Differential Diagnosis

The diagnosis of nicotine dependence is relatively straightforward, particularly in adults. Most adults admit that they smoke cigarettes, and they typically smoke on a daily basis. For adolescents and teens, smoking may not occur on a daily basis. The physician should ask them if they ever smoked and how frequently they smoke. If they do not smoke, or smoke only on occasion, the physician should inquire about expectations for smoking in the future. Older teens, of course, are more likely to report that they smoke on a daily basis, although the number of cigarettes smoked per day may be fewer than those smoked by adults.

The clinician often wishes to determine the severity of tobacco dependence, because such information provides insight into how difficult it will be for the smoker to quit and what kind of quitting strategy will be most effective. Fagerstrom (1978) developed a brief nicotine dependence questionnaire. Among the most discriminating questions are the following: "How soon after you wake up do you smoke your first cigarette?", "How many cigarettes a day do you smoke?", and "Have you stopped smoking or tried to stop smoking in the past?" (Kozlowski et al., 1989).

Heavy smokers, those who smoke soon after waking, and those who have never quit smoking in the past are least likely to quit smoking on their own or with assistance (cf. Hymowitz et al., 1997). They are the smokers who are most likely to benefit from nicotine replacement therapy (NRT) and other pharma-

cological aids (Fagerstrom, 1988). Smokers with psychiatric illness such as schizophrenia, alcoholism, and depression also have an extremely difficult time quitting smoking (Glassman, 1993; American Psychiatric Association, 1996), and for smokers who succeed in quitting, negative affect and stress play a major role in smoking relapse (Shiffman, 1986).

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