In the last decade, the importance of nicotine in maintaining smoking and in cessation difficulty has been acknowledged. Consequently, this has led to efforts to measure nicotine dependence. This paper focuses on a widely used, paper-and-pencil test of nicotine dependence--the Fagerstrom Tolerance Questionnaire (FTQ). The findings indicate that the FTQ correlates with other proposed measures of nicotine dependence (carbon monoxide, nicotine, and cotinine levels). The connection between FTQ scores and withdrawal symptoms is weak. In clinic outcome trials, the FTQ predicted success where no pharmacologic treatment was involved, while nicotine replacement appeared to mask the relation between FTQ scores and outcome. However, the FTQ may predict outcome with nicotine replacement as a function of dose. In placebo-controlled, nicotine replacement trials, FTQ scores were related to success by treatment. Problems with the FTQ are described with focus on item difficulties and analyses of the scale.

Nicotine gum and transdermal nicotine have been shown to relieve withdrawal and double success rates over placebo in trials of smoking cessation. This study tested whether combining the two methods would relieve withdrawal more effectively compared to either treatment alone. Twenty-eight smokers served as their own controls in each of four conditions: active gum + active patch (double active), active gum + placebo patch (gum only active), placebo gum + active patch (patch active) and placebo gum + placebo patch (double placebo). This "double placebo" design controls sensory, psychological and ritual variables associated with each drug form. Withdrawal symptoms were rated four times daily for 3 days in each condition. Total baseline (smoking) withdrawal scores using visual analogue scales (VAS) averaged 101.1. During cessation, total withdrawal increased to 187.0 for the double placebo condition, 142.2 for the active gum/placebo patch treatment and 128.3 for the active patch/placebo gum treatment. The double active condition equalled smoking with score 99.2. All pairwise comparisons were significant (P < 0.001) except between the two single active conditions and between smoking versus the double active condition. Significant time-of-day effects by treatment on withdrawal were observed for the double placebo condition (P < 0.05) with less withdrawal in the morning. The findings suggest: 1) combining nicotine gum with transdermal nicotine may be superior to either treatment alone, 2) more symptoms may be nicotine specific (relieved by replacement) than previously thought.

SummaryThe urge to smoke is by far the most commonly reported subjective response to cigarette withdrawal. It is worse in smokers with higher nicotine intake and can be reduced by a nicotine substitute. Although it may occur at any time during abstinence, it can be increased by stress and boredom and reduced when the smoker is kept occupied. Craving for cigarettes probably has multiple causation arising partly out of the perceived benefits of smoking and negative consequences of not smoking and partly as a direct result of loss of nicotine. Whatever its root causes it would be expected to involve general psychological processes such as associative learning and attribution. This paper draws together the threads of pharmacological and psychological levels of explanation for cigarette craving in an attempt to provide a clearer understanding of this phenomenon.

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