Abstract
Objective
This study evaluated four of the major scales used to measure nicotine withdrawal symptoms plus one new scale.
Methods
Eighty-three smokers were randomly assigned to continue smoking (n=37) or abstain completely for 24 h (n=46), by which time the symptoms should become manifest. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) withdrawal symptoms (irritability, depression, restlessness, insomnia, anxiety, hunger and poor concentration) plus craving were measured at baseline and after 24 h. The scales tested were the Minnesota Nicotine Withdrawal Scale (MNWS), the Mood and Physical Symptoms Scale (MPSS), the Shiffman Scale (SS), the Wisconsin Smoking Withdrawal Scale (WSWS) and the newly developed Cigarette Withdrawal Scale (CWS).
Results
Measurement of withdrawal symptoms was robust in the case of all scales for total withdrawal score, irritability, restlessness, poor concentration and craving. The MNWS and CWS were less sensitive to depression; the WSWS and MNWS were less sensitive to insomnia; the MPSS was less sensitive to anxiety and hunger; the CWS and WSWS did not include restlessness as a distinct symptom; the SS did not include insomnia, and its scores tended to decline over time during ad lib smoking. Longer scales, using multiple items to measure each symptom, did not yield more reliable or accurate measurement than briefer scales.
Conclusions
To measure total withdrawal discomfort or craving, all of the scales examined can be recommended, and there is little to choose between them apart from length. When it comes to assessing individual symptoms, different scales have different strengths and weaknesses. There would be merits in developing a new questionnaire that combined the best features of the scales tested.
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Appendix: Withdrawal symptom measures and relationship between items and symptom scores
Appendix: Withdrawal symptom measures and relationship between items and symptom scores
Item | DSM-IV symptom plus urge to smoke |
Mood and Physical Symptoms Scale [MPSS; 5-point response scale (not at all, slightly, somewhat, very, extremely)] | |
Irritable | Irritability |
Restless | Restlessness |
Depressed | Depression |
Hungry | Increased appetite |
Poor concentration | Difficulty concentrating |
Anxious | Anxiety |
Poor sleep at night | Insomnia |
Strength of urges of smoke | Urge to smoke |
Time spent with urges to smoke | Urge to smoke |
Minnesota Nicotine Withdrawal Scale [MNWS; 5-point scale (none, slight, mild, moderate, severe)] | |
Angry, irritable, frustrated | Irritability |
Restless, impatient | Restlessness |
Depressed mood, sad | Depression |
Increased appetite, hungry, weight gain | Increased appetite |
Difficulty concentrating | Difficulty concentrating |
Insomnia, sleep problems, awakening at night | Insomnia |
Anxious, nervous | Anxiety |
Desire, craving to smoke | Urge to smoke |
Shiffman Scale | |
10-point scale (low to high) | |
Irritable | Irritability |
Frustrated, angry | Irritability |
Restless | Restlessness |
Depressed | Depression |
Sad | Depression |
Blue | Depression |
Miserable | Depression |
Hungry | Increased appetite |
Eat more | Increased appetite |
Increased appetite | Increased appetite |
Hard to concentrate | Difficulty concentrating |
Mentally sharp (reversed) | Difficulty concentrating |
Anxious | Anxiety |
Tense | Anxiety |
Wisconsin Smoking Withdrawal Scale [WSWS; 5-point scale (strongly disagree, disagree, neutral, agree, strongly agree)] | |
I have been irritable, easily angered | Irritability |
I have been bothered by negative moods such as anger, frustration and irritability | Irritability |
I have felt frustrated | Irritability |
I have felt upbeat and optimistic (reverse) | Depression |
I have felt sad or depressed | Depression |
I have felt hopeless or discouraged | Depression |
I have felt happy and content (reverse) | Depression |
Food is not particularly appealing to me (reverse) | Increased appetite |
I want to nibble on snacks and sweets | Increased appetite |
I have been eating a lot | Increased appetite |
I have felt hungry | Increased appetite |
I think about food a lot | Increased appetite |
My level of concentration is excellent (reverse) | Difficulty concentrating |
It’s hard to pay attention to things | Difficulty concentrating |
It has been difficult to think clearly | Difficulty concentrating |
I am getting restful sleep (reverse) | Insomnia |
I awaken from sleep frequently during the night | Insomnia |
I am satisfied with my sleep (reverse) | Insomnia |
I feel that I am getting enough sleep | Insomnia |
My sleep has been troubled | Insomnia |
I have felt impatient | Anxiety |
I have been tense or anxious | Anxiety |
I have felt myself worrying about my problems | Anxiety |
I have felt calm lately (reverse) | Anxiety |
I have frequent urges to smoke | Urge to smoke |
I have been bothered by the desire to smoke a cigarette | Urge to smoke |
I have thought about smoking a lot | Urge to smoke |
I have trouble getting cigarettes off my mind | Urge to smoke |
Cigarette Withdrawal Scale [CWS; 5-point scale (totally disagree, mostly disagree, more or less agree, mostly agree, totally agree)] | |
I am irritable | Irritability |
I get angry easily | Irritability |
I have no patience | Irritability |
I feel nervous | Irritability |
I feel depressed | Depression |
My morale is low | Depression |
I am eating more than usual | Increased appetite |
My appetite has increased | Increased appetite |
I have put on weight recently | Increased appetite |
I find it difficult to think clearly | Difficulty concentrating |
I find it hard to concentrate | Difficulty concentrating |
I find it hard to focus on the task at hand | Difficulty concentrating |
I have difficulty sleeping | Insomnia |
I have trouble falling asleep at night | Insomnia |
I feel worried | Anxiety |
I feel anxious | Anxiety |
The only thing I can think about is smoking a cigarette | Urge to smoke |
I miss cigarettes terribly | Urge to smoke |
I feel an irresistible need to smoke | Urge to smoke |
I would like to hold a cigarette between my fingers | Urge to smoke |
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West, R., Ussher, M., Evans, M. et al. Assessing DSM-IV nicotine withdrawal symptoms: a comparison and evaluation of five different scales. Psychopharmacology 184, 619–627 (2006). https://doi.org/10.1007/s00213-005-0216-z
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DOI: https://doi.org/10.1007/s00213-005-0216-z