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An examination of the Fagerstrom test for nicotine dependence among concurrent tobacco and khat users.

The Fagerstrom Test for Nicotine Dependence (FTND; Heatherton et al. 1991) is a six-item instrument, ranging from 0 (least dependent) and 10 (most dependent), to assess levels of nicotine dependence (Piper, McCarthy & Baker 2006). Although the scale is widely adopted in research as well as clinical settings, reports examining its psychometric properties have shown moderate reliability and validity (de Meneses-Gaya et al. 2009b; Piper, McCarthy & Baker 2006). This limitation may be pronounced in FTND tested in different countries. For example, Indian (.57; Jhanjee & Sethi 2010) and Turkish (.56; Uysal et al. 2004) versions were found to have poor internal consistency, suggesting a need for more cross-national research into the feasibility of FTND. The current study was therefore designed to develop and examine an Arabic version of the scale.

In the Middle East, including Yemen, cigarette smoking often occurs while an individual is using khat (Catha edulis). Khat is a widely used substance in East Africa, Yemen, and among immigrant communities around the world. It is consumed by chewing leaves of the evergreen shrub that grows in these areas (Cox & Rampes 2003). More than 70% of men and 30% of women in Yemen are daily khat users (World Bank 2007) and up to 62% of khat chewers smoke cigarettes in Middle Eastern countries (al'Absi & Grabowski 2011; Hoffman & al'Absi 2010; Tesfaye et al. 2006), suggesting the wide prevalence of concurrent use. However, patterns of tobacco use among smokers who also use khat are largely unknown. Thus, we examined the reliability and validity of FTND among concurrent users of tobacco and khat in Yemen.

We also sought to explore gender differences in patterns of tobacco use. In Middle Eastern countries cigarette smoking is culturally more acceptable for men than for women, and men consume more cigarettes than women (Maziak 2002). Because smoking has been historically considered to be a problem for men, very few attempts have been made to investigate patterns of cigarette consumption among women (Maziak, Asfar & Mock 2003). To our best knowledge, the present study was the first to investigate sex differences in patterns of nicotine intake among smokers who also use khat.



Participants were recruited in two sites, Taiz University and Sana'a University, Yemen, by flyers posted around the campus and in the community between 2007 and 2011. To be included in the study, participants needed to be generally healthy, not on any prescribed medications, and to have completed at least a high school education level (Bongard et al. 2011). They were also required to be concurrent users of tobacco and khat. Screened participants read and signed a consent form approved by the research ethical committee at Taiz University or Sana'a University. A total of 103 (38 women) participants completed the study. The majority of them were college students. Sixty percent of them consumed khat regularly and 25% chewed it occasionally. The age (mean [+ or -] standard deviation) of the sample was 24.4 [+ or -] 5.2 with a range from 18 to 40 years.

Measures and Data Analysis

An Arabic version of FTND was developed for the current study. The original English version of the scale was translated into Arabic and was back-translated into English. Descriptive statistics for each response item were calculated for the entire sample. Chronbach's alpha was used to examine the internal consistency of the scale. Principal component analysis was conducted to examine the factor structure of FTND in light of findings that the instrument has two subcomponents; one dimension is associated with patterns of smoking during the day and the other reflects smoking patterns in the morning after nighttime abstinence (Richardson & Ratner 2005; Chabrol et al 2003; Radzius et al. 2003). Promax with Kaiser Normalization was used for the rotation method as it has been shown to have better loading structures than the Varimax method solutions (Radzius et al. 2003). Kaiser-Meyer-Olkin (KMO) measure was calculated to test the sampling adequacy of the analysis. Eigenvalues greater than one were regarded as identifying a factor, and a factor loading of .35 was employed as the a priori criterion for an item to be included in a factor. To explore gender differences, a series of chi-square analyses were conducted on FTND items.


Male and female concurrent users were comparable regarding age (mean [+ or -] SEM; men: 24.0 [+ or -] 0.6; women: 25.0[+ or -] 0.8). Descriptive statistics found that 38% of the sample smoked more than ten cigarettes per day. They tended to smoke during the day rather than in the morning and many reported not having difficulties in refraining from smoking (see Table 1). Less than 10% said that the last thing they would give up is the first cigarette in the morning. Internal consistency reliability was .58 and item-total correlations with total scores ranged from .26 to .52 (ps < .01).

For the principal component analysis, the KMO index of .67 indicates that the sample was acceptable for the analysis. Eigenvalues (greater than one) identified two factors, accounting for 56.8 % of the variance (36.0% for factor 1 and 20.8% for factor 2; see Table 1). Factor 1 included three items: "Do you find it difficult to refrain from smoking in a place where it is forbidden?"; "How many cigarettes do you smoke?" and "Do you smoke even if you are so ill that you are in bed most of the day?" Factor 2 consisted of the items: "How soon after you wake up do you smoke your first cigarette?"; "Which cigarette do you hate most to give up?" and "Do you smoke more frequently during the first hours after waking than the rest of the day?" Internal consistency for factor 1 and factor 2 were .52 and .44, respectively. The correlation between the two factors was .27.

Chi-square analysis examining gender differences in responses to FTND items found that men smoked more cigarettes than women (p < .001; see Table 2). In addition, as compared with women, men smoked their first cigarette sooner after they woke up, had more difficulty refraining from smoking, and did not want to give up the first cigarette in the morning (ps < .05). FTND total scores were higher for men (mean [+ or -] SEM; 2.88 [+ or -] 0.2) than women (0.79 [+ or -] 0.3; F (1, 101) = 32.8, p < .001).


The current study was among the first to examine psychometrics of FTND among daily smokers who also use khat. Internal consistency of the scale (Chronbach's [alpha] =.58) was very similar to that found among smokers in India (.57; Jhanjee & Sethi 2010) and Turkey (.56; Uysal et al. 2004); however, it was lower than that of other studies (de Meneses-Gaya et al. 2009a; also see Piper, McCarthy & Baker 2006 for a review). The finding of two-factor structure is consistent with previous work (Richardson & Ratner 2005; Chabrol et al. 2003; Radzius et al. 2003). The amount of variance accounted for (57%) suggests that the two-factor solution may be adequate to assess nicotine dependence in this population. We also found that men consume more cigarettes and showed greater indications of nicotine dependence than women, which is consistent with previous research conducted in other Middle Eastern countries (Maziak 2002). Although modest reliability calls for a cautious interpretation, the results on factor structure and gender differences provides initial support that FTND may be useful in assessing patterns of nicotine intake among smokers who also consume khat in Yemen.

The internal consistency of FTND in the present sample was low, but consistent with results obtained in other countries with comparable sample size. However, it is worth noting that this sample of concurrent tobacco and khat users included a large proportion of college students and half of the sample reported that they smoked less than ten cigarettes per day. Women also reported very low FTND scores. One study (Okuyemi et al. 2007) using light smokers found a modest reliability (.63) of the scale. It is possible that sample characteristics of the present study were not reported by highly dependent smokers, which might have confounded the results.

In Yemen, people often smoke cigarettes while they use khat. The users often gather in the afternoon and chew khat for several hours. It is therefore possible that concurrent users smoke cigarettes primarily in the afternoon. In addition, social tradition has a greater influence on smoking patterns among women than men in Middle Eastern countries (Maziak 2002). Women tend to avoid smoking cigarettes in public or during the daytime because it is considered socially unacceptable. These factors may influence responses on the FTND, especially items related to patterns of nicotine intake in the morning hours. Moreover, female smokers tend to hesitate to disclose or underestimate their smoking behavior (Maziak 2002), potentially producing confounds in the results. Taken together, more research is clearly needed to elucidate cultural and contextual determinants of tobacco consumption to target those who are addicted to nicotine.

The results of the current study are limited by a small sample size. A larger sample with equal numbers of men and women smokers may enhance the generalizability of the findings. We note, however, that the sample in this study consisted of smokers from two different cities in Yemen, adding strength with respect to representation of the sample. As mentioned, this study did not directly examine the role of other drugs, such as khat, in patterns of cigarette use. Nevertheless, to our best knowledge, this report was the first to examine psychometric properties of an Arabic version of FTND among concurrent tobacco and khat users. It also explored gender differences in symptoms associated with nicotine dependence in this population.

In summary, while FTND demonstrated only a modest internal consistency among smokers who use khat in Yemen, the two-factor solution suggested by the previous studies was confirmed. In addition, male smokers reported greater symptoms of nicotine dependence than female smokers. Sample characteristics, cultural influences, and the concurrent use of khat may influence patterns and manifestations of nicotine dependence, and accounting for these factors should improve the usefulness of FTND in this population.

DOI: 10.1080/02791072.2012.737224


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Motohiro Nakajima, Ph.D. (a) Mustafa al'Absi, Ph.D. (b) Anisa Dokam, Ph.D. (c) Mohammed Alsoofi, Ph.D. (d) Najat Sayem Khalil, Ph.D. (e)

The Khat Research Program (KRP) was supported by a FIRCA grant from the National Institutes of Health/Fogarty International Center (R03TW007219), an R21 National Institute for Drug Abuse grant (DA024626), and a grant from the Office of International Programs at the University of Minnesota. The authors do not have any conflict of interest regarding this manuscript. They thank Dr. Abed Naji Kasim for his help in coordinating the program and Basma Ali Thabe, and Khaled Al-Sahmiry for help with data collection.

(a) Assistant Professor, University of Minnesota Medical School, Duluth, MN.

(b) Professor, University of Minnesota Medical School, Duluth, MN.

(c) Assistant Professor, Taiz University, Taiz, Yemen.

(d) Professor, Taiz University, Taiz, Yemen.

(e) Associate Professor, Sana'a University, Sana'a, Yemen.

Please address correspondence to Mustafa al'Absi, Ph.D., Khat Research Program (KRP), University of Minnesota Medical School, 1035 University Drive, Duluth, MN 55812; phone: +1 218 726 7144; fax: + 1 218 726 7559; email:
Frequency of Responses, Internal Consistency, and Factor
Structures of FTND in Yemeni Sample (N = 103)

                                          %of        Mean
Item                   Options            Response   (SD)

How soon after you     Within 5 minutes   11.7       0.90
wake up do you smoke   6-30 minutes       17.5       (1.07)
your first             31-60 minutes      20.4
cigarette?             After 60 minutes   50.5

Do you find it         Yes                40.8       0.41
difficult to refrain   No                 59.2       (0.49)
from smoking in a
place where it is

Which cigarette do     The first one in   8.7        0.09
you hate most to       the morning                   (0.29)
give up?               All others         91.3

How many cigarettes    10 or less         62.1       0.47
do you smoke?          11-20              33.0       (0.71)
                       21-30              1.0
                       31 or more         3.9

Do you smoke more      Yes                13.6       0.14
frequently during      No                 86.4       (0.34)
the first hours
after waking than
the rest of the day?

Do you smoke even if   Yes                10.7       0.11
you are so ill that    No                 89.3       (0.31)
you are in bed most
of the day?

                       Item-Total    if Item
                       Correlation   Deleted   Factor Loading (c)
Item                   (a)           (b)       1          2

How soon after you     .46           .51       .21        71 (e)
wake up do you smoke
your first

Do you find it         .52           .46       .74 (d)    .21
difficult to refrain
from smoking in a
place where it is

Which cigarette do     .28           .56       -.31       .85 (e)
you hate most to
give up?

How many cigarettes    .29           .55       .77d (d)   -.12
do you smoke?

Do you smoke more      .38           .53       .13        .66 (e)
frequently during
the first hours
after waking than
the rest of the day?

Do you smoke even if   .26           .56       .63 (d)     -.05
you are so ill that
you are in bed most
of the day?

(a) Item-to-total correlations were all significant atp <.01.
(b) Chronbach's a for the scale was .58; (c) Two factors accounted
for 56.8% of the total variance.
(d) Items that constituted Factor 1; (e) Items that constituted
Factor 2.

Differences in Correspondence (%) of Six FTND Items Between
Male and Female Smokers Who also Use Khat

                               Men       Women
                             (n = 65)   (n = 38)    [chi square]

Time to First Cigarette                                42.3 **

Within Five Minutes            16.9       2.6

6-30 Minutes                   24.6       5.3

31-60 Minutes                  32.3        0

After 60 Minutes               26.2       92.1

Able to Refrain from           55.4       15.8         15.6 **

Hate Most to Give up First     14.8        0           6.01 *

Number of Cigarettes                                   26.9 **
per Day

10 or Less                     47.7       86.8

11-20                          50.8       2.6

21-30                           0         2.6

31 or More                     1.5        7.9

Smoke in the Morning           18.5       5.3      3.56 ([dagger])

Smoke if Sick                  12.3       7.9           0.49

([dagger]) p = .06. * p < .05. ** p < .001.
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Article Details
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Title Annotation:Short Communication
Author:Nakajima, Motohiro; al'Absi, Mustafa; Dokam, Anisa; Alsoofi, Mohammed; Khalil, Najat Sayem
Publication:Journal of Psychoactive Drugs
Article Type:Report
Geographic Code:7YEME
Date:Dec 1, 2012
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