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Dependence measures for non-cigarette tobacco products within the context of the global epidemic: a systematic review
  1. Elaine De Leon,
  2. Katherine Clegg Smith,
  3. Joanna E Cohen
  1. Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Institute for Global Tobacco Control, Baltimore, Maryland, USA
  1. Correspondence to Dr Katherine Clegg Smith, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Institute for Global Tobacco Control, 624 N. Broadway Room 726, Baltimore, MD 21205, USA; kasmith{at}


Objectives Validated metrics of tobacco dependence exist, but their value for global surveillance of tobacco dependence and development of tobacco control interventions is not well understood. This paper reviews tobacco dependence metrics for non-cigarette products, and whether measures of tobacco dependence have been validated in low-income and middle-income countries (LMIC).

Data sources Searches were conducted in PubMed, Scopus, PsycINFO, EMBASE, CINAHL and Global Health databases using variant terms for types of tobacco, dependence, measures and validity/reliability. Articles discussing dependence theories and/or metrics were fully reviewed and synthesised.

Study selection Searches yielded 2702 unique articles. Two independent coders identified 587 articles for abstract review, and 229 were subsequently fully reviewed. Findings from 50 eligible papers are summarised.

Data extraction An initial thematic analysis concentrated on four concepts: general tobacco dependence, dependence metrics, tobacco dependence in LMIC and dependence on non-cigarette tobacco.

Data synthesis Analysis identified 14 distinct tobacco dependence instruments. Existing metrics treat tobacco dependence as multifaceted. Measures have been developed almost exclusively around cigarette smoking, although some validation and application across products has occurred. Where cross-national validation has occurred, however, this has rarely included LMIC.

Conclusions For purposes of global surveillance of tobacco dependence, there is a compelling need for validated measures to apply universally across social contexts and a multitude of tobacco products. Alternatively, effective tobacco control interventions require validated dependence measures that integrate specific behavioural elements and social context of product use. While different measures of dependence are required to fulfil each of these goals, both have value in addressing the global tobacco epidemic.

  • Low/Middle income country
  • Non-cigarette tobacco products
  • Addiction

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