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 Table of Contents    
Year : 2016  |  Volume : 38  |  Issue : 2  |  Page : 105-108  

Need for validation of fagerstrom test for nicotine dependence in Indian context: Implications for nicotine replacement therapy

1 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Web Publication16-Mar-2016

Correspondence Address:
Manoj Kumar Sharma
Department of Clinical Psychology, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7176.178768

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Background: Variety of smokeable and chewable tobacco products with diverse nicotine content are used in India. Nicotine quantity in tobacco products has a direct bearing on developing tobacco dependence. The present work used this information to derive scores on the Fagerstrom test for nicotine dependence (FTND). It was used to determine the dosing of nicotine replacement treatment (NRT). Materials and Methods: Nicotine score quantitation was taken from the previous study. This data was applied to FTND to determine the relationship of nicotine content to the potential degree of dependence. Results: Application of nicotine quantitation to FTND in a hypothetical experiment significantly altered the scores from medium to high depending on the brand the used. Conclusion: Application of qunatitation of nicotine content in FTND score has implications for the assessment of tobacco dependence and NRT dose. The study implies validation of FTND using nicotine quantity in the consumed tobacco product as a scorable parameter in the FTND.

Keywords: Fagerstrom test for nicotine dependence, nicotine, nicotine replacement treatment, quantitation

How to cite this article:
Sharma MK, Sharma P. Need for validation of fagerstrom test for nicotine dependence in Indian context: Implications for nicotine replacement therapy. Indian J Psychol Med 2016;38:105-8

How to cite this URL:
Sharma MK, Sharma P. Need for validation of fagerstrom test for nicotine dependence in Indian context: Implications for nicotine replacement therapy. Indian J Psychol Med [serial online] 2016 [cited 2020 Feb 24];38:105-8. Available from:

   Introduction Top

Tobacco use is a major health threat in the Southeast Asian region and India has one of the largest numbers of tobacco users in the region accounting for an annual consumption of ~250 million kg tobacco. [1] Consequences of tobacco use in India are compounded by the prevalence of both smoking and smokeless tobacco products widespread across socioeconomic and ethnic groups both in urban and rural areas. [2]

It is the addictive nature of tobacco that maintains its use and though a majority of users would like to quit, only 2-3% spontaneously quit each year. [3] Addiction to cigarettes and tobacco products is attributed to the presence of nicotine. [4] Nicotine replacement treatments (NRTs) form the first line management of nicotine dependence in many countries. There are many nicotine delivery devices commercially available including nicotine gum, transdermal patches, vapor inhalers, nasal spray, lozenges, and sublingual tablets. [5] These treatments enhance tobacco cessation by delivering nicotine without exposure to other carcinogens found in the tobacco products. The use of these nicotine replacement products have led to varying degrees of success in long-term smoking cessation. [6] In India, a preliminary experience from the tobacco cessation centers in the country suggests improved cessation rates with the use of nicotine replacement therapy or bupropion combined with counseling. [7]

The prescription and dosage of NRT is directly related to the quantity of tobacco consumed and the nicotine content of these products. Further based on the pattern of smoking and the type of product (smoked/chewed), the nicotine ingestion is highly variable. [8] A cigarette typically contains ~8.4 mg of nicotine which upon smoking delivers ~1.6 mg of nicotine. Five milligram of nicotine per day is the threshold level to sustain addiction. [9] No such clear quantification exists for bidis or smokeless tobacco products such as gutkha, zarda, khaini, mishri, and kaddipudi, which are widely used in different parts of India. [2]

Nicotine content ranged from 5.7 to 13 mg/rod in cigarettes, 1.01 to 8.7 mg/rod in bidi, 1.7 to 11.8 mg/pack in gutkha, and 17.3 to 76.2 mg nicotine/pack in khaini. It was done using liquid-liquid extraction. 1% methanolic potassium hydroxide [1] was applied for extracting nicotine from products and quantification was done using high-performance thin-layer chromatography. [10] In the present, we applied the nicotine quantitation scores to Fagerstrom test for nicotine dependence (FTND) which may have important implications for NRT dosage.

   Materials and methods Top

Since the nicotine content of the various products varied significantly, we investigated whether variations in the nicotine content of a particular tobacco product influenced the severity rating on the FTND [Table 1]. FTND-It is used to assess the use of smoking. It got the internal consistency of 0.61 and obtained score are related to biochemical indices of the heaviness of smoking. [11] The nicotine content of brands used in the current study are: Brand 1-5.7 mg/rod; brand 2-1.01 mg/rod; brand 3-8.8 mg/rod; brand 4-2.7 mg/rod; brand 5-1.3 mg/rod and brand 6-4.8 mg/rod. [10] For this, we analyzed the FTND of three hypothetical patients (named X, Y, and Z), one each in the cigarette smoker and bidi smoker categories. We also presumed that the three patients used different tobacco products in each of the categories. For unfussiness, scores of all questions in FTND except question 4 were presumed equal to one. The fourth question, which refers to the number of cigarettes/bidis consumed/day, was also maintained at 10 units [Table 1]. On question 5, we scored these patients in two groups as follows:

  1. Based only on the number of units (rods or packets) without knowledge of nicotine content/based on self-report, that is, all patients in this group scored 0, thus giving a final FTND score of indicating medium nicotine dependence.
  2. In the second group, where nicotine content was presumed to be known, we scored the patients based on the nicotine content in the respective products (corresponding to 10 units/product).
Table 1: Application of nicotine content in tobacco products in FS of nicotine dependence with implications for NRT in a hypothetical experiment

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Thus, depending on the brand used, the nicotine intake varied, which in turn would alter the nicotine load on the patient. For example, patient X smoked 10 bidis of particular brand corresponding to an intake of 10.1 mg nicotine/day and score of '0' with total FTND score = 5 thereby classifying the patient as medium-dependence on nicotine. Patients Y and Z also smoked 10 units, but of brands 4 and 6 corresponding to an intake of 27 and 48 mg nicotine/day respectively, which in turn corresponded to 2.7 and 4.8 bidis of particular brand respectively. Taking the nicotine content into consideration, we would score patients Y and Z 2 and 3, respectively on question number 4, now placing them in the high dependence category.

   Results Top

[Table 1] also indicates how a specific brand of cigarette or smokeless product with varying nicotine content can alter the dependence severity scoring on the Fagerstrom's questionnaire in comparison to scores obtained based on self-report.

   Discussion and conclusions Top

The study document that nicotine quantitation based rating score for the individual smoking brand has altered the nicotine dependence scores. It will also affect the tobacco cessation treatment outcome [Table 1]. The current used approach to determine the dosage for NRT is based on the empirical score of FTND. [12] The amount of nicotine in a particular product will have a direct bearing on the level of dependence with implications for NRT. [1],[13] The validity of using the FTND to determine NRT dosing is highly questionable, as it does not take into consideration the nicotine content of tobacco products. [6] The FTND scores were found to have a relatively weaker correlation with other smoking questionnaires when the question related to the number of cigarettes smoked per day was omitted. [14] Among relatively light smokers, FTND measure found to be higher than the number of cigarettes smoked per day thereby emphasizing the need for designing an improved and broadly applicable test for nicotine dependence. [12] Similarly, a recent study from India based on the FTND among smokers with poly-drug abuse concluded that FTND had low internal consistency and reliability and suggested a two-factor structure of FTND based assessment. [15] The limitation observed in the form of the absence of longitudinal assessment of efficacy of prescription of NRT based on nicotine quantitation altered scores. It also has implication of inclusion of nicotine quantitation scores for validation of FTND scores in the Indian context.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Reddy SS, Shaik HA. Estimation of nicotine content in popular Indian brands of smoking and chewing tobacco products. Indian J Dent Res 2008;19:88-91.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4.  Back to cited text no. 2
Jha P, Chaloupka FJ, Moore J, Gajalakshmi V, Gupta PC, Peck R, et al. Disease Control Priorities in Developing Countries. Tobacco Addiction. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al. Editors. 2 nd ed. Washington (DC): World Bank; 2006.  Back to cited text no. 3
Benowitz NL. Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiol Rev 1996;18:188-204.  Back to cited text no. 4
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;14:CD000146.  Back to cited text no. 5
Moore D, Aveyard P, Connock M, Wang D, Fry-Smith A, Barton P. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: Systematic review and meta-analysis. BMJ 2009;338:b1024.  Back to cited text no. 6
Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47 Suppl 1:69-74.  Back to cited text no. 7
Cook MR, Gerkovich MM, Graham C, Hoffman SJ, Peterson RC. Effects of the nicotine patch on performance during the first week of smoking cessation. Nicotine Tob Res 2003;5:169-80.  Back to cited text no. 8
The World Bank. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Development in Practice Series. Washington, DC; 1999.  Back to cited text no. 9
Sharma P, Murthy P, Shivhare P. Nicotine quantity and packaging disclosure in smoked and smokeless tobacco products in India. Indian J Pharmacol 2015;47:440-3.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. Br J Addict 1991;86:1119-27.  Back to cited text no. 11
Etter JF, Duc TV, Perneger TV. Validity of the Fagerström test for nicotine dependence and of the heaviness of smoking index among relatively light smokers. Addiction 1999;94: 269-81.  Back to cited text no. 12
Malson JL, Sims K, Murty R, Pickworth WB. Comparison of the nicotine content of tobacco used in bidis and conventional cigarettes. Tob Control 2001;10:181-3.  Back to cited text no. 13
Muhammad-Kah RS, Hayden AD, Liang Q, Frost-Pineda K, Sarkar M. The relationship between nicotine dependence scores and biomarkers of exposure in adult cigarette smokers. Regul Toxicol Pharmacol 2011;60:79-83.  Back to cited text no. 14
Jhanjee S, Sethi H. The Fagerström test for nicotine dependence in an Indian sample of daily smokers with poly drug use. Nicotine Tob Res 2010;12:1162-6.  Back to cited text no. 15


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