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Addiction. 2013 Nov;108(11):1989-2000. doi: 10.1111/add.12285. Epub 2013 Aug 14.

The prevalence, predictors and associated health outcomes of high nicotine dependence using three measures among US smokers.

Author information

  • 1Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA.



Using the Fagerström Test of Nicotine Dependence (FTND), the Heaviness of Smoking Index (HSI) and the time-to-first-cigarette (TTFC), this study estimated prevalence, evaluated optimal scale cut-offs, identified predictors and assessed potential impact on health, productivity and health-care use of high nicotine dependence among US smokers.


This cross-sectional study used 2011 National Health and Wellness Survey data (n = 50 000).


Nicotine dependence, demographic data, measures of health, productivity and health-care use and health attitudes were assessed.


The prevalence of high nicotine dependence ranged from 23% (TTFC < 5 minutes) to 63.6% (TTFC < 30 minutes). Based on diagnostic accuracy, the cut-offs for high nicotine dependence using HSI and TTFC varied according to FTND cut-off: if FTND > 4, then HSI > 3 and TTFC < 30 minutes represented optimal cut-offs; if FTND > 5, HSI > 4 and TTFC < 5 minutes represented optimal cut-offs. Across all measures, high nicotine dependence was related significantly to being male, single, age 45-64 years and Caucasian; lower education; lack of health insurance; under/unemployment; comorbid respiratory or cardiovascular disease, diabetes or psychiatric illness; and lower rates of exercise and concern for weight control. Controlling for demographic variables and comorbid physical and psychiatric illness, high nicotine dependence, measured by FTND, HSI or TTFC, was associated significantly with reduced mental and physical quality of life, reduced work-place productivity and more health-care use.


High nicotine dependence is associated with lower quality of life, lower work productivity and higher health-care use. The Heaviness of Smoking Index and the time-to-first-cigarette can provide useful screening measures of nicotine dependence in clinical and research settings.

© 2013 Society for the Study of Addiction.


Fagerström; Heaviness of Smoking Index; health-care use; nicotine dependence; productivity; sensitivity and specificity; time to first cigarette

[PubMed - indexed for MEDLINE]
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