Original reportReliability of Selected Measures of Nicotine Dependence among Adolescents
Introduction
Although classic models postulate that nicotine dependence (ND) develops only after several years of regular smoking (1), several lines of recent evidence suggest that symptoms of ND exist even in the early stages of smoking onset. First, young smokers absorb as much nicotine per cigarette as do adults, even with their first few cigarettes 2, 3. Second, surveys have documented ND symptoms including cravings and withdrawal symptoms among adolescent smokers 4, 5, 6, 7, 8, 9. Third, although substantial proportions of youth smokers try to quit, the success rate is low 10, 11; adolescents who attempt to quit report withdrawal symptoms 12, 13 and the number of symptoms and likelihood of relapse is related to the number of cigarettes smoked 12, 14. Finally, a recent study provided the first prospective evidence that ND symptoms occur early in the smoking onset process, before daily use, with low exposure to cigarettes, and over very short time intervals after smoking initiation (15). Collectively these findings suggest that we need to learn more about how early in the smoking onset process ND symptoms develop, and when these symptoms begin to influence patterns of smoking.
However, a major barrier to studying the natural history of ND is the lack of a widely accepted, theoretically derived, and psychometrically sound tool to measure ND in adolescents (16). More specifically, a valid and reliable instrument is needed to assess ND symptoms early in the onset process when smoking can be sporadic, irregular, and infrequent. While several instruments have been used to measure ND in both adults and adolescents, each has been criticized. The DSM definition of ND provides criteria to assess ND (17), but was not derived from addiction theory and is not accepted as a “gold standard” 16, 18, 19. Individual researchers must translate these criteria into survey items, so those instruments based on DSM criteria are not standardized across studies (18). In addition, although DSM criteria have been applied in modified forms to adolescents 9, 18, 20, 21, 22 they were not developed, tested, or validated for use in adolescents.
The Fagerstrom Tolerance Questionnaire (FTQ) (23) assesses the compulsion to use cigarettes to achieve pleasurable effects and to avoid withdrawal symptoms, and is widely used in research to categorize adult smokers by degree of ND. It was adapted for use among youth by Prokhorov et al. 24, 25 and in the Stanford Dependence Index (SDI) (13). While the FTQ (and SDI) measures the strength of physical dependence, it was not designed to measure when ND begins and therefore might not be useful in studies in which detection of early ND symptoms are crucial 16, 23, 24, 26. Although cotinine is used to describe dependence, it in fact measures nicotine intake rather than ND 9, 16, 27. Finally, the ICD-10 includes criteria for assessing tobacco dependence, but has not been used in studies of adolescents (28).
While measures of ND for adolescent smokers exist, their psychometric properties including test retest reliability, internal consistency (i.e. the extent to which individual items in a multi-item indicator, scale or index all measure the same underlying concept), and their content, convergent construct and criterion-related validity have not yet been systematically compared. This study describes selected psychometric properties of two measures of ND for adolescents — the SDI, and a newer measure, the Hooked on Nicotine Checklist (HONC), which was used in a recent study on the natural history of ND in adolescents (15). We also tested 45 “new” items that emerged from telephone consultation with seven North American experts on youth smoking, and from six focus group interviews with teenage smokers aged 14 to 17 years (29).
Section snippets
Methods
Data were collected during May/June 1999 in 45-minute classroom-administered questionnaires, in a convenience sample of nine grade 7, 9, and 11 classes in three secondary schools in Montreal. Schools were recruited by the principal investigator (JOL) through direct contact with the school principal or vice principal. After obtaining parental and/or student consent, two interviewers visited each class on two occasions. During the first visit, one interviewer stood at the front of the classroom
Results
A total of 249 students were eligible and consented to participate, including 104 subjects in grade 7, 58 in grade 9, and 87 in grade 11; 238 students (95.6%) participated in the first data collection; 220 (88.4%) participated in the second data collection. Of students who completed the first questionnaire, 45.4% were boys; 81.0% were born in Canada; 64.1% spoke English at home, 18.1% spoke French at home and 17.7% spoke another language at home. The average age of students in grade 7 was 13.3
Discussion
This study examined the psychometric properties of several measures currently in use to assess ND in adolescents including the HONC and SDI, as well as 45 “new” items derived from focus group interviews with adolescent smokers and from consultation with experts on youth smoking. Overall, most individual items showed acceptable test retest reliability as well as convergent construct validity against smoking intensity, and therefore show promise in terms of measuring some aspect of nicotine
Acknowledgements
This research was funded by the Canadian Tobacco Research Initiative of the National Cancer Institute of Canada, with funds from the Canadian Cancer Society. Jennifer O'Loughlin was a National Health Scholar during the time this project was undertaken and is currently a Research Scholar of the Fonds de la recherche en santé du Québec (FRSQ). The authors thank Stephen Tiffany, Gary Giovino, William Corrigall, Paul McDonald, Joy Johnson, Joel Killen, and Mark Myers for their contributions. They
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