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Errors in using tobacco withdrawal scale
  1. JOHN HUGHES
  1. Department of Psychiatry, University of Vermont, Burlington, Vermont 05401–1419, USA. john.hughes{at}uvm.edu
  2. Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA.
  3. hatsu001{at}tx.umn.edu
    1. DOROTHY K HATSUKAMI
    1. Department of Psychiatry, University of Vermont, Burlington, Vermont 05401–1419, USA. john.hughes{at}uvm.edu
    2. Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA.
    3. hatsu001{at}tx.umn.edu

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      Editor,— Several scientists and clinicians have used a tobacco withdrawal scale either received from us or based on our published work. We would like to make some suggestions about use of our scale to minimise misinterpretation.

      First, the name we prefer is the “Minnesota Nicotine Withdrawal Scale.” Second, total withdrawal scores are often reported; however, there is some variance in which symptoms are included and thus scores across studies are not comparable. Many researchers include drowsiness, fatigue, gastrointestinal complaints, headaches, and somatic complaints as scale items because we measured them in our earlier articles. Although a few studies have found evidence of these as withdrawal phenomena, most work indicates these are not valid measures of nicotine withdrawal.1 2 Many also omit depression, which was not included in our 1986 study but data collected since then show depression to be a valid withdrawal symptom for some smokers.2 3Some include craving and some do not. Craving was included in our original scale as it was included in the versions of nicotine withdrawal in the third edition and revised third edition of Diagnostic and statistical manual of mental disorders. Craving has been dropped in the fourth edition (DSM–IV).4 We believe that if craving is queried, it should not be included when calculating a total withdrawal summary score so that the total score represents a sum of DSM-IV items and because there is evidence that craving behaves differently from other withdrawal items.5

      In summary, we believe the most appropriate scale is one that includes only seven DSM–IV items: depression, insomnia, irritability/frustration/anger, anxiety, difficulty concentrating, restlessness, and increased appetite/weight gain (the eighth item, decreased heart rate, is not detectable on a self-report scale). Items can be rated on an ordinal scale with 0 = not present, 1 = mild, 2 = moderate, and 3 = severe, or on a 0–4 scale with the additional descriptor of “slight” between not present and mild, or using a 100 mm visual analogue scale. The last measure is probably the most sensitive but cannot provide an adjective descriptor to any given value. Whether or not researchers use only the DSM–IV items, we suggest they report which items they have included and the mean score across symptoms rather than a total score. This will improve comparability across reports.

      Finally, researchers can obtain our scale and further tips on its use from one of us (JH: fax +1 802 656 9628; john.hughes{at}uvm.edu; DK: fax +1 612 626 5168; hatsu001{at}tx.umn.edu).

      Other withdrawal scales can be obtained from Doug Jorenby (fax: +1 608 265 3102; dej{at}ctri.medicine.wisc.edu), Nina Schneider (fax: +1 310 478 6349; ngs{at}ucla.edu), or Saul Shiffman (fax: +1 412 687 4855;shiffman{at}pinneyassociates.com).

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