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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.
ABSTRACT
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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.
INTRODUCTION
NICOTINE INTERACTS with a variety of receptors, neurotransmitter systems,
and neural pathways in the central nervous system, but it has not been established
how nicotine produces dependence.1 Many behavioral
and neurobiological theories of addiction have been advanced, but none offers
a complete explanation.2-4
Without an understanding of the pathophysiological mechanisms, it has not
been possible to develop a "gold standard" for identifying or measuring nicotine
dependence.5-7
A recent exhaustive review of dependence measures concluded that "the field
lacks a widely accepted, theoretically-derived, and psychometrically-sound
research tool for evaluating nicotine dependence."6(pS36)
This is especially true for the pediatric population.
The Fagerstrom Tolerance Questionnaire (FTQ) was developed in 1978 to
predict physiological tolerance to nicotine as measured by heart rate and
temperature responses.8 Many have found it
useful, and it has been widely employed.9-14
However, poor performance on psychometric testing has led to several modifications.11, 13, 15 In addition, the
FTQ and its progeny were not derived from addiction theory, and it is unclear
what is being measured.7 In one study, the
FTQ and 2 related measures explained only about 1% of the variance as to which
smokers were successful at quitting.15 Thus,
the FTQ may measure the motivation to maintain serum nicotine levels rather
than dependence.6 This measure may not be relevant
to the onset of dependence; adolescents report symptoms of dependence when
nicotine intake is too low to achieve consistent blood levels.16-17
Some FTQ questions, such as those assessing smoking when too sick to get out
of bed and the time between waking and smoking, may also be inappropriate
for youths.9, 11 Without parental
permission, youths may be unable to light up within 5 minutes of rising or
smoke when sick in bed.
Although they are often used as guidelines for treatment, the definitions
of nicotine dependence developed by official committees are not immutable,
mutually consistent, applicable to all populations, or universally accepted.6, 18-22
Specifically, the Diagnostic and Statistical Manual of Mental
Disorders (DSM)19-20
definition of nicotine dependence has not been validated with adolescents,
and it offers no description or explanation of how nicotine dependence develops
in youths.22-23 It prejudges how
dependence begins with its requirements for daily, prolonged, and heavy use,
and, therefore, may not be applicable to the onset of dependence in adolescence,
when symptoms of dependence can appear with occasional use.6, 16-17,24-25
The DSM definition originated in Edwards' and Gross
atheoretical empirical description of the behavior of advanced alcoholics,26 which was later adapted based on clinical observations
of heavy adult smokers.20, 27-30
Edwards himself later warned that "those who study dependence and argue for
the clinical utility of the dependence concept should make sure that an idea
does not become an over-valued idea, or themselves the victims of an idée
fixe."27(p172) Appealing to this spirit of
remaining receptive to new concepts of dependence, we offer an alternative
to the DSM approach for evaluating the onset of nicotine
dependence.
The World Health Organization holds that the cardinal feature of substance
abuse is impaired control over substance use.22
The DSM describes loss of control in terms of the
amount or duration of use, but we believe that this concept can be usefully
expanded to encompass the loss of autonomy over tobacco use. In our autonomy
theory, we propose that the onset of dependence can be defined as the moment
when an individual loses full autonomy over the use of tobacco. In philosophical
terms, the loss of autonomy begins when discontinuing the use of tobacco is
no longer an effortless exercise of free will. Operationalizing this concept,
a person has lost autonomy when the sequelae of tobacco use, either physical
or psychological, present a barrier to quitting.
Autonomy can be lost through different mechanisms. The autonomy theory
does not assume that all symptoms of dependence are a result of the pharmacological
effects of nicotine. In some individuals, the loss of autonomy may be caused
by neuropharmacological mechanisms. In others, psychological or behavioral
processes may predominate. The assumption that dependence entails a single
clinical entity has left addiction theorists unable to provide a theory that
explains all of the clinical manifestations of the hypothesized dependence
syndrome. The autonomy model assumes that what appears to be a single clinical
syndrome actually represents a mixture of overlapping conditions that result
from multiple independent mechanisms. Therefore, a single mechanistic theory
cannot explain all of the manifestations of the clinical syndrome of dependence.
The autonomy model allows for the reconciliation of competing theories of
addiction into a single model; several existing theories of addiction may
be valid.2-4
The validity of the autonomy model can be tested by determining if a
measure of lost autonomy is predictive of continued smoking or failed cessation.
To assess autonomy in youths, an instrument was developed based on 3 mechanistic
theories of addiction.2-4
According to the self-medication theory, people become addicted through the
use of a drug to medicate unpleasant affective states.2
Nicotine is a mood-modulating drug that is used by adolescents primarily to
reduce excessive arousal (anxiety), but also to boost low arousal (boredom).31-37
Stress provokes urges to smoke in 70% of adolescent smokers, and relapse is
most commonly blamed on "being upset."36-37
When youths depend on tobacco as a "psychological crutch" it becomes an obstacle
to cessation.38 Under the self-medication theory,
a loss of autonomy occurs when one depends on nicotine to cope.
The negative reinforcement theory holds that addictive behavior is motivated
primarily by the desire to avoid unpleasant emotional states, including nicotine
withdrawal.4 Withdrawal symptoms predict relapse,
and adults titrate nicotine intake to avoid them.4, 39-40
They are common prior to daily smoking and accompany the first attempt to
quit for most youths.17, 24-25,41-42
A single symptom can make quitting unpleasant, representing a price to be
paid for cessation and, therefore, a loss of autonomy.
The incentive-sensitization theory proposes that separate neuropathways
mediate "pleasure" and "wanting."3 With ordinary
stimuli, such as food, sensory receptors stimulate the pleasure pathway, which
in turn stimulates the pathway responsible for wanting. With their direct
effect on brain neuroreceptors, addictive drugs appear to be capable of bypassing
the pleasure pathways to stimulate the wanting pathways directly. According
to this theory, addictive drugs produce persistent neuronal sensitization,
resulting in "craving," a pathologically intense "wanting." It is important
to distinguish between cravings for food and those that result from nicotine-induced
alterations in the sensitization of neural pathways. There is a good deal
of experimental evidence supporting the sensitization model.3, 43-47
Cravings in adolescents correlate with measures of nicotine intake, suggesting
a physiological mechanism.25, 42
Cravings also predict relapse and dependence.39, 42, 48-49
In youths, craving is the most common, and often, the most severe, withdrawal
symptom.17, 23-25,36, 42, 49
As the primary mechanism of addiction in this model, craving indicates a loss
of autonomy.
Drawing from these 3 theories of addiction, the Hooked on Nicotine Checklist
(HONC) was constructed to screen for symptoms that signify a loss of autonomy
in youths (Figure 1). Based on the
philosophical concept that an individual either has autonomy or does not,
we hypothesized that the endorsement of a single item on the HONC would indicate
a loss of autonomy. We also considered that the HONC could be scored to measure
the degree of lost autonomy. The psychometric properties of the HONC and the
validity of the autonomy concept as an indicator of dependence were evaluated
in a prospective study.
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Figure 1. The Hooked on Nicotine Checklist.
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PARTICIPANTS AND METHODS
The methods for this study have been described in detail.16
Briefly, this longitudinal study was conducted in 2 small cities in central
Massachusetts with a cohort of 679 seventh-grade students of mixed racial
and ethnic backgrounds (mean age, 13 years; age range, 12-15 years at the
start of the study). Eight rounds of private individual interviews were conducted
in the schools using a structured protocol between January 1998 and June 2000.
ASSEMBLING THE COHORT
The Institutional Review Board of the University of Massachusetts Medical
School, Worcester, approved a passive consent process. Random number assignments
were used to assemble a cohort of subjects from 2 school systems. Subjects
were told the study was confidential and concerned tobacco. Prior tobacco
use did not preclude participation. No subjects were added after the first
set of interviews was completed. This report covers 8 rounds of interviews.
SURVEY INSTRUMENT
The survey instrument collected detailed information about prior and
current tobacco use, including the duration of use, the frequency of use,
the amount used, the pattern of use, the types of tobacco used, periods of
abstinence, and attempts to quit smoking. Students were asked to provide exact
dates for the first puff, the first inhalation, the first monthly use, the
first daily use, and the first occurrence of 10 indicators of lost autonomy
(Figure 1). These indicators were
identified by a review of the literature conducted to locate validated survey
items used as indicators of dependence in previous studies.17, 24-25,36, 50-52
MAIN OUTCOME MEASURES
Data were collected concerning the date of birth, sex, and race/ethnicity
of participants. Subjects were asked about the smoking status of both parents
(never smokers, ex-smokers, or current smokers). Subjects were considered
to be tobacco users if they had ever used any form of tobacco, and those who
had ever smoked 2 cigarettes within a period of less than 2 months were termed
"monthly smokers." The category would include subjects who were daily smokers
from their first cigarette, as well as subjects who smoked on 2 consecutive
days and then stopped. The onset of monthly smoking was defined as the point
in time when the subject first smoked with a frequency of at least once per
month.
An unsuccessful attempt to quit was defined as a conscious decision
to discontinue tobacco use followed by a relapse. The reason the subject resumed
smoking was ascertained, and the interviewer determined whether it would count
as a relapse (eg, resumed smoking at the end of a sports season would not
be a relapse).
The current smoking status was recorded at each interview. This included
information on the amount smoked (converted to cigarettes per year); the frequency
of smoking (converted to days per year); and the maximum intensity of smoking
in terms of cigarettes per year and days per year.
DATA ANALYSIS
A loss of autonomy was registered if any of the 10 HONC items was endorsed
at any time. A HONC score was computed by summing the cumulative number of
items endorsed over the course of the study. The item concerning failed cessation
was removed to analyze the ability of the HONC to predict failed cessation.
A HONC-9 score was computed from the remaining 9 items.
The validity of the loss of autonomy concept, and the ability of the
HONC to measure loss of autonomy, was evaluated by determining if a score
of 1 or greater on the HONC predicted that smoking would continue until the
end of follow-up. This analysis was conducted for all tobacco users and for
the subset of monthly smokers. No subjects were regular users of cigars or
smokeless tobacco. The validity of the HONC as a measure of lost autonomy
was further evaluated by assessing whether the endorsement of 1 or more items
on the HONC-9 was associated with a failed attempt to quit. Scores on the
HONC were analyzed for correlations with the maximum frequency of smoking
and the maximum amount smoked using the Pearson correlation coefficient.
To evaluate the dimensionality of the HONC, a principal component factor
analysis was conducted. To evaluate its internal consistency, Cronbach 
was computed. Logistic regression analysis was used to examine the predictive
properties of the HONC in terms of continued smoking, failed cessation, and
progression to daily smoking, while controlling for sex and the age at first
use or age at first monthly use. Continuous data were analyzed using the t test. Because of skewness in variables such as the HONC
score and maximum amount smoked, nonparametric equivalent statistics were
also computed (eg, Mann-Whitney U test). Results
were identical using both parametric and nonparametric statistics and, thus,
for the ease of interpretation, the results from the t
tests are presented herein. A P value of <.05
was used as a test of statistical significance.
RESULTS
Of the 679 subjects, 332 had used tobacco, and 145 had progressed to
monthly smoking. Throughout each section of the "Results," data will be presented
first for the population of all tobacco users and then for the subpopulation
of monthly smokers.
Table 1 shows the mean HONC
scores for all tobacco users and monthly smokers broken down by sex and according
to whether the subject had quit smoking or had continued smoking until his
or her last interview. The mean HONC scores were significantly higher for
subjects who had inhaled, for those who had progressed to monthly smoking,
for girls, and for those who were still smoking at their last interview. The
HONC symptoms were much more prevalent among the 237 subjects who reported
inhaling tobacco (53% had at least 1 HONC symptom) than among the 95 subjects
who had tried tobacco but who denied inhaling (6%; odds ratio [OR], 16.8;
95% confidence interval [CI], 7-40; Table
1). Among the 332 tobacco users, 200 subjects had HONC scores of
0, whereas the remaining 132 subjects were fairly evenly distributed from
scores of 1 to 10 (Figure 2). When
the analysis was limited to the 145 monthly smokers, the distribution of scores
showed a different pattern (Figure 3).
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Mean Scores for the Hooked on Nicotine Checklist (HONC)*
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Figure 2. Sex differences in the distribution
of scores on the Hooked on Nicotine Checklist (HONC) among 332 adolescents
who had ever used tobacco.
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Figure 3. Sex differences in the distribution
of scores on the Hooked on Nicotine Checklist (HONC) among 145 adolescents
who had ever used tobacco monthly.
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CORRELATES OF THE HONC
Among all 332 tobacco users, the HONC score showed a Pearson correlation
coefficient of 0.65 with the maximum amount smoked (P<.001),
0.79 for the maximum frequency of smoking (P<.001),
0.18 for duration of tobacco use (P<.05), and -0.11
for age at first use (P<.05). Among monthly smokers,
correlations were 0.53 for maximum amount smoked (P<.001),
0.57 for maximum frequency of smoking (P<.001),
0.18 for duration of tobacco use (P<.05), and -0.10
for age at first use (P = .3).
Among all subjects who had ever tried tobacco, subjects who had at any
time responded positively to 1 of the 10 HONC items had an OR of 44 (95% CI,
17-114) for continuing to smoke until their last interview (P<.001; sensitivity, 93%; specificity, 76%). When adjusted for sex
and the age at the first cigarette, the OR was 48 (95% CI, 18-126). Age of
initiation and sex were not independent predictors of continued smoking. The
endorsement of 1 or more HONC items accounted for 35% of the variance in predicting
continued smoking.
Subjects reporting 1 or more HONC symptoms had an OR of 58 for having
progressed to daily smoking by their last interview (95% CI, 24-142). The
HONC symptoms preceded daily smoking in 70% of cases. Among 200 subjects with
HONC scores of 0, only 3% had progressed to daily smoking, compared with 64%
of 132 subjects with HONC scores greater than 0. None of the 200 subjects
with HONC scores of 0 had progressed to smoking one half pack per day, compared
with 40% of 132 subjects with HONC scores greater than 0 (P<.001; OR, incalculable).
Among all subjects who had tried smoking, those endorsing at least 1
of the HONC-9 items were 29 times more likely to report a failed attempt to
quit than subjects with HONC-9 scores of 0 (95% CI, 13-65). When adjusted
for sex and the age at the first cigarette, the OR remained significant at
30 (95% CI, 13-68). Sex and age of initiation were not independent predictors
of a failed attempt to quit. The HONC-9 accounted for 34% of the variance
predicting a failed attempt at cessation.
Among subjects who had progressed to monthly smoking, those endorsing
1 or more HONC symptoms had an OR of 11 for continued smoking until their
last interview (95% CI, 3.2-40). When adjusted for sex and the age of the
onset of monthly smoking, the OR remained significant at 12 (95% CI, 3.3-43).
Age of onset and sex were not independent predictors of continued smoking.
Among monthly smokers, those endorsing 1 or more of the HONC-9 symptoms had
an OR of 5.1 (95% CI, 2.1-12.2) for a failed attempt to quit. Monthly smokers
who had a failed attempt to quit had a mean (SD) of 5.7 (3.1) HONC symptoms
in addition to the symptom of a failed attempt to quit, compared with a mean
(SD) of 2.5 (2.7) HONC symptoms among monthly smokers who had not failed an
attempt to quit (P<.001).
FACTOR ANALYSIS
The factor analysis included all 332 subjects who had used tobacco,
revealing one domain that included all 10 items and explained 66% of the total
variance. This factor had an eigenvalue of 6.6. All items had factor loadings
of 0.70 or higher. The internal consistency analysis produced a Cronbach
of .94 for both the HONC and the HONC-9.
COMMENT
Some drugs of dependence produce tolerance, whereas others cause the
reverse.3, 39 Some have life-threatening
withdrawal syndromes, whereas others have none.20
Some are intoxicating, whereas nicotine is not generally considered to be
an intoxicating drug.20, 53 The
ability to cause a loss of autonomy is the common denominator among drugs
of dependence.22 Our autonomy theory offers
several advantages over other conceptualizations of dependence. The validity
of any definition of dependence as a disease will be in doubt until the pathophysiological
mechanism of dependence is better understood. In contrast, the loss of autonomy,
as a philosophical concept, has face validity. It can be defined precisely
without an understanding of the pathophysiological mechanism of dependence.
The autonomy theory proposes that the loss of autonomy marks the onset
of dependence and defines the loss of autonomy as when the physiological or
psychological sequelae of tobacco use present a barrier to quitting. If the
loss of autonomy marks the onset of dependence, a measure of lost autonomy
should be related to the subsequent course of tobacco use and the outcome
of cessation attempts. To test the autonomy theory, a measure of lost autonomy,
the HONC, was constructed from 3 competing mechanistic theories of addiction.
As hypothesized, endorsement of a single item on the HONC was associated with
marked increases in the likelihood of having a failed attempt at cessation
(OR, 29), continuing to smoke until the end of follow-up (OR, 44), and established
daily smoking (OR, 58).
The HONC was developed and tested on adolescents. Focus group testing
demonstrated content validity, in that youths understand the HONC items in
the same way adults do.54 The test-retest reliability
of individual HONC items was high, ranging from 0.61 to 0.93.55
The test-retest reliability of the HONC as a whole was  = 0.61 (95%
CI, 0.35-0.87).55 The high internal consistency
of 0.94 measured in the current study agrees closely with that of 0.91 reported
by O'Loughlin et al.55 Because each of the
items listed in the HONC can be the first symptom to appear, the inclusion
of all 10 items contributes to the measure's ability to detect the onset of
the loss of autonomy.16
Our data, and that reported by O'Loughlin et al,55
show a strong correlation between HONC scores and measures of tobacco use.
In the current study, the HONC correlated with the maximum amount smoked (r = 0.65) and the maximum frequency of smoking (r = 0.78). The weak correlation with duration of smoking (r = 0.18) was expected based on our previous report of wide individual
variability in the latency to the onset of symptoms.16
Although the HONC correlates well with measures of cigarette use, we question
the practice of validating instruments by using consumption as a measure of
dependence.
The HONC is the only tool for diagnosing nicotine dependence that has
been validated with outcome measures in adolescents. None of the FTQ-related
measures has face validity as a measure of dependence, nor has any measure
been validated for the purpose of establishing the presence or absence of
dependence.5, 9 The original FTQ
has poor internal consistency (average Cronbach , .51).5, 9-10,56-57
The modified FTQ of Prokhorov et al12-14
for adolescents has adequate internal consistency ( = .7-.8) and good
test-retest reliability (correlation of 0.71), but it was validated against
the amount and duration of smoking, not against outcome measures, such as
cessation. Correlations with the amount smoked were much lower for the modified
FTQ (0.4) than those reported here for the HONC (0.65-0.78).12
Although this might be because of population selection, the superior performance
of the HONC is surprising because the FTQ records the amount smoked, whereas
the HONC does not.12
There is no "true rate" of dependence against which the validity of
the DSM definition can be tested.30
The lack of standardized questionnaire items makes it impossible to assess
the DSM definition for internal reliability, and
its predictive value in adolescents has not been assessed.6
The prevalence of a DSM diagnosis in adolescent smokers
has been determined, but there are no studies of the validity of the DSM or World Health Organization definitions in this population.18, 23, 30 Moreover, a DSM diagnosis did not correlate with cotinine levels in
18 year olds.23
Most of the evaluations of the FTQ and the DSM
have been performed on homogeneous populations, such as adult daily smokers,
heavy smokers, military recruits, or participants in cessation programs.5, 12, 28, 57-58
The HONC was developed and tested with unselected, culturally diverse populations
of adolescents.16, 55 Additional
strengths of the HONC include its derivation from addiction theory, its face
validity, its reliability, its predictive properties, and the fact that it
does not prejudge the nature of dependence by placing prerequisites on the
duration or frequency of smoking. The HONC has been more thoroughly evaluated
with adolescents and performs better than any of the clinical definitions
of dependence or FTQ-related measures.18, 20
With craving being reported by 88% of youths who smoke regularly, the
HONC criteria indicate that a very high proportion of young smokers have suffered
a loss of autonomy.30 This is supported by
data from 6 surveys that indicate that 71% to 83% of adolescent smokers had
tried unsuccessfully to quit.17, 34, 36, 41, 59-60
The HONC may be useful to practicing clinicians as a self-administered
office tool (Figure 1; complete
copies are also available on the Web at http://www.umassmed.edu/fmch/research/publications/). It identifies youths for whom help and encouragement with cessation
would be appropriate. As a self-assessment tool, the HONC might promote progression
to a more advanced stage of change, stimulating youths to attempt cessation
earlier when success is more likely.41, 61-63
The HONC could be used in mass media campaigns to educate youths to recognize
the first signs of dependence. In research applications, a HONC score of 1
or higher would be more appropriate for defining the transition from "experimental"
to "established" smoking than either "lifetime use of 100 cigarettes" or "daily
smoking," as these measures do not assess dependence. The HONC is being adopted
as a measure of dependence and a predictor of relapse in ongoing smoking cessation
trials. The performance of the HONC in adult populations should be evaluated,
as it may provide a better basis than existing measures for a comparison of
dependence between adults and adolescents.
Limitations of this study include the narrow age range of the subjects.
As with any diagnostic test, the performance of the HONC will depend on the
population studied, and different results might be obtained if the population
were much older than the one studied here. We considered whether youths might
have reported HONC symptoms because of performance expectations or sociocultural
influences. Random false reporting is inconsistent with the observed reliability
and internal consistency of the HONC, with its strong correlations with several
measures of tobacco use and its predictive powers in terms of failed cessation
and continued smoking until the end of follow-up.
In the current study, data were collected by an interviewer, but in
the study by O'Loughlin et al,55 the HONC was
self-administered. We are conducting additional research to evaluate the reliability
and performance of the HONC as a self-administered survey. Additional research
is needed to confirm the results of this study, especially in regard to sex
differences. While our factor analysis produced a single-factor solution,
O'Loughlin et al55 found a 2-factor solution
with one factor representing the withdrawal symptoms included in the HONC
and a second factor representing the remaining HONC items. Because the autonomy
theory holds that the loss of autonomy can occur through multiple mechanisms,
a multifactor solution is not inconsistent with the theory. Additional factor
analyses will be performed with different populations to further explore this
issue.
Youths' expectations about dependence may be important. If youths believe
they are invulnerable to dependence, it may cause them to initially deny their
symptoms. On the other hand, Bandura's concept of self-efficacy64
would predict that if youths expect to be dependent, this might hamper their
ability to quit. Expectations, rather than representing a source of bias,
might contribute to a loss of autonomy through a self-fulfilling and self-defeating
process. We plan to conduct focus groups with smoking and nonsmoking youths
to learn more about what their expectations might be.
The autonomy theory provides for the possibility that there may be multiple
independent and overlapping mechanisms underlying the clinical syndrome of
dependence. Our data suggest that the initial loss of autonomy occurs through
physiological processes in some youths and through psychological processes
in others.16 With time, many youths develop
symptoms involving both mechanisms. In conclusion, the autonomy theory appears
to be a useful new approach to evaluating nicotine dependence in adolescents.
It provides an overarching function that integrates competing mechanistic
theories of dependence into a unified theory.
| What This Study Adds
A recent review concluded that there is no widely accepted, theoretically
derived, and psychometrically sound research tool for evaluating tobacco dependence.
This assessment is particularly true for the problem of identifying the onset
of dependence in the pediatric population because all currently available
measures were initially developed for adult smokers.
This article presents a new theory of dependence, the autonomy theory,
which represents a marked departure from traditional thinking. The autonomy
theory postulates that tobacco dependence begins when the sequelae of tobacco
use, either psychological or physiological, present a barrier to quitting.
The HONC represents the first validated, theory-derived tool for measuring
tobacco dependence. The HONC is an easy-to-use measure that demonstrates psychometric
properties superior to those of previously available measures.
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AUTHOR INFORMATION
Accepted for publication January 14, 2002.
This study was funded by grant CA77067-03 from the National Cancer Institute,
Bethesda, Md.
The opinions expressed in this paper are those of the authors and do
not necessarily represent the official views of the National Cancer Institute.
Corresponding author and reprints: Joseph R. DiFranza, MD, Department
of Family Medicine and Community Health, University of Massachusetts Medical
School, 55 Lake Ave, Worcester, MA 01655 (e-mail: difranzj{at}ummhc.org).
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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