An evaluation of a clinical approach to staging tobacco addiction

Psychoactive Comfort Products or Snacks: How Chinese Young Adults Perceive the Potentially Addictive Nature of E-Cigarettes

The potential health value and pitfalls of e-cigarettes are currently under dispute in the scientific community. Exploring young adult e-cigarette users' perceptions would assist in adding a public dimension of understanding to the literature and in scientific public health decision making. Therefore, in this study, we collected and analyzed data from interviews with young adult (n = 14) e-cigarette users and found that many referred to e-cigarettes as "snacks," indicating that they considered that both their frequency of use and addiction were manageable and that they could stop using e-cigarettes at any time. To further understand the behavior of Chinese young adults in relation to their perception of e-cigarettes as a "snack", the study developed a social context framework (crossroads model) and psychological judgment model to explain how youth e-cigarette users' perception of "controlled addiction and ready cessation" arises. These models can be used to assess the effectiveness of e-cigarette policy.

E-Cigarettes as a Growing Threat for Children and Adolescents: Position Statement From the European Academy of Paediatrics

As the tobacco epidemic has waned, it has been followed by the advent of electronic nicotine delivery devices (ENDS) primarily manufactured by the tobacco industry to try to recruit replacements for deceased tobacco addicts. This document sets out the ten recommendations of the European Academy of Paediatrics (EAP) with regard to e-cigarettes and children and young people (CYP). The EAP notes that nicotine is itself a drug of addiction, with toxicity to the foetus, child and adult, and were ENDS only to contain nicotine, their use to create a new generation of addicts would be rigorously opposed. However, e-cigarettes include numerous unregulated chemicals, including known carcinogens, whose acute and long term toxicities are unknown. The EAP asserts that there is incontrovertible evidence that the acute toxicity of e-cigarettes is greater than that of "traditional" tobacco smoking, and a variety of acute pulmonary toxicities, including acute lung injuries, have been recorded due to e-cigarettes usage. The chronic toxicity of e-cigarettes is unknown, but given the greater acute toxicity compared to tobacco, the EAP cannot assume that e-cigarettes are safer in the long term. The high uptake of e-cigarettes by CYP, including under-age children, is partly fuelled by deceitful marketing and internet exposure, which is also unregulated. Although proposed as aids to smoking cessation, there is no evidence that e-cigarettes add anything to standard smoking cessation strategies. In summary, the EAP regards these devices and liquids as very dangerous, and ineluctably opposed to their use, and their direct or indirect marketing.

Nicotine Dependence and Loss of Autonomy among Greek Adolescent Smokers: A Countrywide Cross-Sectional Study

Nicotine dependence is one of the main reasons for the continuation of smoking among adolescents. Loss of autonomy (LOA) is a measure of dependence. This study is the first to investigate LOA and its determinants among Greek adolescents. In 2013, 13-to-15-year-old middle-school students were selected by multi-stage clustered sampling. LOA was evaluated with the Hooked-on-Nicotine Checklist (HONC). Multiple univariate analysis was used to assess the association between adolescent demographics, smoking habits, and loss of autonomy. Three-hundred thirty-nine current smokers responded to the questionnaire (response rate: 82.3%). Of these respondents, 51.2% were male and 88.8% reported at least one LOA symptom. The mean HONC score was 4.13/10 (95% CI: 3.82–4.45). Higher scores were negatively associated with lower smoking frequency (cumulative odds ratio (cOR): 0.240, 95% CI: 0.144–0.400) and positively associated with lower age at first cigarette (cOR: 2.29, 95% CI: 1.38–3.82). Female gender was significantly associated with the prevalence but not the degree of LOA. Overall, the prevalence and the degree of nicotine dependence among adolescent smokers in Greece is similar to other countries. Frequent smoking and initiation of smoking at a younger age are linked to nicotine dependence, although it was not possible to make causal inferences. The relationship between nicotine dependence and gender remains unclear.

Smoking Cessation in Adolescents: targeted approaches that work

Smoking Cessation in adolescents can be considered in a developmental context to enable the clinician to individualise the appropriate assessment and management of the young person they are seeing whether it is in a primary or tertiary care setting. Adolescence is a time of rapid neurocognitive and hormonal change with these factors affected by personality and behavioural factors as well as family, cultural and psychosocial context. Adolescents are uniquely vulnerable to smoking initiation and nicotine addiction throughout these years. Increased awareness of the risks of smoking and using opportunities to assess and intervene regarding smoking cessation are integral to clinical practice for all clinicians seeing young people. This review will discuss the demographics of adolescent smoking, risk factors, assessing smoking and nicotine addiction, the importance of brief interventions, the evidence base for appropriate interventions, particularly in high risk groups and will emphasise innovative training for health professionals in adolescent smoking cessation.

Early symptoms of nicotine dependence among adolescent waterpipe smokers

BACKGROUND

Although waterpipe smoking is increasingly popular among youth and can lead to nicotine dependence (ND), no studies have documented how ND develops in waterpipe smokers. We examined the emerging symptoms of ND among adolescent waterpipe smokers in Lebanon.

METHODS

Individual confidential interviews were used to evaluate ND in 160 waterpipe smokers and 24 cigarette smokers from a sample of 498 students enrolled in 8th and 9th grades in Lebanon.

RESULTS

Among waterpipe smokers, 71.3% endorsed at least one Hooked on Nicotine Checklist (HONC) symptom and 38.1% developed the full syndrome of ND (≥3 criteria using the International Classification of Diseases, 10th revision). The early symptoms of ND among waterpipe smokers were craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%). Among those who reached the respective milestones, median tobacco use when the first HONC symptom emerged was 7.5 waterpipes/month with smoking frequency of 6 days/month; the median tobacco use for the full syndrome of ND was 15 waterpipes/month with smoking frequency of 15 days/month. Among those who had already reached these milestones, the first HONC symptom appeared 10.9 months after the initiation of waterpipe smoking, and the full syndrome of ND was reached at 13.9 months. In addition, cues such as seeing or smelling waterpipe, and the café environment triggered craving in most waterpipe smokers with symptoms of ND.

CONCLUSIONS

Symptoms of ND develop among adolescent waterpipe smokers at low levels of consumption and frequency of use. Craving for nicotine triggered by waterpipe-specific cues is reported even at this young age. Waterpipe-specific ND prevention and intervention programmes for youth are needed.

Stages of physical dependence in New Zealand smokers: Prevalence and correlates

BACKGROUND

Physically dependent smokers experience symptoms of wanting, craving or needing to smoke when too much time has passed since the last cigarette. There is interest in whether wanting, craving and needing represent variations in the intensity of a single physiological parameter or whether multiple physiological processes may be involved in the developmental progression of physical dependence.

AIM

Our aim was to determine how a population of cigarette smokers is distributed across the wanting, craving and needing stages of physical dependence.

METHODS

A nationwide survey of 2594 New Zealanders aged 15years and over was conducted in 2014. The stage of physical dependence was assessed using the Levels of Physical Dependence measure. Ordinal logistic regression analysis was used to assess relations between physical dependence and other variables.

RESULTS

Among 590 current smokers (weighted 16.2% of the sample), 22.3% had no physical dependence, 23.5% were in the Wanting stage, 14.4% in the Craving stage, and 39.8% in the Needing stage. The stage of physical dependence was predicted by daily cigarette consumption, and the time to first cigarette, but not by age, gender, ethnicity or socioeconomic status.

CONCLUSION

Fewer individuals were in the craving stage than either the wanting or needing stages. The resulting inverted U-shaped curve with concentrations at either extreme is difficult to explain as a variation of a single biological parameter. The data support an interpretation that progression through the stages of wanting, craving and needing may involve more than one physiological process.

WHAT THIS RESEARCH ADDS

Physical dependence to tobacco develops through a characteristic sequence of wanting, craving and needing which correspond to changes in addiction pathways in the brain. It is important to neuroscience research to determine if the development of physical dependence involves changes in a single brain process, or multiple processes. Our data suggests that more than one physiologic process is involved in the progression of physical dependence.

Levels of physical dependence on tobacco among adolescent smokers in Cyprus

PURPOSE

The purpose of this study is to assess tobacco dependence among Cypriot adolescents and examine its association to cigarette consumption and attitudes towards smoking.

METHODS

The current study used cross-sectional data from the 2011 Cyprus Global Youth Tobacco Survey which adopted multistage cluster sampling methods to select adolescents registered in middle and high schools in Cyprus. Tobacco use, physical dependence on tobacco, and attitudes towards tobacco use were measured in 187 adolescents aged 13-18years old who reported that they had smoked at least once in the preceding 30days. Physical dependence was assessed using the Levels of Physical Dependence scale.

RESULTS

Physical dependence was present in 86% of the adolescent smokers. The mean latency to needing among smokers in the highest dependence group was 101h. Significant associations were observed between physical dependence and the perceived difficulty in quitting (OR=13.1, 95% CI: 4.0, 43.0) as well as the expectation to continue smoking for the next five years (OR=3.3, 95% CI: 1.3, 8.4). Significant associations were also observed between physical dependence and the number of smoking days per month, daily smoking, daily cigarette consumption, lifetime cigarette consumption, and perceived difficulty in abstaining from smoking for one week.

CONCLUSIONS

Physical dependence provides a symptom-based approach to assess dependence and it is a strong predictor of adolescents' perceptions of their ability to quit or to refrain from smoking for a week. Physical dependence on tobacco was highly prevalent among adolescent smokers in Cyprus and it was associated with greater perceived difficulty in quitting. Interventions targeting adolescent smoking must account for the high prevalence of physical dependence.

State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade

Tobacco use and tobacco smoke exposure are among the most important preventable causes of premature disease, disability, and death and therefore constitute a major pediatric health concern. The pediatric primary care setting offers excellent opportunities to prevent tobacco use in youth and to deliver cessation-related treatment to youth and parents who use tobacco. This report updates a "state-of-the-art" article published a decade ago on office-based interventions to address these issues. Since then there has been marked progress in understanding the nature, onset, and trajectories of tobacco use and nicotine addiction in youth with implications for clinical practice. In addition, clinicians need to remain abreast of emerging nicotine delivery systems, such as electronic cigarettes, that may influence uptake or continuation of smoking. Although evidence-based practice guidelines for treating nicotine addiction in youth are not yet available, research continues to build the evidence base toward that goal. In the interim, practical guidelines are available to assist clinicians in addressing nicotine addiction in the pediatric clinical setting. This article reports current practices in addressing tobacco in pediatric primary care settings. It reviews our increasing understanding of youth nicotine addiction, summarizes research efforts on intervention in the past decade and additional research needed going forward, and provides practical guidelines for pediatric health care providers to integrate tobacco use prevention and treatment into their clinical practice. Pediatric providers can and should play an important role in addressing tobacco use and dependence, both in the youth they care for and in parents who use tobacco.

Recalled first reactions to inhaling nicotine predict the level of physical dependence

BACKGROUND

The level of physical dependence is a measure of addiction that correlates highly with addiction-associated changes in brain structure. We sought to determine whether age at first inhalation and initial reactions to inhaling nicotine are related to level of physical dependence in early adulthood.

METHODS

Young adults (n=312; mean age=24 years; 51% female) from the Nicotine Dependence in Teens study who had smoked at least once in the preceding three months completed self-report questionnaires in 2011-12. We assessed level of physical dependence with three validated self-report items assessing 'wanting,' 'craving' and 'needing' triggered by nicotine deprivation. Survey items assessed smoking behavior, including age at first inhalation, and recalled first reactions to inhaling nicotine.

RESULTS

After adjusting for covariates, experiencing relaxation, heart racing/pounding, rush or "buzz" (OR=1.45; 95% CI: 1.08, 1.94) and dizziness (OR=1.58; 95% CI: 1.15, 2.18) at first nicotine inhalation were associated with an increased odds of being at a higher level of physical dependence in young adulthood; the association for experiencing relaxation (OR=1.78; 95% CI: 1.20, 2.64) and heart racing/pounding (OR=1.51; 95% CI: 1.00, 2.28) persisted after additionally controlling for all other first reactions. Neither age at first inhalation nor unpleasant first reactions predicted level of physical dependence.

CONCLUSIONS

In accordance with prior research, our findings suggest that smokers who are particularly sensitive to the pleasant, "buzz-related" and generally arousing effects of nicotine may be more likely to attain higher levels of physical dependence.

Relationship between frequency and intensity of cigarette smoking and TTFC/C among students of the GYTS in select countries, 2007-2009

BACKGROUND

This study assessed the construct validity of a measure of nicotine dependence that was used in the Global Youth Tobacco Survey (GYTS).

METHODS

Using 2007-2009 data from the GYTS, subjects from 6 countries were used to assess current smokers' odds of reporting time to first cigarette or craving positive (TTFC/C+) by the number of cigarette smoking days per month (DPM) and the number of cigarettes smoked per day (CPD).

RESULTS

The percentage of GYTS smokers who reported TTFC/C+ ranged from 58.0% to 69.7%. Compared with students who smoked on 1-2 DPM, those who smoked on 3-9 DPM had 3 times the adjusted odds of reporting TTFC/C+. The adjusted odds of reporting TTFC/C+ were 3 to 7 times higher among those who smoked 10-29 DPM and 6 to 20 times higher among daily smokers. Similarly, the adjusted odds of TTFC/C+ were 3-6 times higher among those who smoked 2-5 CPD and 6 to 20 times higher among those who smoked >6 CPD, compared to those who smoked <1 CPD.

CONCLUSION

Associations of TTFC/C+ prevalence with both frequency and intensity of cigarette smoking provide a construct validation of the GYTS question used to assess respondents' TTFC/C status.

Age-related changes in nicotine response of cholinergic and non-cholinergic laterodorsal tegmental neurons: implications for the heightened adolescent susceptibility to nicotine addiction

The younger an individual starts smoking, the greater the likelihood that addiction to nicotine will develop, suggesting that neurobiological responses vary across age to the addictive component of cigarettes. Cholinergic neurons of the laterodorsal tegmental nucleus (LDT) are importantly involved in the development of addiction, however, the effects of nicotine on LDT neuronal excitability across ontogeny are unknown. Nicotinic effects on LDT cells across different age groups were examined using calcium imaging and whole-cell patch clamping. Within the youngest age group (P7-P15), nicotine induced larger intracellular calcium transients and inward currents. Nicotine induced a greater number of excitatory synaptic currents in the youngest animals, whereas larger amplitude inhibitory synaptic events were induced in cells from the oldest animals (P15-P34). Nicotine increased neuronal firing of cholinergic cells to a greater degree in younger animals, possibly linked to development associated differences found in nicotinic effects on action potential shape and afterhyperpolarization. We conclude that in addition to age-associated alterations of several properties expected to affect resting cell excitability, parameters affecting cell excitability are altered by nicotine differentially across ontogeny. Taken together, our data suggest that nicotine induces a larger excitatory response in cholinergic LDT neurons from the youngest animals, which could result in a greater excitatory output from these cells to target regions involved in development of addiction. Such output would be expected to be promotive of addiction; therefore, ontogenetic differences in nicotine-mediated increases in the excitability of the LDT could contribute to the differential susceptibility to nicotine addiction seen across age.

The development and expression of physical nicotine dependence corresponds to structural and functional alterations in the anterior cingulate-precuneus pathway

INTRODUCTION

Perturbations in neural function provoked by a drug are thought to induce neural adaptations, which, in the absence of the drug, give rise to withdrawal symptoms. Previously published structural data from this study indicated that the progressive development of physical dependence is associated with increasing density of white matter tracts between the anterior cingulum bundle and the precuneus.

METHODS

Using functional magnetic resonance imaging, we compared 11 smokers after 11 h of abstinence from nicotine and after satiation, with 10 nonsmoking controls, using independent component analysis for brain network comparisons as well as a whole brain resting-state functional connectivity analysis using the anterior cingulate cortex as a seed.

RESULTS

Independent component analysis demonstrated increased functional connectivity in brain networks such as the default mode network associated with the withdrawal state in multiple brain regions. In seed-based analysis, smokers in the withdrawal state showed stronger functional connectivity than nonsmoking controls between the anterior cingulate cortex and the precuneus, caudate, putamen, and frontal cortex (P < 0.05). Among smokers, compared to the satiated state, nicotine withdrawal was associated with increased connectivity between the anterior cingulate cortex and the precuneus, insula, orbital frontal gyrus, superior frontal gyrus, posterior cingulate cortex, superior temporal, and inferior temporal lobe (P < 0.02). The intensity of withdrawal-induced craving correlated with the strength of connectivity between the anterior cingulate cortex and the precuneus, insula, caudate, putamen, middle cingulate gyrus, and precentral gyrus (r = 0.60-0.76; P < 0.05).

CONCLUSIONS

In concordance with our previous report that structural neural connectivity between the anterior cingulate area and the precuneus increased in proportion to the progression of physical dependence, resting-state functional connectivity in this pathway increases during nicotine withdrawal in correlation with the intensity of withdrawal-induced craving. These findings suggest that smoking triggers structural and functional neural adaptations in the brain that support withdrawal-induced craving.

Progressive levels of physical dependence to tobacco coincide with changes in the anterior cingulum bundle microstructure

BACKGROUND

The tobacco withdrawal syndrome indicates the development of neurophysiologic dependence. Clinical evidence indicates that neurophysiologic dependence develops through a set sequence of symptom presentation that can be assessed with a new 3-item survey measure of wanting, craving, and needing tobacco, the Level of Physical Dependence (PD). This study sought to determine if advancing neurophysiologic dependence as measured by the Level of PD correlates with characteristics of white matter structure measured by Fractional Anisotropy (FA).

METHODS

Diffusion-MRI based FA and diffusion tensor imaging probabilistic tractography were used to evaluate 11 smokers and 10 nonsmokers. FA was also examined in relation to two additional measures of dependence severity, the Hooked on Nicotine Checklist (HONC), and the Fagerström Test for Nicotine Dependence (FTND).

RESULTS

Among smokers, FA in the left anterior cingulate bundle (ACb) correlated negatively with the Level of PD (r = -0.68, p = 0.02) and HONC scores (r = -0.65, p = 0.03), but the correlation for the FTND did not reach statistical significance (r = -49, p = 0.12). With advancing Levels of PD, the density of streamlines between the ACb and precuneus increased (r = -0.67, p<0.05) and those between the ACb and white matter projecting to the superior-frontal cortex (r = -0.86, p = 0.0006) decreased significantly.

CONCLUSIONS

The correlations between neural structure and both the clinical Level of PD survey measure and the HONC suggest that the Level of PD and the HONC may reflect the microstructural integrity of white matter, as influenced by tobacco abuse. Given that the Level of PD is measuring a sequence of symptoms of neurophysiologic dependence that develops over time, the correlation between the Level of PD and neural structure suggests that these features might represent neuroplastic changes that develop over time to support the development of neurophysiologic dependence.

HIV-infected adolescent, young adult and pregnant smokers: important targets for effective tobacco control programs

Tobacco use is inextricably linked to a number of health risks both in the general and HIV-infected populations. There is, however, a dearth of research on effective tobacco control programs among people living with HIV, and especially among adolescents, young adults and pregnant women, groups with heightened or increased vulnerability secondary to tobacco use. Adolescents and young adults constitute a growing population of persons living with HIV infection. Early and continued tobacco use in this population living with a disease characterized by premature onset multimorbidity and chronic inflammation is of concern. Additionally, there is an increased acuity for tobacco control among HIV-infected pregnant women to reduce pregnancy morbidity and improve fetal outcome. This review will provide an important summary of current knowledge of tobacco use among HIV-infected adolescents, young adults and pregnant women. The effects of tobacco use in these specific populations will be presented and the current state of tobacco control within these populations, assessed.

What aspect of dependence does the fagerström test for nicotine dependence measure?

Although the Fagerström Test for Nicotine Dependence (FTND) and the Heaviness of Smoking Index (HSI) are widely used, there is a uncertainty regarding what is measured by these scales. We examined associations between these instruments and items assessing different aspects of dependence. Adult current smokers (n = 422, mean age 33.3 years, 61.9% female) completed a web-based survey comprised of items related to demographics and smoking behavior plus (1) the FTND and HSI; (2) the Autonomy over Tobacco Scale (AUTOS) with subscales measuring Withdrawal, Psychological Dependence, and Cue-Induced Cravings; (3) 6 questions tapping smokers' wanting, craving, or needing experiences in response to withdrawal and the latency to each experience during abstinence; (4) 3 items concerning how smokers prepare to cope with periods of abstinence. In regression analyses the Withdrawal subscale of the AUTOS was the strongest predictor of FTND and HSI scores, followed by taking precautions not to run out of cigarettes or smoking extra to prepare for abstinence. The FTND and its six items, including the HSI, consistently showed the strongest correlations with withdrawal, suggesting that the behaviors described by the items of the FTND are primarily indicative of a difficulty maintaining abstinence because of withdrawal symptoms.

Neuroadaptation in nicotine addiction: update on the sensitization-homeostasis model

The role of neuronal plasticity in supporting the addictive state has generated much research and some conceptual theories. One such theory, the sensitization-homeostasis (SH) model, postulates that nicotine suppresses craving circuits, and this triggers the development of homeostatic adaptations that autonomously support craving. Based on clinical studies, the SH model predicts the existence of three distinct forms of neuroplasticity that are responsible for withdrawal, tolerance and the resolution of withdrawal. Over the past decade, many controversial aspects of the SH model have become well established by the literature, while some details have been disproven. Here we update the model based on new studies showing that nicotine dependence develops through a set sequence of symptoms in all smokers, and that the latency to withdrawal, the time it takes for withdrawal symptoms to appear during abstinence, is initially very long but shortens by several orders of magnitude over time. We conclude by outlining directions for future research based on the updated model, and commenting on how new experimental studies can gain from the framework put forth in the SH model.

Adolescent cigarette smokers' and non-cigarette smokers' use of alternative tobacco products

INTRODUCTION

This study uses the most recent data from the nationally representative National Youth Tobacco Survey (NYTS) to examine the use of alternative tobacco products among U.S. cigarette smokers and non-cigarette smokers aged 14-17. Alternative tobacco product use is defined as use of one or more of the following products: smokeless tobacco, cigars, pipes, bidis, or kreteks.

METHODS

Using the results from the 2004, 2006, and 2009 NYTS, multivariate logistic regressions were used to investigate separately the extent of alternative tobacco product use in current cigarette smokers and in those who reported not smoking cigarettes controlling for demographic and other independent influences.

RESULTS

The results indicate that for adolescent smokers and nonsmokers, the use of one type of alternative tobacco product made it much more likely the individual would use one or more of the other alternative tobacco products. Non-cigarette smokers using these tobacco products appeared to exhibit symptoms of nicotine dependence comparable to those of cigarette smokers.

CONCLUSIONS

More information on adolescent use of alternative tobacco products is needed. Current cigarette use declined 3.4% annually over 2004-2009 for the NYTS 14- to 17-year-old population, but this cohort's use of alternative tobacco products was unchanged. The number of adolescents aged 14-17 who did not smoke cigarettes but used alternative tobacco products increased 5.9% per year over the same period. Current surveillance measures need to be expanded in order to gain a more comprehensive understanding of adolescent alternative tobacco use.

Does progression through the stages of physical addiction indicate increasing overall addiction to tobacco?

RATIONALE

With physical addiction to tobacco, abstinence triggers a desire to smoke. As physical addiction advances, the desire to smoke changes in quality and intensity from wanting, to craving, to needing. A prior study in adolescents suggested that this progression signifies increasing addiction.

OBJECTIVE

We sought to determine if the sequential appearance of wanting, craving and needing provides an indication of the intensity of other markers of tobacco addiction including psychological and behavioral indicators.

METHODS

A web-based survey was completed by 422 smokers ages 18-78 years. Subjects were assigned to one of four qualitatively distinct stages of physical addiction based on their most advanced symptom: 1-none, 2-wanting, 3-craving, or 4-needing. Using linear Chi square and ANOVA, we determined if higher stages were associated with higher levels of tobacco addiction on more than a dozen measures.

RESULTS

16.8% of subjects were in stage 1, 26.1% in stage 2, 17.1% in stage 3 and 40.0% in stage 4. Each step up in stage was associated with higher levels of addiction as measured by the Fagerström Test for Nicotine Dependence, the Hooked on Nicotine Checklist, the Autonomy over Tobacco Scale, and higher levels of psychological dependence, duration of tobacco use, frequency of tobacco use, daily cigarette consumption, and 10 additional measures.

CONCLUSIONS

In this cross-sectional study, each sequential stage of physical addiction was associated with higher levels of every indicator of addiction. The data suggest that the stages of progression of physical addiction provide a global indication of the severity of tobacco addiction.

Psychometric properties of the Autonomy over Tobacco Scale in German

BACKGROUND/AIMS

We investigated the psychometric properties of a German translation of the 12-item Autonomy over Tobacco Scale (AUTOS) among 1,195 eighth-grade students.

METHODS

Data for this study were collected as part of the fourth wave of data collection of the Smokefree Class Competition intervention in the Saxony-Anhalt region of Germany. Students from the control arm of the Smokefree Class Competition study who indicated that they had ever smoked 'at least a few puffs' on a cigarette were classified as ever-smokers. They self-completed questionnaires distributed by teachers.

RESULTS

AUTOS scores ranged from 0 to 36 with a distribution highly skewed toward lower-response categories. Inter-item correlations ranged from 0.65 to 0.89 (mean = 0.79, SD = 0.06). Composite reliability for the AUTOS was high (Ω = 0.96) and 3 lower-order factors were also reliable (withdrawal: 0.89, psychological dependence: 0.91, cue-induced cravings: 0.87). Concurrent validity was supported by strong relationships between the AUTOS and both lifetime cigarette consumption and current smoking frequency. Youths were 18 times more likely to be current smokers (95% CI = 11.9-27.2, p < 0.001) if they endorsed any AUTOS item.

CONCLUSION

The German AUTOS is reliable and valid, and the results are consistent with the English AUTOS for use with adolescents.