Fagerström Test for Nicotine Dependence

What is the Fagerström test?

The Fagerström Test for Nicotine Dependence (FTND) is a six-item questionnaire that scores physical and behavioral nicotine addiction severity. Heatherton and colleagues published the widely used version in 1991; it remains common in primary care and research. Nicotine dependence reflects brain neuroadaptation. When nicotine levels fall, many smokers experience irritability, craving, poor concentration, and sleep disruption.

Higher FTND scores predict lower odds of unaided quitting and greater benefit from nicotine replacement therapy, varenicline, or combined pharmacotherapy per US Public Health Service guidance. The test takes about one minute and helps clinicians match medication intensity to dependence level.

Scores also correlate with withdrawal severity in placebo arms of quit-intervention studies. Document your score in your medical record photo folder so repeat visits track dependence trends over years. Retake the test after any major change in daily cigarette count.

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The six Fagerström items

Items cover time to the first cigarette after waking (the strongest single predictor), difficulty refraining where smoking is forbidden, which cigarette would be hardest to give up, cigarettes per day, smoking more during the first hours awake, and smoking when ill in bed. Time to first cigarette within five minutes after waking receives the highest weight because it reflects overnight withdrawal and rapid nicotine need.

Answer based on current smoking, not past habits. The calculator applies standard item weights and returns a total score from 0 to 10.

Smoking while ill in bed indicates high dependence because nicotine intake continues despite acute respiratory symptoms. Clinicians use scores to support prior authorization for varenicline or combination nicotine replacement.

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Interpreting Fagerström scores

Scores of 0 to 2 indicate low dependence, 3 to 4 low to moderate, 5 moderate, 6 to 7 high, and 8 to 10 very high dependence.

Scores of 5 or above generally warrant pharmacotherapy. Combination nicotine replacement (patch plus gum or lozenge) often beats a single product in heavier smokers. First cigarette within 30 minutes of waking suggests need for higher patch doses (21 mg versus 14 mg) and longer treatment duration. CDC quitline counselors use dependence scores to recommend patch strength and whether to add gum or lozenge for breakthrough craving.

Re-test after cutting daily cigarettes during a taper. FTND scores can fall as daily count drops, changing medication plans. Retest once daily patterns resume.

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Complete scoring table

Add all six item points for a total from 0 to 10. The original 1991 revision tested 254 smokers and replaced two weak items from the older tolerance questionnaire. Time to first cigarette and cigarettes per day carried much of the association with biochemical exposure. The score orders dependence severity, but adjacent points do not represent equal biological differences.

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Worked example and treatment discussion

| Example response | Points | | --- | --- | | First cigarette 20 minutes after waking | 2 | | Can refrain in prohibited places | 0 | | Morning cigarette hardest to give up | 1 | | Smokes 18 cigarettes per day | 1 | | Smokes more in the morning | 1 | | Does not smoke while ill in bed | 0 | | Total | 5 |

A total of 5 suggests meaningful physical dependence and a higher chance of withdrawal during an unaided attempt, but it does not prescribe a specific drug or dose by itself. A clinician also reviews pregnancy, age, kidney function, seizure history, mental health, other medicines, prior quit attempts, and preference. Counseling and medication together outperform minimal intervention. Combination nicotine replacement or varenicline can be considered for many nonpregnant adults after contraindications and instructions are reviewed.

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Dependence screen versus diagnosis

FTND emphasizes current cigarette quantity and morning smoking. It is not a DSM diagnosis of tobacco use disorder and does not capture every domain, such as persistent desire to quit, time spent obtaining tobacco, social consequences, or continued use despite disease. One comparison found poor agreement between FTND cutoffs and a diagnostic interview, indicating that the tools measure overlapping but different features. A low score therefore does not make smoking safe or exclude a clinically significant disorder.

The instrument was developed for combustible cigarette smokers. It has floor effects among light smokers and lacks validated conversion rules for cigars, smokeless tobacco, heated products, or e-cigarettes. Ask separately about all nicotine sources. Carbon monoxide or cotinine can measure recent exposure in selected settings, but neither replaces a clinical assessment.

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How to use the FTND result

Answer for a typical week before making a quit attempt. Save the six responses, not only the total, because time to first cigarette may predict quitting difficulty better than the sum. Share the result with a clinician or quitline counselor to plan medication, coping strategies, and early follow-up. Nicotine withdrawal often begins within hours, is strongest during the first days, and usually eases over several weeks. A prospective study found measured symptoms returned to baseline within ten days on average, though cravings can recur later. Accurate reporting helps treatment matching.

Set a quit date, remove cigarettes, arrange support, and learn the correct use of any medication. If stopping completely is not yet possible, reduce smoke exposure while arranging evidence-based treatment, but do not treat fewer cigarettes as risk-free. Call emergency services for chest pain, severe breathing difficulty, fainting, or stroke symptoms. Contact a clinician promptly for severe mood change or suicidal thoughts during a quit attempt.

At follow-up, compare each response with the baseline rather than aiming for a particular total. A later first cigarette or lower daily count can show behavior change, while continued smoking during illness may identify a difficult trigger. Treatment success is sustained abstinence, not a lower FTND score while exposure continues. Report nausea, vivid dreams, insomnia, skin reactions, mood changes, or other possible medication effects promptly so the regimen can be adjusted. If a lapse occurs, record its time, setting, and preceding craving. That information can guide the next plan without waiting for dependence to return to the previous level.

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Evidence-based cessation support

Clinical practice guidelines rank varenicline and combination nicotine replacement among the most effective options, with bupropion as an alternative, especially when depression is present. CDC recommends pairing medication with counseling. US quitlines at 1-800-QUIT-NOW provide free coaching. Most successful long-term quitters needed several attempts.

E-cigarettes are not FDA-approved quit aids. Non-smokers and youth should not start nicotine products.

WHO urges governments to ensure access to cessation support. Tobacco remains a leading preventable cause of death worldwide. Combining behavioral support with medication can more than double quit rates at six months compared with unaided attempts in clinical trials summarized by US Public Health Service guidelines. Set a quit date within two weeks of starting medication so you can pre-load nicotine replacement if your clinician recommends it.

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Limitations

The FTND was validated mainly for daily cigarette smokers. It is less reliable for intermittent or social smokers and non-cigarette tobacco.

Dependence score is one input. Stress, alcohol, mood disorders, and household smoking also drive relapse risk. A high score supports treatment but does not replace medical evaluation for cardiovascular or lung disease. Pregnant smokers and adolescents may need tailored cessation programs even when FTND scores are moderate.

Scores can change after hospitalization or illness that temporarily reduces smoking, so retest once daily patterns resume before choosing maintenance pharmacotherapy doses. Self-report can also shift when smoke-free rules, work schedules, cost, or family responsibilities constrain access. A low total during hospitalization may not describe the home pattern. FTND does not measure motivation to quit, confidence, household exposure, depression, alcohol triggers, or practical barriers to obtaining medication. Those factors can matter more than one point on the scale. Do not postpone cessation help while trying to obtain a stable score. Record the context, offer treatment to every person who wants it, and reassess medication response and adverse effects after the quit date rather than assuming the baseline category predicts the full course.

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How it works

Total score 0 to 10. 0 to 2 low, 3 to 4 low-moderate, 5 moderate, 6 to 7 high, 8 to 10 very high dependence.

Frequently asked questions

• What Fagerström score needs medication?Scores ≥5 often benefit from nicotine replacement or varenicline alongside behavioral support.

Related calculators

References

1. Heatherton et al.. The Fagerström Test for Nicotine Dependence
2. Muscat et al.. Time to first cigarette and dependence severity
3. USDHHS. Treating Tobacco Use and Dependence (Clinical Practice Guideline)
4. Si et al.. Combination nicotine replacement therapy
5. CDC. Smoking cessation and cardiovascular benefit
6. US Surgeon General. FTND questions, answers, and scoring
7. Haddock et al.. Psychometric and predictive properties of the FTND
8. USPSTF. Tobacco Smoking Cessation in Adults: Interventions
9. Moolchan et al.. FTND and diagnostic interview comparison
10. Shiffman et al.. Natural history of nicotine withdrawal