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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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