The Short Nicotine Dependence Index: A Simple and Versatile Self-Report Measure of Nicotine Dependence for General Populations

Although some smokers switch to exclusive use of electronic cigarettes (e-cigarettes), others become dual users of combustible cigarettes and e-cigarettes. Little is known about how the onset of vaping affects the use of and dependence on combustible cigarettes or total nicotine use and dependence, which may influence health-related and cessation outcomes. Using self-report data of current combustible and e-cigarette use and retrospective recall of pre-vaping smoking in a sample of dual users, the aims of this study were (1) to compare pre- and post-vaping number of cigarettes per day and combustible cigarette dependence; (2) to compare pre- and post-vaping total nicotine use frequency (number of vaping sessions and cigarettes smoked per day), and total nicotine dependence; and (3) to examine predictors of nicotine dependence. We used baseline data from a smoking cessation trial with 2896 dual users. Nicotine use frequency and the Heaviness of Smoking Index were used as measures of nicotine use and dependence, respectively. Participants decreased cigarettes/day from pre- (M = 19.24, SD = 9.01) to post-vaping (M = 11.15, SD = 8.02, p < .0001) and combustible cigarette dependence declined from pre- (M = 3.55, SD = 1.51) to post-vaping (M = 2.11, SD = 1.60, p < .0001). Total daily nicotine use frequency increased after initiating vaping (M = 19.25, SD = 9.01 vs. M = 29.46, SD = 8.61; p < .0001), as did total nicotine dependence (M = 3.55, SD = 1.51 vs. M = 4.68, SD = 1.38; p < .0001). Hierarchical regression analyses indicated that variables associated with greater overall nicotine dependence included: younger age, lower education, more years smoking, higher pre-vaping nicotine dependence, using e-cigarettes more days per month, more puffs per vaping session, higher e-liquid nicotine concentration, and longer vaping history. Dual use leads to a reduction in the number of combustible cigarettes, but total nicotine use and dependence increases. In dual users, a reduction in smoking following onset of vaping may offer some harm reduction via reduction in cigarette intake. However, the increase in total nicotine use and dependence could affect the ability to quit either or both products.

To compare screening performances of the Fagerstrom Tolerance Questionnaire (FTQ), the Fagerstrom test for nicotine dependence (FTND) and the Heavy Smoking Index (HSI) with a view to determining the optimum cutoff scores using biomarkers as standards. Previous studies proposed inconsistent cutoff scores for the FTQ, the FTND as signalling nicotine dependence and these scores were established by applying diverse standards. Receiver operating characteristic (ROC) analyses were used in pursuit of the study's objectives. Two hundred and forty-five male smokers were recruited in 2005 from among those attending public health stations in southern Taiwan. The three self-report measures of nicotine dependence were compared with the saliva cotinine and expired carbon monoxide (CO). The expired CO level was tested by means of a Micro Smokerlyzer, while salivary cotinine was analysed using an enzyme-linked immunosorbent assay. The areas under the ROC curves for the FTQ, the FTND and the HSI were 0.71, 0.76 and 0.76 for the salivary cotinine and 0.71, 0.79 and 0.80 for the exhaled CO respectively. The sensitivity and specificity of the FTND and the HSI were slightly greater than those for the FTQ. The optimum cutoff scores for the FTQ, the FTND and the HSI as screening tools to establish nicotine dependence would be 5+, 4+ and 3+ respectively. The results indicate that the FTND and the HSI may be more efficacious than the FTQ in assessing nicotine dependence. Further research is needed to confirm these findings, especially among female smokers and for nicotine substitution trials. Relevance to clinical practice. To decrease tobacco-attributable morbidity and mortality, nurses and healthcare professionals need to implement effective smoking cessation interventions. The FTND and the HSI as well as their cutoff scores will be suitably used to assess nicotine dependence in these interventions.

Introduction:The Heaviness of Smoking Index (HSI) is validated to measure nicotine dependence in nonpregnant smokers, and in these smokers, mean salivary and serum cotinine levels are related by a ratio of 1.25. However, as nicotine metabolism increases during gestation, these findings may differ in pregnancy. We investigated the validity of HSI in pregnancy by comparing this with 3 biochemical measures; in a search for a less-invasive cotinine measure in pregnancy, we also explored the relationship between mean blood and salivary cotinine levels.Methods:Cross-sectional analyses using baseline data from the Smoking, Nicotine, and Pregnancy Trial. Participants were 16–46 years old, 12–24 weeks gestation, smoked more than 5 cigarettes per day, and had exhaled carbon monoxide (CO) readings of at least 8 ppm. Linear regression was used to examine correlations between HSI and blood cotinine and salivary cotinine and exhaled CO. Correlation between blood and salivary cotinine was investigated using linear regression through the origin.Results:HSI scores were associated with blood cotinine (R2 = 0.20, n = 662, p < .001), salivary cotinine (R2 = 0.11, n = 967, p < .001), and exhaled CO (R2 = 0.13, n = 1,050, p < .001). Salivary and blood cotinine levels, taken simultaneously, were highly correlated (R2 = 0.91, n = 628, p < .001) and the saliva:blood level ratio was 1.01 (95% CI 0.99–1.04).Conclusions:Correlations between HSI and biochemical measures in pregnancy were comparable with those obtained outside pregnancy, suggesting that HSI has similar validity in pregnant smokers. Salivary and blood cotinine levels are roughly equivalent in pregnant smokers.

On the basis of our previous identified linkage regions for nicotine dependence (ND), we selected seven and four single nucleotide polymorphisms (SNPs) in the beta-arrestins 1 (ARRB1) and 2 (ARRB2), respectively, to determine the associations of the two genes with ND in a total of 2037 subjects from 602 nuclear families of European American (EA) and African American (AA) origin. ND was assessed by Smoking Quantity (SQ), the Heaviness of Smoking Index (HSI) and the Fagerström Test for ND (FTND) score. Individual SNP analysis indicated that SNPs rs472112 within ARRB1 and rs4790694 within ARRB2 in the EA sample was significantly associated with HSI and FTND score, and the association of rs4790694 for ARRB2 remained significant after correction for multiple testing. Haplotype analysis revealed that haplotype C-G-C-G-G-T within ARRB1 at a frequency of 20%, formed by SNPs rs528833, rs1320709, rs480174, rs5786130, rs611908 and rs472112, was positively associated with HSI and FTND in EAs. We also found a haplotype within ARRB2, C-C-A-T at a frequency of 10.7%, formed by SNPs rs3786047, rs4522461, rs1045280 and rs4790694, that showed a significant positive association with HSI and FTND in the EA sample. No significant associations for either individual SNPs or major haplotype of both ARRB1 and ARRB2 were found in the AA sample. Further, the strength of these associations increased after removing the SQ component from HSI and FTND scores in both the EA and AA samples, suggesting that ARRB1 and ARRB2 play an important role in biological processes involved in the regulation of smoking urgency (that is time to smoke first cigarette). In summary, our results provide the first evidence of a significant association for ARRB1 and ARRB2 variants with ND in an EA sample.

Based on our previously identified linkage regions for nicotine dependence (ND), we selected six and five single nucleotide polymorphisms (SNPs) in the muscarinic cholinergic receptor subtype M1 (CHRM1) and nicotinic cholinergic receptor beta1 (CHRNB1), respectively, to determine the association of the two genes with ND in a total of 2,037 subjects from 602 nuclear families of either African-American (AA) or European-American (EA) origin. Individual SNP- and/or haplotype-based analyses indicated that the CHRNB1 was significantly associated with ND, which was assessed by smoking quantity (SQ), the Heaviness of Smoking Index (HSI), and the Fagerström Test for ND (FTND), in both ethnic samples. The association of rs2302763 in the CHRNB1 was significant with adjusted SQ in the EA sample after correction for multiple testing (P=0.013). Haplotype A-T-A formed by SNPs rs2302765, rs2302762, and rs9217 in the CHRNB1 was significantly associated with the high risk allele for all the three ND measures (minimum P=0.009, 0.006, and 0.008 for SQ, HSI and FTND, respectively) in the AA sample while haplotype A-T-A formed by rs2302765, rs2302763, and rs9217 was significantly positively associated with ND (minimum P=0.005, 0.016, and 0.016 for SQ, HSI and FTND, respectively) in the EA sample. The CHRM1 exhibited significant protective associations of haplotype C-C-A-T-G-G formed by all six SNPs of this gene with at least one ND measure in the AA sample after Bonferroni correction (minimum P=0.008, 0.013, and 0.009 for SQ, HSI and FTND, respectively), but no significant association was found in the EA sample. The significant associations, together with their location of linked region to ND, suggest that the CHRNB1 and CHRM1 are likely candidates for further investigation.

Background and objective The heaviness of smoking index (HSI) is a popular tool to assess nicotine dependence in clinical and community settings. Low cigarette consumption and concurrent use of other tobacco products raise concerns about its validity in Indian settings. This study explores the performance of HSI in Indian settings. Methods This study analyzed daily manufactured cigarette smoker data from the cross-sectional Global Adult Tobacco Surveys (GATS) from its first (GAST-1, 2009) and second waves (GATS-2, 2016), both of which were available in the public domain. The HSI scores were calculated based on the number of cigarettes smoked per day (CPD) and time to first smoke (TTFS) after waking up among the current daily cigarette users. This study examined the utility of the HSI scale in Indian settings by estimating the predictability of low dependence on quit attemptsand quit intentions using the likelihood ratio parameter. Results About nine in 10 cigarette users in India consumed less than 10 cigarettes per day, yielding a low score on the HSI scale for most of the daily cigarette users. The majority of daily cigarette smokers scored ≤ 1 (low dependence) on the HSI scale both in GATS-1 and GATS-2, irrespective of their exclusive cigarette use status. The absolute value and the 95% confidence limit of positive likelihood ratios (falling below and above one) suggest that the predictability of low dependence on quit attempts and quit intention in the Indian setting is limited. Conclusions The utility of the HSI scale in assessing nicotine dependence among cigarette users in India is limited. This may be attributed to low average cigarette consumption, concurrent use of various tobacco products, and the sociocultural milieu of Indian smokers. This highlights the need for a new rapid nicotine dependence scale tailored to the specific patterns of tobacco use behavior prevalent in the Indian context.

Using the Fagerström Test of Nicotine Dependence (FTND), the Heaviness of Smoking Index (HSI) and the time-to-first-cigarette (TTFC), this study estimated prevalence, evaluated optimal scale cut-offs, identified predictors and assessed potential impact on health, productivity and health-care use of high nicotine dependence among US smokers. This cross-sectional study used 2011 National Health and Wellness Survey data (n = 50 000). Nicotine dependence, demographic data, measures of health, productivity and health-care use and health attitudes were assessed. The prevalence of high nicotine dependence ranged from 23% (TTFC < 5 minutes) to 63.6% (TTFC < 30 minutes). Based on diagnostic accuracy, the cut-offs for high nicotine dependence using HSI and TTFC varied according to FTND cut-off: if FTND > 4, then HSI > 3 and TTFC < 30 minutes represented optimal cut-offs; if FTND > 5, HSI > 4 and TTFC < 5 minutes represented optimal cut-offs. Across all measures, high nicotine dependence was related significantly to being male, single, age 45-64 years and Caucasian; lower education; lack of health insurance; under/unemployment; comorbid respiratory or cardiovascular disease, diabetes or psychiatric illness; and lower rates of exercise and concern for weight control. Controlling for demographic variables and comorbid physical and psychiatric illness, high nicotine dependence, measured by FTND, HSI or TTFC, was associated significantly with reduced mental and physical quality of life, reduced work-place productivity and more health-care use. High nicotine dependence is associated with lower quality of life, lower work productivity and higher health-care use. The Heaviness of Smoking Index and the time-to-first-cigarette can provide useful screening measures of nicotine dependence in clinical and research settings.

INTRODUCTIONMeasuring the level of nicotine addiction among smokers is an integral part of enhancing smoking cessation as nicotine dependence is one of the barriers to smoking cessation. In this study, we compared the level of agreement between FTND and HSI in detecting high nicotine dependence among daily smokers.METHODSWe collected data from participants of a public smoking cessation clinic in Selangor. A trained pharmacist conducted face-to-face interviews with 152 daily smokers using a structured validated questionnaire. Respondents were classified as having high nicotine dependence using both the HSI (score ≥4) and the FTND (score ≥6), and concordance between the two measures, kappa statistics and sensitivity, specificity of the HSI were then determined with the FTND classification as the reference standard.RESULTSThe HSI had a substantial agreement with the FTND (Cohen’s kappa=0.72) in measuring high levels of nicotine addiction, with good sensitivity (83.3%) and specificity (89.4%).CONCLUSIONSThe findings suggest that the HSI can be used instead of the FTND in clinical-based investigations to screen for high nicotine dependence among daily smokers in the clinical setting.

It is important to perform a routine screening of nicotine dependence in psychiatric patients. The Fagerstrom Test for Nicotine Dependence (FTND) is a widely used six-item questionnaire. The Heavy Smoking Index (HSI) is a briefer measure including only two FTND items (time to first cigarette of day and number of daily cigarettes). In a prior study comparing HSI with FTND, a high HSI (score > or = 4) was a good and briefer alternative for detecting high nicotine dependence. The goals of this study were: (i) to compare the effectiveness of the HSI with the effectiveness of Items 1 and 4 alone for the screening of high nicotine dependence; (ii) to investigate the optimality of 4 as a cut-off score for the HSI so that the HSI can be used as a binary indicator of high nicotine dependence; and (iii) to compare the sensitivity and specificity of four indexes of high nicotine dependence, namely 'High HSI', 'Very Early Smoking', 'Heavy Smoking' and 'High in Either Item'. The FTND was administered to 819 current daily smokers from a general population survey. As in a prior study, an FTND score > or = 6 was considered the reference or 'gold standard' test for detecting high nicotine dependence. Receiver-operating characteristic analyses were performed. This new study using more sophisticated statistical methodology verified that a cut-off of 4 for the HSI is appropriate and that the 'high' HSI has good sensitivity and specificity even across different population subclassifications. With four questions (smoking, daily smoking, time to first cigarette of day and number of daily cigarettes) and minimal calculations, it may be possible to screen whether a smoker has high nicotine dependence. If other studies in other populations and settings verify this finding, this brief measure might be an ideal screening instrument for busy clinicians, epidemiologists developing questionnaires for health surveys and psychiatric researchers.

In line with national guidance, mental health Trusts in England are implementing complete smoke-free policies. We investigated inpatients' changes in smoking behavior, tobacco dependence, vaping, and motivation to stop smoking between pre-admission and post-discharge. We surveyed acute adult mental health inpatients from 14 wards in three mental health Trusts in England in 2019. Structured face-to-face and telephone interviews with patients who smoked on or during admission were conducted during the admission period and at one week and one month after discharge. Data on smoking status; daily cigarette consumption; Heaviness of Smoking Index (HSI); Strength of Urges to Smoke (SUTS); Motivation to Stop Smoking (MTSS) and vaping were collected and analyzed using regression and probit models. Inpatient smoking prevalence was 51.9%, and a total of 152 of all 555 eligible smokers (27%) were recruited. Attrition was high: 49.3% at the first and 50.7% at the second follow-up interview. Changes in self-reported smoking status, motivation to quit, and vaping did not change significantly over the study period. Cigarette consumption (p < 0.001) and Heaviness of Smoking Index (p < 0.001) modestly reduced. The frequency and strength of urges to smoke (p = 0.011 and 0.012, respectively) decreased modestly after discharge but were scored as high by 57% and 60% of participants during admission respectively. Just over half (56%) reported being offered smoking cessation support on admission. This study identified very modest changes in smoking-related outcomes during and after admission and indicates major challenges to smoke-free policy implementation, including limited support for patients who smoke. Despite mental health Trusts in England had developed and implemented smoke-free policies to meet national guidelines, adherence to these policies and provision of effective smoking cessation and temporary abstinence support for inpatients admitted to acute adult mental health wards appear to be limited. Patients who smoke on admission are likely to continue to do so during admission and after discharge, and only a very modest change in smoking behaviors appears to take place. Important opportunities to promote smoking cessation in this population are missed. Barriers to effective support need to be identified and addressed.

Smoking, nicotine dependence and nicotine intake by socio-economic status and marital status

A two-stage association study was conducted targeting a genomic region on chromosome 17p13 that we reported likely to harbor susceptibility gene(s) for nicotine dependence (ND). Participants were 2037 subjects from 602 nuclear families of either African-American (AA) or European-American (EA) origin from our Mid-South Tobacco Family (MSTF) cohort. We first examined 10 single nucleotide polymorphisms (SNPs) in six genes within the targeted region of about 90 kb to determine which SNP/gene was associated with ND, assessed by smoking quantity (SQ), the heaviness of smoking index (HSI) and the Fagerström Test for ND (FTND). Individual SNP analysis revealed that SNPs rs17710 and rs222843 in GABA(A) receptor-associated protein (GABARAP) exhibited a significant association with at least one age- and gender-adjusted ND measure in the EA sample and rs222843 remained significant with the FTND after correction for multiple testing (P = 0.009). Although no SNP in DLG4 was significantly associated with ND, we found a G-G haplotype with a frequency of 14.2% formed by SNPs rs2242449 and rs507506 within the gene that showed significant inverse associations with all three ND measures [P = 0.003, 0.015 and 0.024, for SQ (defined as the number of cigarettes smoked per day), HSI and FTND, respectively]. We also found an A-A haplotype with a frequency of 8.8% formed by SNPs rs17710 and rs222843 in GABARAP, which revealed significant associations with all three ND measures (P = 0.006, 0.019 and 0.024, for SQ, HSI and FTND, respectively). To confirm these findings with a better coverage of GABARAP and DLG4, we conducted a second-stage association analysis by genotyping four more SNPs for GABARAP and nine more for DLG4 on the same set of samples. Our results from the second stage of individual SNP- and/or haplotype-based association analysis supported our finding of significant association of the DLG4 gene with ND. No significant association of GABARAP or DLG4 with ND was detected in the AA sample. Further, by comparing the linkage signal before and after adjustment for the SNPs of GABARAP and DLG4, we found that inclusion of the SNPs of the two genes as covariates largely reduced the linkage signal in the EA sample, but kept nearly unchanged in the AA sample. Taken together, our two-stage association analysis and linkage analysis results indicate that the GABARAP and DLG4 genes are involved in the etiology of ND in EA smokers. Further investigation of neurobiological mechanisms of the two genes in the etiology of ND is thus warranted.

Two methods of identifying smokers with high nicotine dependence, the heaviness of smoking index (HSI) and number of cigarettes per day (CPD) were compared with the Fagerstrom test for nicotine dependence (FTND). The HSI, CPD and the FTND were administered to 316 adult Malaysian male, daily smokers aged between 25-64 years old in the Malaysian NCD Surveillance-1 Survey using a two-stage stratified random sampling of enumeration blocks and living quarters, via an interview based on a validated questionnaire. The cut-off point for classification of high nicotine dependence on the HSI was a score of four or higher, and for the heavy smoking category, smoking more than 20 cigarettes per day. Classification using each method was compared with classification by the FTND (score of six or more) as the reference standard. Sensitivity, specificity and kappa statistics for concordance between both measures and the FTND were evaluated. The HSI gave a similar prevalence rate of high nicotine dependence as the FTND. There was substantial agreement between the HSI and the FTND (kappa=0.63.), with moderate sensitivity (69.8%) and high specificity (92.5%). However, prevalence of high nicotine dependence using the CPD was 7% lower than the FTND. The heavy smoking category also showed fair agreement with the FTND (kappa=0.45) and moderate sensitivity (67.0%), but specificity was high (86.9%). The findings indicate that the HSI can be used as an alternative to the FTND in screening for high nicotine dependence among daily smokers in large population-based studies, while CPD may not be a suitable alternative to the FTND.

New nicotine and tobacco products such as electronic cigarettes and oral nicotine products have increased in use and threaten to addict a new generation of youth. This review summarizes current literature on nicotine and tobacco products used by youth, epidemiology, health effects, prevention and treatment of nicotine dependence, and current policies and regulations. Electronic cigarettes and oral nicotine products are popular among youth, attracting adolescents through exposure to deceptive marketing and fruit, candy and dessert flavors. Electronic cigarettes and oral nicotine product use can lead to nicotine addiction and is associated with respiratory, cardiovascular, and oral health problems, although long-term health effects are not fully known. The Food and Drug Administration (FDA) has authority to regulate nicotine and tobacco products; however, thousands of unregulated and unauthorized products remain on the market. Millions of adolescents continue to use nicotine and tobacco products, which puts them at risk for health problems, including nicotine addiction. Pediatric providers can provide prevention messages, screen youth for tobacco and nicotine use, and offer appropriate treatment options. Regulation of tobacco and nicotine products by the FDA is critical to reverse this public health epidemic of youth nicotine and tobacco use.

Variability in the rate of nicotine metabolism, measured by the nicotine metabolite ratio (NMR), is associated with smoking behavior. However, data linking the NMR with nicotine dependence measured by the Fagerström test for nicotine dependence (FTND) are mixed. Few past studies have examined alternative measures of nicotine dependence and how this relationship may vary by sex and race. Using data from smokers undergoing eligibility evaluation for a smoking cessation clinical trial (n = 833), this study examined variability in the relationship between NMR and nicotine dependence across sex and race and using three measures of nicotine dependence: FTND, time-to-first-cigarette (TTFC), and the heaviness of smoking index (HSI). Controlling for sex and race, nicotine metabolism was associated with nicotine dependence only when using the HSI (p < 0.05). Male normal metabolizers of nicotine were more likely to have high nicotine dependence based on the FTND and HSI (p < 0.05), but NMR was not related to measures of nicotine dependence in women. For African Americans, the NMR was associated with nicotine dependence only for the TTFC (p < 0.05), but NMR was not associated with nicotine dependence among Caucasians. Post hoc analyses indicated that the NMR was associated with cigarettes per day, overall, and among men and Caucasians (p < 0.05). While there was some variation in the relationship between nicotine metabolism and nicotine dependence across measures and sex and race, the results indicate that this relationship may be more attributable to the association between NMR and cigarettes per day.