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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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% E
nd
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Stage 1 Stage 2 Stage 3 Stage 4
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 √ √ √ √ √
