The Fagerström Test

Can we think of a more international success than the Fagerström Test for Nicotine Dependence (FTND) that was translated in every language and is widely used throughout the world? In point of fact, this test that was spawned by the marketing of nicotine drugs, cannot be disassociated from such drugs. It all started with Ove Fernö, a Swedish chemist of the firm LEO, a genuine researcher. During an interview he related the passionate saga of how nicotine gum was developed, from its inception in 1967 until it obtained patent rights in 1978. His personal tobacco cessation experience convinced him that nicotine was the factor of dependence to tobacco [1]. However the team led by Russell in London had already challenged this theory [2].

Karl Fagerström, a 1975 graduate of psychology, collaborated with LEO gum for his thesis. In 1978 he proposed a test to evaluate the dependence of smokers, the FTQ (Fagerström Tolerance Questionnaire). The title was neutral and rather incomprehensible, but Fagerström clearly explained that the goal was to measure dependence to nicotine, deemed to explain dependence to tobacco [3]. In 1983, he joined the firm who has since become Pharmacia & Upjohn. He held the position of Director of Scientific Information on Nicotine Substitutes.

But very quickly, a factorial analysis by Heatherton showed the much improvised character of this FTQ and how it did not respect the generally accepted criteria for questionnaire structures. This questionnaire could have been limited to two orthogonal items that would have summarized the essence of the information: 1 - The hour of the first cigarette of the day which translates credibly the pharmacological need, and 2 - the number of cigarettes one smokes, which expresses the persistence of repeating the gesture [4]. This could have meant the end of this test, but two years later, Fagerström saved it by joining Heatherton’s team and proposing a new test, the FTND (Fagerström Test for Nicotine Dependence) [5]. In this new version the only item in reference to nicotine, namely the nicotine yield of cigarettes, disappeared because it had no relation to biological measurements. The item dealing with inhalation also disappeared. Reduced to 6 behavioral items alone, this test could now only measure one’s dependence to cigarettes. Paradoxically, the title of the questionnaire however, presented it henceforth as a measurement of one’s dependence to nicotine .

But in 2011 Fagerström retires, and kills his baby [6]. Resuming all the arguments which I had developed for him when I had invited him in 1989 at the 5th Day of addiction to smoking in Paris, he changes the name of his famous test which now becomes "Test For Cigarette Dependence", FTCD! It gives me great satisfaction to see him return to reason. But why did it take so long?

The commercial importance of the ‘’dependence to nicotine’’ dogma

What can be more convenient than a test on one’s dependence to nicotine to justify the use of "nicotine substitutes"! It was important to have people swallow that nicotine was THE addictive drug in tobacco. Over a period of more than 30 years, it was hammered during conferences, in the press, through the U.S. Surgeon General’s 1988 report shockingly titled "Nicotine Addiction", until this sophism became dogma. Each and everyone could test their dependence to nicotine, either in popular magazines, through anti-smoking advocacy in schools, or during the demonstrations of World No Tobacco Day on May 31st. The pressure was such that ‘’nicotine replacement’’ products became the standard treatment. It was no longer regarded as ethical to use a simple placebo as a control product in clinical comparisons. The "Test of Dependence to Nicotine" appeared in the "Recommendations of Good Practice " of the AFSSAPS [7] [8]. It is indeed recommended to adapt the nicotine ‘’replacement’’ treatment according to the score of Fagerström. This demonstrates the importance attributed to one’s score on the test, and its link to this type of treatment.

For over 30 years, Fagerström, through his test, was largely instrumental in strengthening the dogma that supports that nicotine is the only substance responsible for the addiction to smoking. The test in itself is without any interest, because two questions would have been sufficient to evaluate one’s addiction to tobacco. A numerical test however, is popular with the public, who enjoys self evaluating tests. But such a test is not without perverse consequences: A low score results in reassuring the smoker who may estimate that he’s not addicted or addicted enough to stop. A high score on the other hand, could discourage him from making quit attempts because the difficulties may appear insurmountable in the face of such strong addiction. In practice, the prognostic for successful stopping is nil. The only real effect of the test is the perfect justification it provides for marketing stronger doses of gum.

This change of heart should normally create the effect of a bomb

To see a tenor of anti-smoking and the nicotine dependence dogma abruptly change his opinion, should normally create the effect of a bomb. However, considering the vested interests at play, one can justifiably doubt that it will. Had it been published earlier, it would have had the effect of nothing more than a wet firecracker. Fagerström could not have possibly ignored the tree that hides the forest, the blatant stifling of essential research on tobacco for the benefit of developing a commercial market, throughout all these years. In reality, he was so much aware of it that in 2003, in an editorial he wrote for the Italian magazine " Tabaccologia " [9], he criticized with the very same words the notion of nicotine dependence. It is relevant to mention that this magazine is hardly referenced, and that its articles are confidential. Faithful to this type of ambiguity, in 2003 he rises against the ban of snus in Europe, a decision that the European Court of justice in 2004 refused to reverse [10].

Conflicts of interest

The conflicts of interest are far from being exclusively financial. Public recognition, glory, invitations to conferences, the writings and adoptions of official positions, one’s own convictions…can get one tangled in a web from which it is difficult to escape. But the support he was getting from the manufacturers of nicotine ‘’replacement’’ treatments, in virtue of his prestige, had become brittle because in 2003 Pharmacia & Upjohn were bought by Pfizer. This firm does not seem to be over enthusiastic for nicotine substitutes, wagering on Chantix® (varenicline) instead, to a point that in 2006 it ceded Nicorette® to Johnson & Johnson. I had very much appreciated Fagerstrom’s stand in favor of snus that he took at the time. It took courage and showed his awareness of the enormous benefits to the health of half of Swedish men who switched from cigarettes to snus. But his position became intolerable considering the competing interests that were involved between his link with Swedish Match  [11], makers of snus, and Big Pharma nicotine substitutes as well as his long past in the anti-smoking fight. It didn’t hold water. This clash of interests was the cause for his resignation from his elected presidency at the SNRT [12] in February, 2004. Moreover, in 2000 he had also established and co-directed Niconovum , a branch of Swedish Match. To make matters worse, in 2009 Niconovum came under the control of the Reynolds Tobacco Company. That was impossible to swallow. The only honorable way out was to retire, to abandon his nicotine dependence test that Pfizer was no longer supporting, and to proclaim himself an ‘’independent consultant’’, with a ‘’No Funding’’ and no conflicts of interest declaration.

Robert MOLIMARD, Emeritus Professor at the Paris-Sud Faculty of Medicine