Exploring Measurement Issues: Sex, Gender and Diversity Analyses of Tobacco Use Instruments

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Exploring Measurement Issues Sex, Gender and
Diversity Analyses of Tobacco Use Instruments

• Lindsay Richardson, Lorraine Greaves, Natasha
  Jategaonkar, Ann Pederson, Ethel Tungohan,
  Kirsten Bell

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History of the Fagerstrom Instruments

• The Fagerstrom Tolerance Questionnaire (FTQ) was
  developed and validated by Karl Fagerstrom in
  1978
• Eight question survey
• Has spawned several modified versions including
  the Fagerstrom Test for Nicotine Dependence

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Fagerstrom Test for Nicotine Dependence

• The FTND was developed and validated by reducing
  the FTQ to six questions (Heatherton, 1991)
• Although the FTND appears to be a valid tool for
  various sub-populations, many studies have failed
  to sex-disaggregate their results
• Sex and gender influence tobacco use and
  dependency (McLellan, Kaufman, 2006 Greaves,
  Jategaonkar, Sanchez, 2006).

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FTND Questionnaire

• How soon after you wake up do you smoke your
  first cigarette?
• Do you find it difficult to refrain from smoking
  in places where it is forbidden?
• Which cigarette would you hate most to give up?
• How many cigarettes per day do you smoke?
• Do you smoke more frequently during the first
  hours after awakening than during the rest of the
  day?
• Do you smoke even if you are so ill that you are
  in bed most of the day?

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Purpose

• The purpose of this paper is to conduct a sex and
  gender analysis (SGBA) of the Fagerstrom Test for
  Nicotine Dependence (FTND) to explore potential
  biases within the instruments, provide
  recommendations regarding the interpretation of
  data collected using them, and improve future
  versions.

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Sex and Gender Analysis

• Is an approach to research and evaluation which
  systematically inquires about biological
  (sex-based) and sociocultural (gender-based)
  differences between women and men, boys and
  girls, without presuming the nature of any
  differences that may exist. (Spitzer, 2006)
• Using such an approach helps to reduce bias
  throughout the research process and can further
  our understanding of how sex and gender influence
  tobacco dependence (Health Canada, 2003)

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Methods

• Literature Search examined sex and gender
  differences in nicotine dependence
• Literature selection was based on articles that
  would specifically support and highlight the
  impact of sex and gender on nicotine dependence.
• Analysis was based on 65 articles

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Sex Differences

• Due to underlying sex differences in lung anatomy
  and physiology, women experience different
  development of lung disease than men (Mennecier,
  Lebitasy, Moreau, Hedelin, Purohit, Galichet, et
  al., 2003).
• Consuming the same number of cigarettes produces
  higher relative risk for cardiovascular disease
  development among women than men (Mustonen et
  al., 2005).
• Females metabolize nicotine and cotinine faster
  than males (Benowitz et al., 2006).

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Sex Differences and FTND

• Sex-differences raise questions about whether the
  measure How many cigarettes a day do you smoke?
  (FTND Q4), is an effective markers of dependence
  in women in comparison to men.
• Although females tend to smoke fewer cigarettes
  than males per day they may nevertheless be
  heavily nicotine dependent despite achieving
  low dependency scores on the FTND.

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Genetic Differences in Nicotine Metabolism

• Growing evidence of genetic differences in the
  metabolism of nicotine across diverse populations
  (Mustonen et al., 2005 Daza, Cofta-Woerpel,
  Mazas, Fouladi, Cinciprini, Gritz, et al., 2006
  Henningfield, 1990 Berlin et al., 2003).
• African Americans metabolize nicotine more slowly
  than Whites, blood nicotine levels among African
  Americans may therefore be relatively equivalent
  to Whites, despite smoking fewer cigarettes per
  day on average (Mustonen et al., 2005 Daza et
  al., 2006).
• African Americans are more likely to smoke
  menthol cigarettes, which produce a cooling
  effect that can alter inhalation patterns and
  lead to greater smoke/nicotine dependence
  (Mustonen et al., 2005 Daza et al., 2006).

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Genetic Differences in Nicotine Metabolism
Continued

• African American smokers tend to smoke more of
  each cigarette and longer cigarettes, despite
  smoking fewer total millimeters of cigarettes per
  day (Clark, Gautam, Hlaing, and Gerson, 1996).
• Questions regarding the number of cigarettes
  smoked per day (e.g., FTQ Q4, FTND Q4) may not
  accurately reflect dependence because of subtle
  genetic and/or social factors such as a
  preference for different types of cigarettes
  (Mustonen et al., 2005 Daza et al., 2006 Clark
  et al., 1996).

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Gender Differences Work Roles Smoking Patterns

• Gendered roles and responsibilities have an
  impact on when they smoke, how often they smoke
  and where they smoke.
• Gendered work roles and responsibilities may also
  influence which cigarette of the day is most
  satisfying (FTND Q3), how soon after wakening the
  first cigarette is smoked, or when more
  cigarettes are smoked (FTND Q5).

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Gender Differences Reasons for Smoking

• Traditional gender roles create expectations
  about gender-appropriate behavior which can
  influence smoking uptake, maintenance and
  cessation (Waldron, 2006 Etter, Prokhorov, and
  Perneger, 2002).
• Gender differences in smoking patterns carry on
  into adulthood.
• Gendered differences in tobacco use have
  implications for questions outlined by the FTND
  (Example FTND Q4)

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Diversity and FTND

• Occupation and socio-economic status (SES) also
  likely influence smoking patterns.
• White-collar workers are more likely to work in
  settings that have smoking restrictions than
  blue-collar workers (Emmons et al., 2000).
• This could influence the number of cigarettes
  smoked per day (FTND Q4) and when the majority of
  cigarettes are smoked (FTND Q5).

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Diversity and FTND Continued

• Class bias present in FTND Q2 Do you find it
  difficult to refrain from smoking in places where
  it is forbidden, such as the library, theatre, or
  doctors' office?
• Access to the cultural capital is often
  class-based (Black, 2003 Prior, 2005 Bourdieu,
  2002).
• The bias of this FTND question undermines its
  validity

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Measurement Issues and Other Tobacco Use
Instruments

• Improving health surveillance in Canada is a
  vital aspect of upgrading the countrys overall
  health infrastructure (Umphrey, Kendall,
  MacNeill, 2001).
• Health surveillance systems present
  population-based data for a wide range of health
  outcomes by providing demographic portraits of
  health, a means to detect temporal changes in
  health factors, and information on associations
  between variables (Umphrey et al., 2001).
• Findings from national surveys are widely used to
  guide the development of health policies and
  programs.

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Measurement Issues and Other Tobacco Use
Instruments Continued

• Findings from this analysis raise questions about
  the utility of other tobacco use instruments such
  as the Canadian Tobacco Monitoring Survey (CTUMS)
  
• How might sex, gender and diversity, influence
  responses to questions outlined by surveillance
  instruments?
• How might issues of sex, gender and diversity be
  taken into account in the interpretation of data
  collected from surveillance instruments?
• How might elements of gender and diversity impact
  participation in surveys?
• How can questions on surveillance instruments be
  revised to provide a more accurate survey of
  tobacco use in Canada amongst all populations?

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Discussion

• A fundamental problem with the FTND is that it
  fails to consider the variety of factors which
  influence nicotine dependence.
• In light of the expanding evidence acknowledging
  the variety of factors which influence nicotine
  dependence, sophisticated multi-dimensional
  instruments are being created.

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Discussion Continued

• Failing to consider how sex and gender influence
  respondents answers to tobacco use
  questionnaires has serious implications for the
  diagnosis and treatment of nicotine dependence.  
• It is essential that other tobacco use
  instruments consider the impact of sex, gender
  and diversity to ensure that their findings are
  relevant to all populations.

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Recommendations

• Further research is needed to examine the
  intersections of nicotine dependence since
  accurately assessing dependence is integral to
  effective treatment
• It is vital that self report measures of nicotine
  dependence and other tobacco use instruments be
  made sensitive to the distinct biological and
  social experiences of women and men
• Important that health care professional and
  individuals who administer these tests and
  interpret their results are aware of the
  limitations of existing instruments.

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Journal of Smoking Cessation

• Please look for an upcoming article based on this
  presentation
• Lindsay Richardson Lorraine Greaves Natasha
  Jategaonkar Kirsten Bell Ann Pederson Ethel
  Tungohan. (in press). Rethinking an Assessment of
  Nicotine Dependence A Sex, Gender and Diversity
  Evaluation of the Fagerstrom Test for Nicotine
  Dependence. Journal of Smoking Cessation.

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Questions?

• British Columbia Centre of Excellence for Womens
  Health (www.bccewh.bc.ca)
• Lindsay Richardson
• Tobacco Research Coordinator
• lrichardson_at_cw.bc.ca

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Acknowledgements

• Funded by the Canadian Institute for Health
  Research ICEBERGS project
• The British Columbia Centre of Excellence of
  Women's Health and its activities and products
  have been made possible through a financial
  contribution from Health Canada