale Pros and Cons Easily administered and scoredReliable subscalesSymptom based, so it can be used in all culturesCan be used with all forms of tobaccoCan be used with children and adultsThe only measure that can be used after cessationUseful for counseling before and after quit dateDoes not diagnose addiction
25The 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 smokeMore than four weeksfour weeksthree weekstwo weeksone weeksix daysfive daysfour daysthree daystwo daysone dayless than one day (how many hours?)less than an hour (how many minutes?)
26The Latency to Withdrawal Psychometrics Test-retest reliability is excellent (r = .85)LTNC correlates withTotal AUTOS score, r = -.60Cue-Induced Craving, r = -.64Psychological Dependence, r = -.43Withdrawal, r = -.57Pleasure, r = -.39LTNC varies moderately with daily cigarette consumption -.53, -.53, -.53
27The Latency to Needing a Cigarette Mean LTNC was 243 hours for subjects with <100 cigarette lifetime consumptionMean LTNC was 2 hours for subjects with >100 lifetime consumption
28The Latency to Withdrawal Pros and Cons Very short and reliableRelatively easily scoredContinuous measureIf they have a Latency, they are addicted.Physiologic measureApplicable to all forms of tobaccoCan be used in children and adults
29Pleasure From Smoking“How much pleasure do you get from smoking a cigarette?”Likert scale zero = none, 9 = a great dealAdolescent smokers mean pleasure = 5.7, 6.9Adult smokers mean pleasure = 5.9Test-retest reliability r =
30Pleasure From Smoking Pleasure correlates with Withdrawal, r = .75 Psychological Dependence, r = .79Cue-Induced Craving, r = .84Proportion of time smoking out of need, r = .45Latency to Needing a Cigarette, r = -.39
31The Hooked on Nicotine Checklist What does it measure? 10 symptoms that make quitting more difficult
32Hooked 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?
33Hooked 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?
34The 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 withsmoking frequency, r = .70FTND, r = .71AUTOS, r = .84
35The Hooked on Nicotine Checklist Pros and Cons Easy to administer and score (dichotomous or continuous)Provides a cut-off scoreVery sensitiveMeasures only symptoms, not behaviorFree of age and cultural bias, valid for kids and adultsCan be used for all forms of tobaccoMeasures lifetime incidence, cannot be used after cessation
36The Fagerström Test for Nicotine Dependence What does it measure? Severity of nicotine dependenceDoes not diagnose dependenceNo consensus on what it measuresIndirect behavioral measure of withdrawal and the Latency to Withdrawal
37The 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?
38The 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 withAUTOS, r = .70HONC, r = .71Changes in brain structure, r = -.52, r = -.58, and r = -.64 (compared to -.85 for Stage of Physical Addiction)Latency to Needing a Cigarette, r = .45Smoking days per month, r = .59
39The Fagerström Test for Nicotine Dependence Pros and Cons ShortEasily scoredWidely usedProvides discrimination at high levels of dependenceConsInsensitive to low levels of dependenceNo cut off score- does not diagnose dependenceBased entirely on behavior which lends to cultural biasNot valid for childrenNot valid for nondaily smokersFor current smokers only
40The Diagnostic and Statistical Manual What does it measure? A diagnosis of nicotine dependence
41The Diagnostic and Statistical Manual Unsuccessful efforts to cut down or quitUse despite harmWithdrawalToleranceUse in greater amounts or longer than intendedA great deal of time spent usingSocial, occupational or recreational activities given up.
42The Diagnostic and Statistical Manual Literature review of 169 articlesNo validity to a three-criteria diagnostic thresholdNo validity to a four-symptom withdrawal thresholdPredictive validity was poorIt correlates poorly to modestly with all other measures of dependence and behavior
43The Diagnostic and Statistical Manual Psychometrics Adequate to excellent retest reliabilityUnacceptable internal reliabilityUnacceptable 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
44The Diagnostic and Statistical Manual Pros and Cons It provides a “diagnosis” based on completely arbitrary criteria with no established connection with the pathophysiologyLengthy and difficult to administerVery subjective criteria
45The International Classification of Diseases What does it measure? A diagnosis of tobacco dependence
46The International Classification of Diseases A strong desire or compulsion to take the substanceImpaired capacity to control useA physiological withdrawal stateTolerancePreoccupation with use (activities given up, time spent)Persistent use despite harm
47The International Classification of Diseases Psychometrics Literature search-2010No psychometric data on the official instrumentNo data supportingDiagnostic validityPredictive validity3 symptom diagnostic threshold2 symptom withdrawal threshold
48The International Classification of Diseases Psychometrics Does not correlate strongly withSelf-rated addiction, r = .58Self-rated difficulty quitting, r = .57Daily cigarette consumption, r = .22Time to first morning cigarette, r = -.06
49The International Classification of Diseases Pros and Cons Lengthy to administerIt provides a “diagnosis” based on completely arbitrary criteria with no established connection with the pathophysiology
50Summary Brief Valid and Reliable All forms of tobacco Children and adultsAfter cessationNo cultural biasStages√LTNCAUTOSHONCFTNDDSM-IVICD-10Pleasure