Fagerstrom Test For Nicotine Dependence

The Fagerstrom test for nicotine dependence aims to stratify the severity of nicotine addiction by quantifying smoking habits, the number of cigarettes smoked per day and any related symptoms.

This can in turn help medical professionals refer the patient for nicotine replacement therapy NRT in case quitting smoking proves to be too difficult without help or withdrawal symptoms occur.

The FTND was developed following a 1991 study of 254 smokers and built upon knowledge existent around the Fagerström Tolerance Questionnaire.

Scores below 3 are considered to have a none to low risk of existing nicotine dependence. Scores between 3 and the maximum obtainable of 10 are referred for NRT and monitoring.

Scores 3 and 4 are considered to have a low to moderate risk, scores of 5, 6 and 7 carry a moderate to high risk while scores of 8, 9 and 10 indicate high risk.

Fagerstrom test items

The six questions in the Fagerstrom test for nicotine dependence address the following:

■ Time (in minutes) before first cigarette of the day;

■ Difficulty in refraining from smoking in places where smoking is forbidden;

■ Which of the cigarettes smoked during the day is considered most important;

■ Number of cigarettes smoked per day;

■ In which period of the day, the highest number of cigarettes is smoked;

■ Smoking during periods of illness.

Test results interpretation

Each of the answers to the six questions in the FTND is awarded a number of points, which varies from 0 to 3. As a general rule, the higher the number of points, the more that answer option is indicative of a nicotine addiction being present.

The following table introduces the scores obtainable in the FTND and their associated levels of nicotine addiction:

Fagerstrom score	Nicotine dependence level
0	None
1 - 2	Low
3 - 4	Low to moderate
5 - 7	Moderate to high
8 - 10	High

Beside the above, the general recommendation is that any patient scoring 3 points or more to be referred for further screening.

The maximum score of 10 points, indicates the highest possible degree of nicotine dependence.

About the original study

The FTND was created after an attempt to refine the Fagerström Tolerance Questionnaire (1978). The study included 254 smokers and aimed to establish a relationship between each FTQ item and biochemical measures of heaviness of smoking.

The nicotine rating item and the inhalation item were found to be less relevant for the new purpose of the test. On the other hand, a revised scoring of time to the first cigarette of the day (TTF) and number of cigarettes smoked per day (CPD) was found to improve the scale.

Most of the criticism received by this screening method refers to it lacking sensitivity for lower scores and the fact that it fails to recognize dependence in the case of light smokers.

Dr Karl Fagerström is a founding member of the Society for Research on Nicotine and Tobacco.

NRT therapy recommendations

Nicotine replacement therapy defines the medically approved methods in which nicotine is used to ease smoking cessation and to relieve withdrawal symptoms. These methods bring nicotine to the blood stream in parallel with gradually cutting down on smoked cigarettes or straight away without smoking.

NRT requires the accurate establishing of the start/ beginning doze and then constant monitoring and reductions in the long term. To ensure the success of the therapy, treatment should be administered for at least 8 to 12 weeks.

In theory, success rates are of 50-70%, but the results are usually more dependent on the capacity of the patient to follow treatment.

Forms of NRT include lozenges, patches, chewing gum or nose sprays. Adverse reactions may include a risk of nicotine poisoning.

Dependence level	NRT therapy dosage	Combination therapy
High	Patches: 21 mg/24 hr or 15 mg/16 hr Inhaler: 6 –12 cartridges per day Lozenge: 4 mg Gum: 4 mg	Patches: 21 mg/24 hr or 15 mg/16 hr AND Lozenge or Gum: 2 mg
Moderate	Patches: 21 mg/24 hr or 15 mg/16 hr Inhaler: 6 –12 cartridges per day Lozenge: 4 mg Gum: 4 mg	Patches: 21 mg/24 hr or 15 mg/16 hr AND Lozenge or Gum: 2 mg
Low to moderate	Patches: 14 mg/24 hr patch or 10 mg/16 hr Inhaler: 6 –12 cartridges per day Lozenge: 2 mg Gum: 2 mg	Patches: 14mg/24hr or 15 mg/16 hr AND Lozenge or Gum: 2 mg
Low	May not need NRT Monitor for withdrawal symptoms Patches: 7 mg/24 hr patch or 5 mg/16 hr Lozenge: 2 mg Gum: 2 mg	n/a

Original reference

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(9):1119-27.

Other reference

Storr CL, Reboussin BA, Anthony JC. The Fagerstrom test for nicotine dependence: a comparison of standard scoring and latent class analysis approaches. Drug Alcohol Depend. 2005; 80(2):241-50.

Fagerstrom Test For Nicotine Dependence

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How soon after you wake up do you smoke your first cigarette?

Do you find it difficult to refrain from smoking in places where it is forbidden?

Which cigarette would you hate most to give up?

How many cigarettes per day do you smoke?

Do you smoke more frequently during the first hours after awakening than during the rest of the day?