PHILADELPHIA — American smokers have, on average, become significantly more nicotine dependent since 1989—which means that more aggressive interventions are needed to help them quit.
That's because most of the smokers who could more easily quit have already done so. “The low-hanging fruit has been plucked. The less-addicted smokers are out of the pool. We're left with people who are more dependent,” Dr. David P.L. Sachs said at the annual meeting of the American College of Chest Physicians.
“The vast majority of patients we see now in actual clinical practice are more highly nicotine dependent,” said Dr. Sachs, director of the Palo Alto (Calif.) Center for Pulmonary Disease Prevention. Dr. Sachs documented this shift by comparing the average level of nicotine dependence in patients who participated in three smoking-cessation studies that he collaborated on during 1989–2006. In all three studies, nicotine dependence at baseline was quantified with the Fagerström Tolerance Questionnaire (FTQ). (See box.)
Among 220 U.S. smokers enrolled in 1989 and 1990 in a study of a nicotine patch, the average FTQ score was 6.65. The next study enrolled 206 patients in 1994 in a study of sustained-release bupropion; their average FTQ score was 7.02, significantly higher than in the prior study. This average also fell into the category of “high” nicotine dependence, which applies to FTQ scores of 7 or greater.
The third study group cited by Dr. Sachs included 204 patients who were enrolled in 2005–2006 to assess an individualized treatment regimen. These people had an average FTQ score of 7.44, a significant jump above the 1994 average.
Thus, the percentage of patients rated as highly nicotine dependent was 56% in 1989–1990, 66% in 1994, and 73% in 2005–2006.
Dr. Sachs suggested measuring the FTQ score for each prospective quitter. “If you do not measure nicotine dependence, you can't know how physically dependent a person is,” he said. “It would be like trying to manage hypertension without first measuring a patient's blood pressure.”
If the smoker is highly dependent (FTQ score of 9 or 10), the physician will most likely need to prescribe several agents. Three or more standard, OTC nicotine patches worn simultaneously may be necessary, plus an additional nicotine source for times of stress, such as nicotine gum, nasal spray, inhaler, or lozenges. In addition, highly dependent patients will likely need treatment with bupropion (Zyban) or varenicline (Chantix). Some patients may need treatment with all four agents.
Some patients may require some type of maintenance treatment indefinitely, he added.
Dr. Sachs has received research grants from, been a consultant to, and been a speaker for Pfizer (Chantix) and GlaxoSmithKline (Zyban).
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The Fagerström Tolerance Questionnaire (1991 Revision)
1. How soon after you wake up do you smoke your first cigarette?
▸ Within 5 minutes: 3 points.
▸ 6–30 minutes: 2 points.
▸ 31–60 minutes: 1 point.
▸ After 60 minutes: 0 points.
2. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, at the library, in cinemas?
▸ Yes: 1 point.
▸ No: 0 points.
3. Which cigarette would you hate most to give up?
▸ The first in the morning: 1 point.
▸ Any other: 0 points.
4. How many cigarettes per day do you smoke?
▸ 31 or more: 3 points.
▸ 21–30: 2 points.
▸ 11–20: 1 point.
▸ 10 or less: 0 points.
5. Do you smoke more frequently during the first hours after awakening than during the rest of the day?
▸ Yes: 1 point.
▸ No: 0 points.
6. Do you smoke when you are so ill that you are in bed most of the day? (If you never get sick, give the most likely response.)
▸ Yes: 1 point.
▸ No: 0 points.
Source: Br. J. Addict. 1991;86:1119–27