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J Psychoactive Drugs. Author manuscript; available in PMC 2013 November 01.
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J Psychoactive Drugs. 2012 ; 44(5): 437441.

AN EXAMINATION OF THE FAGERSTRM TEST FOR NICOTINE

DEPENDENCE AMONG CONCURRENT TOBACCO AND KHAT
USERS
Motohiro Nakajima, Ph.D.a [Assistant Professor], Mustafa alAbsi, Ph.D.b [Professor],
Anisa Dokam, Ph.D.c [Assistant Professor], Mohammed Alsoofi, Ph.D.d [Professor], and
Najat Sayem Khalil, Ph.D.e [Associate Professor]
aUniversity of Minnesota Medical School, Duluth, MN

bUniversity of Minnesota Medical School, Duluth, MN

cTaiz University, Taiz, Yemen
dTaiz University, Taiz, Yemen
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eSanaa University, Sanaa, Yemen

Abstract
The current study examined the psychometric properties of the Fagerstrm Test for Nicotine
Dependence (FTND) among tobacco smokers who use khat (Catha edulis), a widely used
substance in East Africa and Arabian Peninsula. We also explored gender differences in response
to FTND items because little attention has been paid to womens smoking behavior in Middle
Eastern societies. A total of 103 (38 women) concurrent users (mean age SD: 24.4 5.2) were
recruited from two universities in Yemen. An Arabic version of FTND was developed using back-
translation method. Chronbachs alpha was used to examine the reliability and principal
component analysis was conducted to test the factor structure of the scale. The scale was found to
have low internal consistency reliability (Chronbachs = .58). Two factors were identified,
accounting for 57% of the total variance. A series of chi-square analyses found that men indicated
more symptoms associated with nicotine dependence than women (ps < .05). Although the poor
reliability observed in the present sample argues for a cautious approach when assessing nicotine
dependence among khat users, the findings on factor structure and gender differences may provide
support for the validity of the scale. Taking into account sociocultural factors associated with
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patterns of smoking behavior among this population should improve the psychometric properties
of FTND.

Keywords
FTND; gender difference; khat use; psychometrics; smoking

The Fagerstrm 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

Please address correspondence to Mustafa alAbsi, 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;malabsi@umn.edu.
The authors do not have any conflict of interest regarding this manuscript.
 Nakajima et al. Page 2

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
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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 (Al-Hebshi & Skaug 2005). More than 70% of
men and 30% of women in Yemen are daily khat users (World Bank 2007) and up to 65% of
khat chewers smoke cigarettes in Middle Eastern countries (Hoffman & alAbsi 2010),
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
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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.

METHOD
Participants
Participants were recruited in two sites, Taiz University and Sanaa 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 Sanaa 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 standard deviation) of the
sample was 24.4 5.2 with a range from 18 to 40 years.
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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.
Chronbachs 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

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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.
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RESULTS
Male and female concurrent users were comparable regarding age (mean SEM; men: 24.0
0.6; women: 25.0 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
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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 SEM; 2.88 0.2) than women (0.79
0.3; F (1, 101) = 32.8, p < .001).

DISCUSSION
The current study was among the first to examine psychometrics of FTND among daily
smokers who also use khat. Internal consistency of the scale (Chronbachs =.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
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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.

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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
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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,
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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.

Acknowledgments
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. 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.
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TABLE 1
Frequency of Responses, Internal Consistency, and Factor Structures of FTND in Yemeni Sample (N = 103)

Item Options % of Response Item-Total Alpha if Item c

Mean Factor Loading
(SD) a b
Correlation Deleted 1 2
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How soon after you wake up do you smoke 0.90 e

Within 5 minutes 11.7 .46 .51 .21 .71
your first cigarette? (1.07)
6-30 minutes 17.5
31-60 minutes 20.4
After 60 minutes 50.5
Do you find it difficult to refrain from 0.41 d
Yes 40.8 .52 .46 .74 .21
smoking in a place where it is forbidden? (0.49)
No 59.2
0.09 e
Which cigarette do you hate most to give up? The first one in the morning 8.7 .28 .56 .31 .85
(0.29)
All others 91.3
0.47 d
How many cigarettes do you smoke? 10 or less 62.1 .29 .55 .77 .12
(0.71)
11-20 33.0
21-30 1.0
31 or more 3.9
Do you smoke more frequently during the
0.14 e
first hours after waking than the rest of the Yes 13.6 .38 .53 .13 .66
(0.34)
day?
No 86.4
Do you smoke even if you are so ill that you 0.11 d
Yes 10.7 .26 .56 .63 .05
are in bed most of the day? (0.31)
No 89.3

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a
Item-to-total correlations were all significant at p <.01.
b
Chronbachs 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.
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TABLE 2
Differences in Correspondence (%) of Six FTND Items Between Male and Female
Smokers Who also Use Khat
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Men (n = 65) Women (n = 38) 2

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 Smoking 55.4 15.8 15.6**

Hate Most to Give up First Cigarette 14.8 0 6.01*

Number of Cigarettes per Day 26.9**

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
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Smoke in the Morning 18.5 5.3 3.56

Smoke if Sick 12.3 7.9 0.49

p = .06.
*
p < .05.
**
p < .001.
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