| Abstract|| |
Aim and Objectives : To estimate the level of nicotine dependence in a group of smokers by using six- question Fagerstrom Test for Nicotine dependence (FTND). 1) To assess the level of nicotine dependence. 2) To evaluate the level of nicotine dependence with duration of the habit.
Materials and Methods : The total sample size of the above study includes 130 patients. The age groups ranged between 16-60 years were selected. Six- questions from Fagerstrom Test for Nicotine dependence (FTND) were used to elicit the nicotine dependence. The study group included tobacco users with only smoking habit and excluded the subjects not willing to participate and also smokers who are also tobacco chewers. All the results were transferred onto Microsoft excel sheet and evaluated statistically by using Chi-square test.
Results : Depending upon the age of the smokers, 4 grouping was done as follows. The number of individuals in study participation noticed between 21-30 years were 101 smokers (77.69%). With least noticed in >40 years age group 6 (4.6%). Frequency of smoking ranging between <5day to >10 |day, no of smokers, with frequency of <5 |day were more 91 (70%), followed by 6-10 |day among 31 (23.85%) of them, with frequency of >10 |day in 8 (6.15%) individuals. Duration of smoking mentioned in number of years ranging from <5 years to >10 years. Highest no. of smokers that is 105 (80.77%) were smoking <5 years with least number of smokers 5 (3.85%) smoking from last 10 years. Determines type of nicotine dependence, ranging from mild to severe variant. Majority of Nicotine dependence was mild noticed among 86 (66.15%). Smokers with least numbers noticed as severe nicotine dependence among 6 (4.62%) smokers. Association of duration of smoking with dependence statistical significance noticed. Statistical significant noticed between the association of frequency of smoking with dependence.
Conclusion: Short study reveals the type of nicotine dependence, ranging from mild to severe by six- question Fagerstrom Test for Nicotine dependence (FTND) based on duration & frequency of smoking
Keywords: Dependence, nicotine, smoking, tobacco
|How to cite this article:|
Samatha SS, Byahatti SM, Ammanagi R, Tantradi P. Assessing the level of nicotine dependence in smokers visiting a dental college in belgaum city: A questionnaire study. J Educ Ethics Dent 2015;5:25-9
|How to cite this URL:|
Samatha SS, Byahatti SM, Ammanagi R, Tantradi P. Assessing the level of nicotine dependence in smokers visiting a dental college in belgaum city: A questionnaire study. J Educ Ethics Dent [serial online] 2015 [cited 2019 Jul 18];5:25-9. Available from: http://www.jeed.in/text.asp?2015/5/1/25/178027
| Introduction|| |
Tobacco was introduced to India in the year 1600 AD,  whereas the habit of smoking here in India has been known since 2000 BC when cannabis was smoked as first mentioned in the Atharvaveda. Ayurveda mentions regarding smoking as dhumapana which literally means "drinking smoke".  According to the World Health Organization, presently there are around 120 million smokers in India, and India is home to about 12% of the smokers among the world.
A report published in 2009 shows there are nearly 9 lakh people who die every year in India due to the habit of smoking.  A case-control study of smoking and death in India conducted in 2010 has shown that tobacco plays as a major role in causing death of 1 in 5 of all males and 1 in 20 of all female. In 2010, 1 million Indians died from the smoking habit alone.  If immediate action is not taken, the annual death rate could rise up to more than 8 million by 2030.  Oral physicians should take motivative step of encouraging these smokers in support of quitting smoking. After a patient is known as a smoker, various measures are available to assess readiness for change. Individual or Group counseling can facilitate smoking cessation and improve the patient's chance of quitting the habit of smoking. When the chances of relapses are expected, a systematic planning should be in place for recalling the patient with the appropriate stages.
Till date, very few studies mention regarding Nicotine dependence in India. This Paper is an attempt to show such Nicotine dependence in a small group of smokers of a South Indian city. Considering the importance of tobacco cessation, this study was aimed at assessing the frequency, duration and level of nicotine dependence in a group of the population. This in turn helps us to decide whether to do counseling or nicotine replacement therapy as a mode of deaddiction management.
| Materials and Methods|| |
Smokers who were visiting Department of Oral Medicine and Radiology at Maratha Mandal's Nathajirao G. Halgekar Institute of Dental sciences and Research Centre, Belgaum, Karnataka within the age group ranging between 18 and 60 years were selected. The total sample included 130 patients who had the habit of smoking tobacco and excluded the subjects not willing to participate and also smokers who were also tobacco chewers. A short clinical case history with six-questions from Fagerstrom test for nicotine dependence (FTND) was filled by interviewing the individual smoker.  This questionnaire helps us to elicit the nicotine dependence.
All the results were transferred onto Microsoft excel sheet and evaluated statistically using Chi-square test.
Fagerstrom test for nicotine dependence 
| Results|| |
The total number 130 male participants with age ranging between 18 and 60 years were included. The age divided into following groups:
Group 1: <20 years.
Group 2: 21-30 years.
Group 3: 31-40 years.
Group 4: >40 years.
The majority of smokers in this study participated were noted between 21 and 30 years that is, 101 (77.69%). With least being noted in >40 years age group 6 (4.6%) [Figure 1].
Frequency of smoking ranged between <5 day and >10/day wherein the number of smokers, with least frequency of <5/day were noted more in 91 (70%), with least frequency of >10/day in 8 (6.15%) individuals [Figure 2]. Duration of smoking ranged from <5 years to >10 years. Highest number of smokers that is, 105 (80.77%) were smoking for <5 years with the least number of smokers 5 (3.85%) smoking from last 10 years [Figure 3].
Fagerstrom test for nicotine dependence determines the type of nicotine dependence, ranging from mild to severe variant. Majority of Nicotine dependence was mild type which was noticed among 86 (66.15%). Smokers with severe nicotine dependency noticed as least among 6 (4.62%) smokers [Table 1]. Association between duration of smoking with dependence has been noted with a statistical significance [Table 2]. Whereas statistical significance noticed between the association of frequency of smoking with dependence [Table 3].
| Discussion|| |
Various methods are used to estimate the level of nicotine dependence such as the fagerstrom tolerance questionnaire and the FTND, the tobacco dependence screener, the wisconsin inventory of smoking dependence motives, the cigarette dependence scale, the nicotine dependence syndrome scale, CAGE questionnaire modified for smoking behavior, "Four Cs" test,….etc. 
Among various methods mentioned above we used FTND, as it is a simple, reliable tool and easy to follow in assessing nicotine dependence.  In spite of the growing social and legal restrictions on tobacco consumption, people are consuming tobacco in various forms. 
Diagnostic and statistical manual of mental disorders has been included nicotine related disorders in its list of mental disorders since 2000.  Almost 35 million tobacco users attempt to quit every year, but only about 6% are successful for more than just a month. Many quitting programs need to measure how much an individual is psychologically dependent on tobacco. 
As it has been stated by Mark Twain "giving up smoking is easy I have done it a thousand times" which is the adage that puts in perspective the difficulties of tobacco cessation.  The pathophysiology of nicotine dependence is an effort of an individual to adjust and feel normal. The brain will alter its physical neurocircuitry to meet the changed chemical onslaughts of nicotine, dopamine, adrenaline, acetaldehyde, etc. The number of neuroreceptors and transporters available to receive nicotine will vanish. At the same time, extra acetylcholine receptors develop. The new sense of "normal" depends upon the presence of nicotine. 
Nicotine involves cholinergic receptors and strengthens the release of acetylcholine, serotonin, and beta-endorphin. Smoking causes lung cancer, upper respiratory tract cancer, esophagus, bladder, pancreas cancer, and cancer in other organs, emphysema, cardiovascular diseases, and stroke.  Ashley et al. have stated, although nicotine is blamed for chemical causing a high level of dependence, but certain byproducts and additives in tobacco are also responsible for dependence. 
The de-addiction which are categorized into counseling 5 as:
Asking about smoking;
Alerting the patient to the benefits of quitting;
Assessing readiness to make a quit attempt;
Assisting those willing to quit; and
Arranging for follow-up contact and referral to further resources, such as quit lines,  placebo and NRT. Recently tobacco cessation counseling has been proposed to play a vital role in oral health assessment. 
The present study was taken to evaluate the nicotine dependence in a group of smokers using FTND questionnaire which included 6 questions.
The total sample size in this study was 130 subjects with habit of smoking. The size of the sample was lesser as compared with a study by Jadhav et al. which included 200 people, where there was a highly significant difference observed between the proportions of duration of habit and FTND score with both tobacco smoking habit and smokeless tobacco with age 51 years and above.  The results obtained in this study showed the age group included were younger and with a maximum frequency noted with least >10/day.
Number of smokers was highest with duration of <5 years and then least with >10 years duration.
Whereas Pai et al. conducted a study with a sample size of 45 patients who divided the smokers based on the duration of smoking into four categories. Patients who smoked since 1-5 years were maximum in the placebo group and people who smoked for more than 15 years were maximum in the NRT group. As the subjects were grouped into 4 groups based on the frequency. The least frequency noted in 1-5 which being maximum in placebo, and those with the frequency of more than 20 being maximum in the NRT group. 
The present study also included only male smokers. The mean age of 39 years this was greater than Jadhav et al. study.
In this study, mild nicotine dependence was noted higher as compared to moderate to severe nicotine dependence. The smoker with mild to moderate nicotine dependence counseling was done, and for the severe nicotine dependence NRT was advised in an order to quit the habit of smoking. Severe nicotine dependence was advised for pharmacotherapy like NRT. Currently, four forms of nicotine delivery are available: Patch, gum, inhaler, and nasal spray. Some data indicate that use of a combination of delivery methods, such as the gum and the patch, may be useful in severe nicotine-dependent smokers.  Based upon the type of dependence these measures can be advised with the least number of side effects. Although the sample size used in the present study was smaller to give a thought on effective way of treatment, which definitely needs a follow up at the regular intervals, the larger sample size. As this study was done as an initiative program to analyze the type of smokers available and visit in our department, so that later the larger sample with regular follow-up with treatment planning, and outcome can be checked.
| Conclusion|| |
This short study reveals that the six-question FTND revealed many of them were young with mild nicotine dependence. Hence, oral physicians should use FTND as a simple tool to assess nicotine dependence in a day-to-day and use NRT or counseling or refer the patient to higher center for further treatment.
| References|| |
The History of Tobacco. World Health Organization (WHO). [Last retrieved on 2013 Oct 07].
Manohar R. Smoking and ayurvedic medicine in India. In: Smoke. p. 68-75.
Singh S. "1 mn Indian smokers will die every year". Livemint; 14 February, 2008. [Last retrieved on 2013 May 02].
World Health Organization. WHO Report on the Global Tobacco Epidemic, Implementation Smoke Free Environment 2009: The MPOWER Package. Geneva: World Health Organization; 2009.
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. Br J Addict 1991;86:1119-27.
Fagerström K, Russ C, Yu CR, Yunis C, Foulds J. The Fagerström test for nicotine dependence as a predictor of smoking abstinence: A pooled analysis of varenicline clinical trial data. Nicotine Tob Res 2012;14:1467-73.
Rustin TA. Assessing nicotine dependence. Am Fam Physician 2000;62:579-84, 91.
Uysal MA, Kadakal F, Karsidag C, Bayram NG, Uysal O, Yilmaz V. Fagerstrom test for nicotine dependence: Reliability in a Turkish sample and factor analysis. Tuberk Toraks 2004;52:115-21.
Diagnostic and Statistical Manual of Mental Disorders by American Psychiatric Association; 2000. Available from: http://www.psych
. org/Main Menu/Research/DSMIV.aspx.
Jadhav K, Singh D, Assessment of psychological dependence among tobacco users: A survey held among the rural population of India to call for attention of tobacco cessation centers. Dent Resh J (Isfahan) 2013;10:467-73.
Amit S, Bhambal A, Saxena V, Basha S, Saxena S, Vanka A. Tobacco cessation and counseling: A dentists′ perspective in Bhopal city, Madhya Pradesh. Indian J Dent Res 2011;22:400-3.
Nasirian M, Ziaaddini H, Asadollahi S. Smoking intensity and its relation to general health of the students of Kerman university of medical sciences, Iran. Addict Health 2013;5:102-7.
Ashley DL, Burns D, Djordjevic M, Dybing E, Gray N, Hammond SK, et al. Kobe, Japan; 2006. The scientific basis of tobacco product regulation: Report of a WHO study group. Available from: http://www.who.int/tobacco/global -
Fiore MC. Treating tobacco use and dependence: 2008 update U.S. Public health service clinical practice guideline executive summary. Respir Care 2008;53:1217-22.
Davis JM. Tobacco cessation for the dental team: A practical guide part II: Evidence-based interventions. J Contemp Dent Pract 2005;6:178-86.
Pai A, Prasad S. Attempting tobacco cessation - an oral physician′s perspective. Asian Pac J Cancer Prev 2012;13:4973-7.
Mallin R. Smoking cessation: Integration of behavioral and drug therapies. Am Fam Physician 2002;65:1107-14.
Sujata Mohan Byahatti
Plot No 49, Sector No. 9, Malmaruti Extn., Belgaum - 590 016, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]