The Fagerstrom Test for Nicotine Dependence and the Diagnostic Interview Schedule: Do they diagnose the same smokers?

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Abstract

Two common assessment tools for nicotine dependence are the Fagerstrom Test for Nicotine Dependence (FTND) and the Nicotine Dependence section of the Diagnostic Interview Schedule [(DIS)-III-R or -IV based on the Diagnostic and Statistical Manual (DSM)-III-R and -IV, respectively]. The FTND emphasizes morning smoking and overall “heaviness” of smoking. The DSM emphasizes adverse consequences, desire to cut down, and mood changes during withdrawal. We tested (1) how the DSM-III-R diagnosis of Nicotine Dependence is related to FTND score; and (2) how the (a) DSM-III-R or (b) elevated FTND score is related to longer smoking histories, greater psychiatric symptomatology, and tobacco liking scores. Retrospective chart reviews were conducted on 370 smokers, the majority (55.9%) of whom had a current DSM-III-R diagnosis of Substance Dependence other than nicotine. All subjects had completed the FTND, the DIS-III-R, the Symptom Checklist-90-Revised (SCL-90-R), and a survey on drug liking. Agreement statistics were calculated between the DSM-III-R diagnosis of Nicotine Dependence and various cutoff scores values that were assigned as thresholds for nicotine dependence on the FTND. At no cutoff score did the two instruments reliably agree; the highest κ (at a cutoff of FTND≥7) was 0.205. At cutoffs above 5, the FTND diagnosed fewer cases than the DSM-III-R. Multiple regression analysis showed that DSM diagnosis was associated with greater psychiatric symptomatology on the SCL-90-R, while FTND scores were associated with greater tobacco liking. The FTND and the DSM-III-R appear to measure different aspects of the tobacco dependence process. Specifically, the FTND may provide a stronger measure of physical dependence, while the DSM may tap other domains such as awareness of dependence, behaviors resulting from that awareness, and psychiatric symptomatology. Disagreements between the FTND and the DSM are likely to become greater with the changes in the DSM-IV.

Introduction

As the leading cause of preventable deaths and acute and chronic health problems, tobacco dependence remains a clinically challenging yet treatable entity. A variety of treatment approaches available to the individual, either directly or through medical practitioners, have shown success in helping heavily dependent smokers to quit Abrams et al., 1996, Fiore et al., 1996, Ockene et al., 1997, Ockene & Zapka, 1997. Therefore, engaging nicotine-dependent smokers into effective treatment is a public health imperative.

Although smokers' interactions with their health care providers present opportunities to engage them in cessation, treatment of tobacco dependence remains suboptimal (Thorndike, Rigotti, Stafford, & Singer, 1998); the Smoking Cessation Clinical Practice Guideline issued by the AHCPR (see Fiore et al., 1996) provides an evidence-based approach for health care providers in various treatment settings, yet the use of modalities proven to be of benefit is lagging. One step toward ameliorating this situation may be to improve the methods of diagnosing tobacco dependence.

Currently, two of the most commonly used measures of nicotine dependence are those derived from the Fagerstrom questionnaires Fagerstrom, 1978, Heatherton et al., 1991, Heatherton et al., 1989 and the Nicotine Dependence section of the Diagnostic Interview Schedule (DIS; Robins et al., 1989, Robins et al., 1981). The DIS, a structured interview based on criteria from the Diagnostic and Statistical Manual (DSM; American Psychiatric Assocation, 1987), is sometimes used in research but rarely in clinical settings. The Fagerstrom instruments, used frequently in both clinical and research settings Cinciripini et al., 1996, Glover et al., 1996, Hurt et al., 1996, Leischow et al., 1996, Moolchan, 1996, Rose et al., 1994, are the Fagerstrom Tolerance Questionnaire (FTQ; Fagerstrom, 1978) and the Fagerstrom Test for Nicotine Dependence (FTND; Heatherton et al., 1991). (The FTND is a revision of the FTQ that omits two items of little utility: inhalation and the use of high-nicotine brands of cigarettes.) An early comparison of the FTQ with the DSM-III Nicotine Dependence criteria (American Psychiatric Association, 1980) suggested a lack of concordance between the two (Hughes, Gust, & Pechacek, 1987). Similarly, FTQ scores have been shown to correlate only weakly (r=.17) with DSM-III-R lifetime symptoms of Nicotine Dependence (Marks, Pomerleau, & Pomerleau, 1998), and a comparison of DSM-III-R diagnosis with FTND scores suggests a lack of concordance (Breslau, Kilbey, & Andreski, 1994).

Differences in content between the FTND and the DSM are immediately apparent. The FTND assesses morning smoking after nocturnal abstinence and overall “heaviness” of smoking without assessing adverse consequences. In addition, by asking “Which cigarette would you hate to give up most?,” the FTND suggests a hedonic component (tobacco liking). In contrast, the DSM emphasizes awareness of adverse consequences, failed quitting, desire to cut down, and withdrawal symptoms, some of which (anxiety and irritability) suggest a psychiatric component.

In light of this, we hypothesized that (1) DSM diagnoses of current Nicotine Dependence would be only weakly related to FTND scores; (2) DSM diagnoses would be associated with longer smoking history (because many adverse consequences of smoking are slow to emerge) and possibly with greater psychiatric symptomatology, but not with greater subjective enjoyment of smoking; and (3) high FTND scores would not be associated with longer smoking history or greater psychiatric symptomatology but would be associated with greater subjective enjoyment of smoking.

Because we used archival data generated by the DIS-III-R instrument, DSM-IV (American Psychiatric Association, 1994) diagnosis could not be obtained. Thus, our analysis focused on the DSM-III-R rather than on the more current DSM-IV. However, our findings are likely to be relevant to the DIS-IV, for reasons that will be discussed below.

Section snippets

Subjects

Chart reviews were conducted retrospectively on men and women over 18 years of age who had been recruited into unrelated inpatient and outpatient studies at NIDA/IRP by advertisements or word of mouth. Of 872 charts reviewed, 370 had complete data on the measures of interest. Eighty (21.5%) subjects were women; 302 (81.6%) were African American. Their mean age was 34.1 years (S.D.=6.6, range=18–57); they had an average of 12.0 years of education (S.D.=1.8, range=4–17). More than half (55.9%)

Results

Subjects' FTND scores, DSM-III-R Nicotine Dependence status, and smoking history are summarized in Table 2. On average, subjects with current DSM-III-R Nicotine Dependence had significantly higher FTND scores than those without. However, there was a great deal of overlap. For example, among the 216 subjects with current DSM-III-R Nicotine Dependence, 11 (5.1%) had FTND scores of 0 and an additional 13 (6.0%) had FTND scores of only 1 (Fig. 1). Among the subset of 108 subjects who had never met

Discussion

The main finding from this study is that FTND scores show poor concordance with diagnosis of Nicotine Dependence according to DSM-III-R criteria. One immediate practical implication is that estimates of the prevalence of nicotine dependence in the general population may vary depending on which instrument is used. For example, the DSM-III-R identified 58% of our sample as dependent, but if we had instead used an FTND cutoff of 6 (as is used in some studies), only 43% would have been identified

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