Measures of Addiction Joseph R DiFranza, MD Department of Family Medicine and Community Health...

Measures of Addiction

Joseph R DiFranza, MDDepartment of Family Medicine and

Community HealthUniversity of Massachusetts Medical School

The Stages of Physical AddictionWhat does it measure?

• The progression through the 4 stages of physical addiction

Stage 1 Stage 2 Stage 3 Stage 4

Most advanced symptom

Abstinence does not

trigger a desire to smoke

Wanting Craving Needing

Duration NA Transient More persistent Unremitting

Salience NA Easily ignoredDifficult to

ignoreImpossible to

ignore

Intrudes on thoughts

NA No Yes Yes

Sense of urgency NA No No Yes

Prevents normal functioning

NA No No Yes

Dysphoric experience

NA No No Yes

Stages 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.

Measure of Stage of Physical Addiction

Stage 1 Stage 2 Stage 3 Stage 40

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Distribution of Stages in 347 Adolescent Smokers

Stage 1 Stage 2 Stage 3 Stage 405

101520253035404550

Distribution of Stages in 271 Adult Smokers

The Stages of Physical AddictionPsychometrics

• Discriminates across all other measures of nicotine dependence

• Correlates with brain structural changes (r= -.85)

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

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

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Days Smoked per Monthby Stage (adults)

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Number of Cigarettes Smoked on Smoking Days (adults)

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Mean Adult FTND Scores by Stage

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Mean Adolescent HONC Scores by Stage

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Mean Adult HONC Scores by Stage

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I am careful not to run out. I make sure I have enough cigarettes for the next morning (adults)

The Stages of Physical AddictionPros 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

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Stage 1 Stage 2 Stage 3 Stage 4

To some degree I have to plan my schedule around when I will be able to smoke (adults)

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.

The Autonomy Over Tobacco ScaleWithdrawal

– 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.

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)

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

The Autonomy Over Tobacco ScalePros 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

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?)

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

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

The Latency to WithdrawalPros 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

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 = .84 - .94

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

The Hooked on Nicotine Checklist What does it measure?

• 10 symptoms that make quitting more difficult

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?

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?

The Hooked on Nicotine Checklist Psychometrics

• Excellent internal consistency α = 0.86-0.93• 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

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

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

The Fagerström Test for Nicotine Dependence1. 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?– No (0)– Yes (1)

6. Do you smoke even if you are so ill that you are in bed most of the day?– No (0)– Yes (1)

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 = .88-.91• 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

The Fagerström Test for Nicotine DependencePros and Cons

• Pros – 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

The Diagnostic and Statistical Manual What does it measure?

• A diagnosis of nicotine dependence

The Diagnostic and Statistical Manual

1. Unsuccessful efforts to cut down or quit2. Use despite harm3. Withdrawal4. Tolerance5. Use in greater amounts or longer than intended6. A great deal of time spent using7. Social, occupational or recreational activities

given up.

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

The Diagnostic and Statistical Manual Psychometrics

• Adequate to excellent retest reliability• Unacceptable internal reliability 0.41 - 0.64• 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

The Diagnostic and Statistical ManualPros 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

The International Classification of Diseases What does it measure?

• A diagnosis of tobacco dependence

The International Classification of Diseases

1. A strong desire or compulsion to take the substance2. Impaired capacity to control use3. A physiological withdrawal state4. Tolerance5. Preoccupation with use (activities given up, time

spent)6. Persistent use despite harm

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

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

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

SummaryBrief Valid and

ReliableAll forms of tobacco

Children and adults

After cessation

No cultural bias

Stages √ √ √ √ √

LTNC √ √ √ √ √

AUTOS √ √ √ √ √

HONC √ √ √ √

FTND √ √

DSM-IV

ICD-10

Pleasure √ √ √ √ √