Measures of Addiction Joseph R DiFranza, MD Department of Family Medicine and Community Health University of Massachusetts Medical School

The Stages of Physical Addiction What does it measure? The progression through the 4 stages of physical addiction

Stages of Physical Addiction Most advanced symptom Abstinence does not trigger a desire to smoke Wanting Craving Needing Duration NA Transient More persistent Unremitting Salience Easily ignored Difficult to ignore Impossible to ignore Intrudes on thoughts No Yes Sense of urgency Prevents normal functioning Dysphoric experience

Measure of Stage of Physical Addiction This describes me… not at all a little pretty well very well If I go too long without smoking the first thing I will notice is a mild desire to smoke that I can ignore. If I go too long without smoking, the desire for a cigarette becomes so strong that it is hard to ignore and it interrupts my thinking. If I go too long without smoking I just can’t function right, and I know I will have to smoke just to feel normal again.

The Stages of Physical Addiction Psychometrics Discriminates across all other measures of nicotine dependence Correlates with brain structural changes (r= -.85)

The dorsal anterior cingulate gyrus- the location of maximal correlation between FA and Stage of Physical Addiction

Structural connectivity increases between the dorsal anterior cingulate and prefrontal cortex with advancing Stage of Addiction.

The Stages of Physical Addiction Pros and Cons Very easily assessed and scored A physiological measure that correlates with brain structure Demonstrates concurrent validity with dozens of measures It is not subject to cultural bias Can be used with children and adults Can be used with all types of tobacco

The Autonomy Over Tobacco Scale What does it measure? Three aspects of addiction that contribute to a loss of autonomy Withdrawal Psychological Dependence Cue-Induced Urges to Use Tobacco It measures current symptoms only, so it can be used after cessation.

The Autonomy Over Tobacco Scale Withdrawal When I go too long without a cigarette, I get impatient. When I go too long without a cigarette, I get strong urges that are hard to get rid of. When I go too long without a cigarette, I lose my temper more easily. When I go too long without a cigarette, I get nervous or anxious. Psychological Dependence I rely on smoking to focus my attention. I rely on smoking to take my mind off being bored. I rely on smoking to deal with stress. I would go crazy if I couldn’t smoke. Cue-Induced Urges to Smoke When I feel stressed, I want a cigarette. When I see other people smoking, I want a cigarette. When I smell cigarette smoke, I want a cigarette. After eating, I want a cigarette.

The Autonomy Over Tobacco Scale Response options Describes me not at all (0) Describes me a little (1) Describes me pretty well (2) Describes me very well (3) Scoring options Add up total score (0-36) Score items dichotomously (0-12)

The Autonomy Over Tobacco Scale Psychometrics Excellent internal consistency Total scale α = .94 Withdrawal α = .93 Psychological Dependence α = .77 Cue-Induced Urges α = .81 Correlates with FTND r = .70 HONC r = .84 Smoking days per month r = .68 Latency to wanting r = .56 Validated for children and adults Predictive validity in cessation study

The Autonomy Over Tobacco Scale Pros and Cons Easily administered and scored Reliable subscales Symptom based, so it can be used in all cultures Can be used with all forms of tobacco Can be used with children and adults The only measure that can be used after cessation Useful for counseling before and after quit date Does not diagnose addiction

The Latency to Needing a Cigarette What does it measure? “After you have smoked a cigarette, how long can you go before you need to smoke again?” I don’t feel a regular need to smoke More than four weeks four weeks three weeks two weeks one week six days five days four days three days two days one day less than one day (how many hours?) less than an hour (how many minutes?)

The Latency to Withdrawal Psychometrics Test-retest reliability is excellent (r = .85) LTNC correlates with Total AUTOS score, r = -.60 Cue-Induced Craving, r = -.64 Psychological Dependence, r = -.43 Withdrawal, r = -.57 Pleasure, r = -.39 LTNC varies moderately with daily cigarette consumption -.53, -.53, -.53

The Latency to Needing a Cigarette Mean LTNC was 243 hours for subjects with <100 cigarette lifetime consumption Mean LTNC was 2 hours for subjects with >100 lifetime consumption

The Latency to Withdrawal Pros and Cons Very short and reliable Relatively easily scored Continuous measure If they have a Latency, they are addicted. Physiologic measure Applicable to all forms of tobacco Can be used in children and adults

Pleasure From Smoking “How much pleasure do you get from smoking a cigarette?” Likert scale zero = none, 9 = a great deal Adolescent smokers mean pleasure = 5.7, 6.9 Adult smokers mean pleasure = 5.9 Test-retest reliability r = .84 - .94

Pleasure From Smoking Pleasure correlates with Withdrawal, r = .75 Psychological Dependence, r = .79 Cue-Induced Craving, r = .84 Proportion of time smoking out of need, r = .45 Latency to Needing a Cigarette, r = -.39

The Hooked on Nicotine Checklist What does it measure? 10 symptoms that make quitting more difficult

Hooked on Nicotine Checklist 1) Have you ever tried to quit, but couldn’t? 2) Do you smoke now because it is really hard to quit? 3) Have you ever felt like you were addicted to tobacco? 4) Do you ever have strong cravings to smoke? 5) Have you ever felt like you really needed a cigarette? 6) Is it hard to keep from smoking in places where you are not supposed to?

Hooked on Nicotine Checklist When you haven't smoked for a while do you… 7) find it hard to concentrate? 8) feel more irritable? 9) feel a strong need or urge to smoke? 10) feel nervous, restless or anxious?

The Hooked on Nicotine Checklist Psychometrics Excellent internal consistency α = 0.86-0.93 Excellent retest reliability (intraclass correlation = 0.88) Excellent predictive validity: a HONC symptom increased the risk of daily smoking: OR= 83. Correlates with smoking frequency, r = .70 FTND, r = .71 AUTOS, r = .84

The Hooked on Nicotine Checklist Pros and Cons Easy to administer and score (dichotomous or continuous) Provides a cut-off score Very sensitive Measures only symptoms, not behavior Free of age and cultural bias, valid for kids and adults Can be used for all forms of tobacco Measures lifetime incidence, cannot be used after cessation

The Fagerström Test for Nicotine Dependence What does it measure? Severity of nicotine dependence Does not diagnose dependence No consensus on what it measures Indirect behavioral measure of withdrawal and the Latency to Withdrawal

The Fagerström Test for Nicotine Dependence 1. How soon after you wake up do you smoke your first cigarette? After 60 minutes (0) 31-60 minutes (1) 6-30 minutes (2) Within 5 minutes (3) 2. Do you find it difficult to refrain from smoking in places where it is forbidden? No (0) Yes (1) 3. Which cigarette would you hate most to give up? The first in the morning (1) Any other (0) 4. How many cigarettes per day do you smoke? 10 or less (0) 11-20 (1) 21-30 (2) 31 or more (3) 5. Do you smoke more frequently during the first hours after awakening than during the rest of the day? 6. Do you smoke even if you are so ill that you are in bed most of the day?

The Fagerström Test for Nicotine Dependence Psychometrics α = .73 (compared to .92 for HONC and .93 for AUTOS in the same sample) Test-retest, r = .88-.91 Correlates with AUTOS, r = .70 HONC, r = .71 Changes in brain structure, r = -.52, r = -.58, and r = -.64 (compared to -.85 for Stage of Physical Addiction) Latency to Needing a Cigarette, r = .45 Smoking days per month, r = .59

The Fagerström Test for Nicotine Dependence Pros and Cons Short Easily scored Widely used Provides discrimination at high levels of dependence Cons Insensitive to low levels of dependence No cut off score- does not diagnose dependence Based entirely on behavior which lends to cultural bias Not valid for children Not valid for nondaily smokers For current smokers only

The Diagnostic and Statistical Manual What does it measure? A diagnosis of nicotine dependence

The Diagnostic and Statistical Manual Unsuccessful efforts to cut down or quit Use despite harm Withdrawal Tolerance Use in greater amounts or longer than intended A great deal of time spent using Social, occupational or recreational activities given up.

The Diagnostic and Statistical Manual Literature review of 169 articles No validity to a three-criteria diagnostic threshold No validity to a four-symptom withdrawal threshold Predictive validity was poor It correlates poorly to modestly with all other measures of dependence and behavior

The Diagnostic and Statistical Manual Psychometrics Adequate to excellent retest reliability Unacceptable internal reliability 0.41 - 0.64 Unacceptable sensitivity (In one study DSM diagnosed only two thirds of smokers who had six of more failed quit attempts.) Correlates poorly with self-diagnosed addiction, r = .48

The Diagnostic and Statistical Manual Pros and Cons It provides a “diagnosis” based on completely arbitrary criteria with no established connection with the pathophysiology Lengthy and difficult to administer Very subjective criteria

The International Classification of Diseases What does it measure? A diagnosis of tobacco dependence

The International Classification of Diseases A strong desire or compulsion to take the substance Impaired capacity to control use A physiological withdrawal state Tolerance Preoccupation with use (activities given up, time spent) Persistent use despite harm

The International Classification of Diseases Psychometrics Literature search-2010 No psychometric data on the official instrument No data supporting Diagnostic validity Predictive validity 3 symptom diagnostic threshold 2 symptom withdrawal threshold

The International Classification of Diseases Psychometrics Does not correlate strongly with Self-rated addiction, r = .58 Self-rated difficulty quitting, r = .57 Daily cigarette consumption, r = .22 Time to first morning cigarette, r = -.06

The International Classification of Diseases Pros and Cons Lengthy to administer It provides a “diagnosis” based on completely arbitrary criteria with no established connection with the pathophysiology

Summary Brief Valid and Reliable All forms of tobacco Children and adults After cessation No cultural bias Stages √ LTNC AUTOS HONC FTND DSM-IV ICD-10 Pleasure