desire to use nicotine. Nicotine raises levels of endorphins, often referred to as the body’s natural pain killer . Endorphins can also produce feelings of euphoria. Nicotine also stimulates the release of serotonin, which is responsible for mood modulation and appetite suppression. 52
of neurons in these areas of the brain causes a sense of euphoria, which reinforces drug-seeking behavior. The release of glutamate, a neurotransmitter involved in learning and memory, enhances the connections between neurons. These stronger connections may be the physical basis of memory, which may create a memory loop that drives the Fagerström Test for Cigarette Dependence The Fagerström Test for Cigarette Dependence (FTCD) , formerly known as the Fagerström Test for Nicotine Dependence (FTND), is a quick assessment of the patient’s nicotine dependence that is useful in a clinical setting. 53 A modified version of this test is shown in Table 1. The scoring system can be used to provide patients with an objective view of their dependence level. It also can assist clinicians in the discussion of withdrawal symptoms and serve as a guide for decisions on the appropriate level of nicotine replacement therapy.
The most salient determinants of a high level of nicotine dependence using this assessment are smoking within 5 minutes of waking, smoking more in the morning than the rest of the day, and finding it more difficult to give up the first cigarette of the day. This assessment can provide both clinicians and patients with a greater understanding of nicotine dependence levels as compared to simply knowing the number of cigarettes smoked per day.
Table 1: Modified Fagerström Test for Cigarette Dependence Questions How soon after you wake up in the morning do you smoke?
Answers
Points
After 60 min
0 1 2 3 1 0 1 0 0 1 2 3 1 0 1 0
Within 31-60 min Within 6-30 min
Within 5 min
Do you find it difficult not to smoke where it is forbidden?
Yes No
Which cigarette of the day would you hate most to give up?
First cigarette in the morning
Any other
How many cigarettes per day do you smoke?
10 or less a day 11-20 day (1 pack)
21-30 per day
31 or more
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Yes No Yes No
Do you smoke if you are so ill that you are in bed most of the day?
Scoring: 1-2 = very low dependence 3 = low to moderate dependence 4 = moderate dependence 5+ = high dependence Note . Adapted from “The Fagerström Test for Nicotine Dependence: A Revision of the Fagerström Tolerance Questionnaire,” by T. F. Heatherton, L. T. Kozlowski, R. C. Frecker, and K. O. Fagerström, 1991, British Journal of Addiction, 86 , p. 1125. Used with permission from author. Assessing nicotine dependence
quit attempts in the past year, social factors, and salivary cotinine. 54 (Cotinine is the principal metabolite of nicotine; salivary cotinine is an indirect measure of recent exposure to cigarette smoke and is an established research tool used to validate self-reported tobacco abstinence.) Nevertheless, the FTCD serves as a useful clinical tool to provide patients with an objective assessment of their nicotine dependence level. It is particularly useful in patients who have reduced the number of cigarettes they smoke per day either by choice or as a response to smoke-free environments. with multiple symptoms. Symptoms of nicotine withdrawal generally start within two to three hours after tobacco has last been used and peak about two to three days later. Symptoms may be severe, depending on how long the
Given the implementation of smoke-free regulations in workplaces, commercial establishments, and public spaces, the number of cigarettes smoked per day is not necessarily an accurate measure of the patient’s level of nicotine dependence. The FTND has been widely used to assess patients’ level of nicotine dependence; however, it assesses only physical dependence. 53,54 The validity of the FTCD has been challenged because it does not assess aspects of tobacco dependence such as withdrawal symptoms, relief of withdrawal symptoms, quitting self-efficacy, number of Nicotine withdrawal symptoms The number and intensity of effects noticed or felt varies from person to person, and even between each person’s own cessation experiences. Some smokers experience almost no symptoms at all, while others are confronted
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