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Measuring the Loss of Autonomy Over Nicotine Use in Adolescents
The DANDY (Development and Assessment of Nicotine Dependence in Youths) Study
Joseph R. DiFranza, MD;
Judith A. Savageau, MPH;
Kenneth Fletcher, PhD;
Judith K. Ockene, PhD;
Nancy A. Rigotti, MD;
Ann D. McNeill, PhD, PGCE;
Mardia Coleman, BS;
Constance Wood, MSW
Arch Pediatr Adolesc Med. 2002;156:397-403.
Context There is no validated, theory-based tool for assessing the onset of
nicotine dependence. However, the use of all addictive substances can result
in a loss of autonomy. We propose that nicotine dependence begins when autonomy
is lost, ie, when the sequelae of tobacco use, either physical or psychological,
present a barrier to quitting.
Objectives To test the autonomy theory of nicotine dependence, and to evaluate
the Hooked on Nicotine Checklist (HONC) as a measure of the loss of autonomy
over tobacco use.
Design The psychometric performance and concept validity of the HONC were evaluated
in a 30-month prospective longitudinal study of the natural history of tobacco
use in a cohort of 679 seventh-grade students.
Results As hypothesized, endorsement of a single item on the HONC was associated
with a failed attempt at smoking cessation (odds ratio [OR], 29; 95% confidence
interval [CI], 13-65), continued smoking until the end of follow-up (OR, 44;
95% CI, 17-114), and daily smoking (OR, 58; 95% CI, 24-142). Scores on the
HONC correlated with the maximum amount smoked (r
= 0.65; P<.001) and the maximum frequency of smoking
(r = 0.79; P<.001). Internal
reliability was 0.94. A 1-factor solution explained 66% of the total variance.
Conclusions The data support the autonomy theory that dependence begins with the
loss of autonomy. The autonomy theory represents a potentially useful alternative
to current concepts of nicotine dependence for adolescents, and the HONC appears
to measure lost autonomy in adolescents. Construct validity was demonstrated
by its utility in predicting failed cessation and the progression of tobacco
use. In addition, the psychometric properties were excellent.
From the University of Massachusetts Medical School, Worcester (Drs
DiFranza, Fletcher, and Ockene and Mss Savageau, Coleman, and Wood); the Tobacco
Research and Treatment Center, Massachusetts General Hospital, and Harvard
University Medical School, Boston (Dr Rigotti); and St George's Hospital Medical
School, University of London, London, England (Dr McNeill).
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