Abstract
Introduction
Impaired illness awareness or the inability to recognize that one has a dependence on nicotine may be a major barrier to seeking cessation treatment. To better understand the role of impaired illness awareness on treatment-seeking behavior and clinical outcomes, we developed and examined the psychometric properties of a novel scale measuring illness awareness in individuals with dependence on nicotine.
Aims and Methods
We developed the Nicotine Use Awareness and Insight Scale (NAS), a 7-item self-report measure to assess the theoretical construct of illness awareness in individuals with dependence on nicotine (www.illnessawarenessscales.com). Data from participants 18 years of age or older were collected via a web-based survey company, Dynata. Participants with moderate dependence on nicotine were included, defined by a score of four or more on the Fagerström Test for Cigarette Dependence (FTCD) or the FTCD adapted for electronic cigarettes (eFTCD).
Results
A total of 100 participants (mean [SD] age = 49.1 [16.1] years, 52% women) that met the inclusion criteria for either FTCD (n = 50) or eFTCD (n = 50) were included. The NAS demonstrated good convergent (r = .74, p < .001) and discriminant validity (r = .03, p = .786). It also demonstrated good internal consistency (Cronbach’s alpha = 0.78) and one-month test-retest reliability (intra-class correlation = 0.86). An exploratory factor analysis yielded the retention of two components.
Conclusions
The NAS is a novel scale to asses illness awareness in individuals with dependence on nicotine. This study provides initial support for the psychometric validity and reliability of NAS.
Implications
The NAS may be used in research and clinical practice to evaluate the impact of impaired illness awareness on treatment-seeking behavior and clinical outcomes.
Introduction
Impaired illness awareness or the inability to recognize that one has a dependence on nicotine may be one of the major barriers to seeking cessation treatment.1–4 Cigarette smoking raises the risk for chronic respiratory disease, atherosclerosis, and type II diabetes, while electronic cigarettes (e-cigarettes) are an emerging addiction in adolescents and younger adults with associated negative effects on lung health.5–10
Impaired illness awareness is widespread among nicotine users. Individuals with impaired illness awareness may minimize the health risks of nicotine use, making it more difficult for individuals to quit.3,11,12 On the other hand, illness recognition and awareness of the negative health consequences of nicotine use are associated with proactive changes in behavior, such as self-motivated cessation efforts.3,13 Interventions that aim to improve illness awareness, especially in individuals at high risk of becoming heavy nicotine users, may facilitate early initiation and engagement in cessation treatment.2,3,12
Despite its clinical implications, illness awareness in individuals with nicotine dependence remains poorly conceptualized. The term illness awareness in this study refers to one’s subjective awareness or acceptance of having a problem with nicotine use rather than one’s general knowledge about nicotine and its health consequences. Illness awareness can be conceptualized as a construct that consists of the following core domains: (1) general awareness of having a problem with nicotine use, (2) accurate attribution of symptoms of nicotine dependence, intoxication, and withdrawal to nicotine use, (3) awareness that one needs treatment for nicotine cessation, and (4) awareness of the negative health consequences of nicotine use. This four-domain structure of illness awareness is well-recognized in other psychiatric and medical disorders where impaired illness awareness commonly occurs14–20 and provides a framework for studying illness awareness in other conditions, such as nicotine dependence.
To better understand the role of impaired illness awareness in individuals with nicotine dependence on seeking nicotine cessation treatment, there is a need for a validated scale to assess this construct. Currently available scales for nicotine dependence were not designed to assess illness awareness and its four theoreotical domains. For instance, the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) Recognition subscale predominantly measures general awareness, or the degree in which the individual acknowledges that they have dependence on nicotine.21,22 The Smoking Consequences Questionnaire measures awareness of the negative consequences associated with smoking, but not any of the other domains.23 The aim of this study was to develop a psychometrically valid and reliable instrument, the Nicotine Use Awareness and Insight Scale (NAS) to assess illness awareness and its core domains in adults with dependence on nicotine. The NAS was developed for both clinical and research applications and we, therefore, prioritized a brief, temporally sensitive measure to detect changes in illness awareness. We hypothesized that the NAS would demonstrate good psychometric properties, including good convergent and discriminant validity with measures of illness recognition and affect states, respectively, internal consistency, and test-retest reliability. Although the NAS was developed based on a four-domain model, we hypothesized a one-factor structure as only a few items were included per domain, making a multidimensional structure less likely.18,19
Methods
Scale Development and Validation
The NAS can be found online at the following link: www.illnessawarenessscales.com. The development of NAS was guided by earlier studies evaluating awareness of nicotine dependence (i.e., tobacco and e-cigarette products) and validated scales measuring illness awareness in other medical conditions.18–21,24,26 Eight items were initially created and were distributed across four subscales: two items for General Illness Awareness, two items for Symptom Attribution, three items for Awareness of Need for Treatment, and one item for Awareness of Negative Consequences. However, one of the Symptom Attribution items was removed due to issues with face validity and internal consistency in prior analyses of other illness awareness measures.18,19 A 10-point-Likert scale was utilized to evaluate each item, ranging from “0 = Strongly Disagree” to “10 = Strongly Agree.” Items 4 and 5 were negatively keyed. An average was derived for each of the four subscales, along with a total average score. A higher score is reflective of greater illness awareness. Professionals at the Centre for Addiction and Mental Health assessed the scale items. The team consisted of addiction specialists and those who have worked with individuals with nicotine dependence, comprising a psychologist and physicians, including psychiatrists.
Data Collection and Inclusion Criteria
A total of 100 participants aged 18 years or older from English-speaking regions of Canada were included. Participants were recruited from a large online research panel via a web-based survey company, Dynata. Participants were able to take the survey by accessing an invitation link that was distributed via email by Dynata or by directly accessing the company’s survey platform. Before taking the survey, all the participants were informed about the objective of the study, along with the estimated duration of the survey (i.e., approximately 15 min). Each participant only took the survey once, as ensured through IP addresses and digital fingerprints. At the end of the survey, all participants were given panel credit points that can be redeemed as coupons. The study was approved by the Centre of Addiction and Mental Health’s Research Ethics Board. Additional information about the survey design, recruitment process, and survey response rates can be found in Supplementary Material 1.
Participants with moderate dependence on nicotine were included as defined by a score of 4 or more on either the Fagerström Test for Cigarette Dependence (FTCD)27,28 or the FTCD adapted for e-cigarette use (eFTCD).29 The FTCD is a common tool to assess the severity of nicotine dependence in cigarette users. The scale includes 6 items that measure the quantity of cigarette use, the compulsion to use, along with dependence.27 The items are summed to derive a total score ranging from 0 to 10, with a higher score representing greater dependence on nicotine.27
A total of 100 participants that met the inclusion criteria for either FTCD (n = 50) or eFTCD (n = 50) were included. From this point forward, these participants will be referred to as participants with dependence on tobacco and on e-cigarettes, respectively.
Participants were asked to read a brief information sheet on nicotine dependence, its core symptoms, health consequences, and available intervention strategies prior to completing the NAS. This was done to ensure that the NAS was assessing subjective addiction awareness and the participant’s level of acceptance of their condition rather than the participant’s degree of knowledge about the condition.
Demographic and Clinical Variables
Participants provided their demographic and clinical information, consisting of their level of education, medical history, and substance use amount and frequency. Participants also completed the following questionnaires: The SOCRATES, adapted for nicotine use21,22 and the Positive and Negative Affect Schedule (PANAS).30 The SOCRATES consists of 19 items designed to assess states of readiness to change in substance users. The scale includes three subscales: “Recognition,” “Ambivalence,” and “Taking Steps.” For the purposes of this study, the SOCRATES was modified to specifically measure motivation for nicotine cessation.21,22 The PANAS is a valid and reliable method to assess positive and negative emotions in nonclinical adult samples.30
Statistical analyses were conducted using SPSS statistical software version 26.0 (Armonk, NY). Descriptive analyses were conducted and Pearson correlation analyses were performed to examine the association between illness awareness (i.e., NAS), age, education, and illness severity (i.e., FTCD/eFTCD). For exploratory purposes, we also compared the demographic and clinical characteristics, including the level of illness awareness among participants that used tobacco only, e-cigarettes only, and dual users.
Validity
The SOCRATES Recognition subscale was used to evaluate convergent validity. The Recognition subscale measures the degree to which participants acknowledge that they have a problem with nicotine use. The PANAS was used to evaluate discriminant validity.
An exploratory principal component analysis was carried out to determine the factor structure of the NAS. To accomplish this, a parallel analysis was first conducted to determine the number of components to extract.31,32 Subsequently, a principal components analysis was performed with the number of components specified by the parallel analysis. An oblique rotation was applied.
Internal Consistency
The internal consistency of NAS was evaluated using Cronbach’s alpha and corrected item-to-total correlation. Items with the corrected item-to-total correlations > 0.25 with the corresponding factor scores and corrected item-to-total correlations > 0.10 with the non-corresponding factor scores were retained.33
Test-Retest Reliability
One-month test-retest reliability was calculated from randomly selected participants that had agreed to retake the survey. At the 95% confidence interval, a two-way mixed absolute agreement intra-class correlation coefficient was assessed. A total of 10 participants were included to detect an intra-class correlation coefficient of 0.7 at α = 0.05 and power of 80%.34
Results
Demographic and Clinical Characteristics
Table 1 shows the demographic and clinical characteristics for participants (n = 100, mean age = 49.1, SD = 16.1, range = 19–85 years). Of the participants included, 47.0% were from Ontario, 8.0% from British Columbia, 31.0% from other Western provinces, and 14% from Atlantic provinces. Our sample included a higher proportion of White (78%) and Indigenous (7%) individuals and a lower proportion of Asian (10%) and Black (1%) individuals compared to the national percentages in Canada.35
Table 1.
Demographic and Clinical Characteristics
| All participants (n = 100) |
Tobacco dependence (n = 50) |
E-cigarette dependence (n = 50) |
|
|---|---|---|---|
| Mean (SD), range or n (%) | |||
| Age | 49.1 (16.1), 19.0–85.0 | 56.6 (10.1), 33.0–74.0 | 41.6 (17.6), 19.0–85.0 |
| Gender (man/woman) | 48 (48.0%)/52 (52.0%) | 22 (44.0%)/28 (56.0%) | 26 (52.0%)/24 (48.0%) |
| Race/ethnicity | |||
| Indigenous (Native American and Indigenous People of Canada including First Nations, Inuit or Métis) | 7 (7.0%) | 4 (8.0%) | 3 (6.0%) |
| Black | 1 (1.0%) | 1 (2.0%) | 0 (0.0%) |
| Latin American | 1 (1.0%) | 0 (0.0%) | 1 (2.0%) |
| East Asians | 5 (5.0%) | 0 (0.0%) | 5 (10.0%) |
| South Asian | 5 (5.0%) | 0 (0.0%) | 5 (10.0%) |
| White | 78 (78.0%) | 45 (90.0) | 33 (66.0%) |
| Other | 3 (3.0%) | 0 (0.0%) | 3 (6.0%) |
| Education (years) | 14.4 (3.5), 2.0–27.0 | 14.5 (2.9), 10.0–26.0 | 14.3 (4.0), 2.0–27.0 |
| FTCD/eFTCD score | — | 5.6 (1.6), 4.0–10.0 | 5.1 (1.3), 4.0–9.0 |
| NAS score | |||
| Average score | 5.3 (1.9), 1.0–10.0 | 5.4 (1.9), 1.0–9.0 | 5.2 (1.9), 1.5–10.0 |
| Illness Awarenessa | 4.9 (2.3), 0–10.0 | 5.3 (2.3), 0–10.0 | 4.5 (2.3), 0–10.0 |
| Symptom Attributionb | 5.6 (2.8), 0–10.0 | 5.3 (2.9), 0–10.0 | 5.8 (2.6), 0–10.0 |
| Need for Treatmentc | 4.6 (2.5), 0–10.0 | 4.9 (2.8), 0–10.0 | 4.4 (2.2), 0–10.0 |
| Negative Consequencesd | 6.4 (3.1), 0–10.0 | 6.5 (3.0), 0–10.0 | 6.2 (3.2), 0–10.0 |
| SOCRATES | |||
| Recognition | 22.3 (6.8), 7.0–35.0 | 22.9 (7.1), 7–35.0 | 21.6 (6.4), 7–35.0 |
| Ambivalence | 11.7 (3.8), 4.0–19.0 | 11.6 (4.1), 4–19.0 | 11.8 (3.6), 4–19.0 |
| Taking Steps | 24.5 (7.4), 8.0–40.0 | 22.8 (7.5), 8–40.0 | 26.1 (7.0), 8–39.0 |
| PANAS | |||
| Positive | 30.4 (8.0), 10.0–50.0 | 28.6 (7.9), 10–45.0 | 32.2 (7.8), 15–50.0 |
| Negative | 21.5 (8.9), 10.0–47.0 | 18 (6.1), 10–33.0 | 25.1 (9.8), 10–47.0 |
| Drinking frequency | |||
| Monthly or less | 15 (21.1%) | 11 (32.4%) | 4 (10.8%) |
| 2–4 times a month | 22 (31.0%) | 12 (35.3%) | 10 (27.0%) |
| 2–3 times a week | 23 (32.4%) | 7 (20.6%) | 16 (43.2%) |
| Four or more times a week | 10 (14.1%) | 4 (11.8%) | 6 (16.2%) |
| Substance use frequency | |||
| Monthly or less | 3 (13.0%) | 1 (16.7%) | 2 (11.8%) |
| 2–4 times a month | 5 (21.7%) | 2 (33.3%) | 3 (17.6%) |
| 2–3 times a week | 10 (43.5%) | 1 (16.7%) | 9 (52.9%) |
| Four or more times a week | 4 (17.4%) | 2 (33.3%) | 2 (11.8%) |
| Nicotine use per day | |||
| Number of cigarettes smoked | 14.7 (8.8), 1.0–40.0 | 18.1 (8.0), 2.0–40.0 | 7.1 (5.1), 1.0–20.0 |
| Number of 10-minute e-cigarette sessions | 12.3 (13.4), 1.0–30.0 | 1.0, 1–1.0 | 12.7 (8.1), 2–30.0 |
| Depression, anxiety, or other mental health issues | |||
| Currently have this condition | 21 (21.0%) | 10 (20.0%) | 11 (22.0%) |
| Previously had this condition | 21 (21.0%) | 9 (18.0%) | 12 (24.0%) |
| Never had this condition | 55 (55.0%) | 28 (56.0%) | 27 (54.0%) |
| Not sure | 3 (3.0%) | 3 (6.0%) | 0 (0.0%) |
| Receiving treatment for nicotine use (yes/no) | 3 (3.0%)/97 (97.0%) | 0/50 (100%) | 3 (6.0%)/47 (94.0%) |
| Trying to cut down or quit (yes/no) | 49 (49.0%)/51 (51.0%) | 21 (42.0%)/29 (58.0%) | 28 (56.0%)/22 (44.0%) |
eFTCD = FTCD adapted for electronic cigarettes; E-cigarette = electronic cigarette; FTCD = Fagerstrome Test for Cigarette Dependence; NAS = Nicotine Use Awareness and Insight Scale; PANAS = Positive and Negative Affect Schedule; SOCRATES = The Stages of Change Readiness and Treatment Eagerness Scale.
aNAS Illness Awareness score includes items 2 and 4.
bNAS Symptom Attribution score includes item 1.
cNAS Need for Treatment score includes items 3, 5, and 7.
dNAS Negative consequences score includes item 6.
The mean number of cigarettes per day in the whole sample was 14.7 (SD = 8.8) and the mean amount of 10-minute e-cigarettes sessions per day was 12.3 (SD = 13.4). Among participants with dependence on tobacco, 4% also reported using e-cigarettes once or more per day. Among participants with dependence on e-cigarettes, 62% also reported using cigarettes once or more per day. In the whole sample, 21.0% of participants reported that they currently have depression, anxiety, or other mental health disorder, while another 21.0% reported having these conditions in the past.
The mean FTCD score was 5.6 (SD = 1.6, range = 4.0–10.0) and the mean eFTCD score was 5.1 (SD = 1.3, range = 4.0–9.0), corresponding to a moderate level of dependence on nicotine. The mean SOCRATES Recognition subscale score was 22.3 (SD = 6.8, range = 7.0–35.0), corresponding to a very low Recognition score, suggesting that participants do not recognize that their nicotine use is problematic and that they do not have a desire to modify their nicotine use behavior. Participants also had low SOCRATES Ambivalence and Taking Steps subscale scores (mean [SD] = 11.7 [3.8], range = 4.0–19.0 and mean [SD] = 24.5 [7.4], range = 8.0–40.0, respectively), which indicates that they have low levels of ambivalence about whether their nicotine use is excessive and that they are not currently taking action to change their nicotine usage, respectively.25 The mean NAS Average total score was relatively low (mean = 5.3, SD = 1.8, range = 1.4–10.0). In our sample, 97% of the participants were not receiving treatment for nicotine use. However, 49% of all participants indicated that they would like to minimize or abstain from nicotine use.
The demographic and clinical characteristics, including the degree of illness awareness among participants that used tobacco only, e-cigarettes only, and dual users can be found in Supplementary Table 1. Participants that use tobacco only were older and had higher PANAS negative affect scores than participants that use e-cigarettes only or dual users. No other group differences were found.
We found no association between NAS Average score and either age or level of education. These findings remained the same when participants with dependence on tobacco and e-cigarettes were examined separately. There was also no correlation between the NAS Average score and the FTCD or eFTCD, suggesting there is no relationship between illness awareness and illness severity in individuals with dependence on nicotine. The finding remained the same when examining the illness severity measures with the NAS subscales.
Validity
The NAS Average score was strongly correlated with the SOCRATES Recognition subscale, reflective of good convergent validity. Specifically, the NAS Illness Awareness subscale and Need for Treatment subscale demonstrated a strong association, whereas the Symptom Attribution subscale demonstrated a weak-to-moderate correlation with the SOCRATES Recognition subscale (Table 2, Figure 1). The NAS Average score was weakly correlated with the PANAS Positive and Negative Affect scale scores, suggestive of good discriminant validity (Table 2).
Table 2.
Correlations for the NAS, SOCRATES, and PANAS in all Participants (n = 100)
| NAS Average | Illness Awarenessa | Symptom Attributionb | Need for Treatmentc | Negative Consequencesd | Factor 1e | Factor 2f | SOCRATES Recognition | SOCRATES Ambivalence | SOCRATES Taking Steps | PANAS Positive | PANAS Negative | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age | .11 | .25* | −.06 | .09 | .06 | .06 | .26* | .08 | −.16 | −.03 | −.10 | −.51** |
| Education | .05 | .08 | .06 | −.05 | .06 | .08 | −.01 | −.09 | −.13 | .05 | −.05 | −.24* |
| NAS Average | — | .76** | .63** | .80** | .67** | .95** | .33** | .74** | .43** | .46** | .03 | .17 |
| Illness Awarenessa | .76** | — | .32** | .69** | .25* | .68** | .63** | .61** | .30** | .33** | −.04 | .07 |
| Symptom Attributionb | .63** | .32** | — | .30** | .16 | .59** | .00 | .38** | .10 | .27* | .31** | .08 |
| Need for Treatmentc | .80** | .69** | .30** | — | .36** | .82** | .54** | .73** | .48** | .41** | −.04 | .20* |
| Negative Consequencesd | .67** | .25* | .16 | .36** | — | .62** | −.07 | .39** | .23** | .27** | −.10 | .10 |
| NAS item 1 | .63** | .32** | — | .30** | .16 | .59** | .00 | .38** | .10 | .27* | .31** | .08 |
| NAS item 2 | .79** | .78** | .48** | .64** | .39** | .85** | .09 | .66** | .39** | .52** | .08 | .13 |
| NAS item 3 | .79** | .64** | .38** | .89** | .38** | .87** | .22* | .73** | .48** | .47** | −.07 | .17 |
| NAS item 4 | .33** | .72** | −.01 | .38** | −.04 | .16 | .89** | .24* | .04 | −.07 | −.15 | −.03 |
| NAS item 5 | .27** | .42** | .01 | .58** | −.09 | .25* | .90** | .26** | .09 | −.03 | .02 | −.01 |
| NAS item 6 | .67** | .25* | .16 | .36** | 1.00** | .62** | −.07 | .39** | .27** | .26** | −.10 | .10 |
| NAS item 7 | .81** | .57** | .33** | .89** | .53** | .89** | .20 | .72** | .54** | .50** | −.05 | .30** |
| SOCRATES Recognition | .74** | .61** | .38** | .73** | .39** | .73** | .28** | — | .75** | .56** | .04 | .31** |
| SOCRATES Ambivalence | .43** | .30** | .10 | .48** | .27** | .41** | .07 | .75** | — | .43** | .05 | .46** |
| SOCRATES Taking Steps | .46** | .33** | .27 | .41** | .26** | .45** | −.05 | .56** | .43** | — | .09 | .26** |
| PANAS Positive | .03 | −.04 | .31* | −0.04 | −.10 | .08 | −.07 | .04 | .05 | .09 | — | .05 |
| PANAS Negative | .17 | .07 | .08 | .20* | .33 | .16 | −.02 | .31** | .46** | .26** | .05 | — |
NAS = Nicotine Use Awareness and Insight Scale; PANAS = Positive and Negative Affect Schedule; SOCRATES = The Stages of Change Readiness and Treatment Eagerness Scale.
aNAS Illness Awareness includes items 2 and 4.
bNAS Symptom Attribution includes item 1.
cNAS Need for Treatment includes items 3, 5, and 7.
dNAS Negative consequences includes item 6.
eNAS Factor 1 includes items 1, 2, 3, 6, and 7.
fNAS Factor 2 includes items 4 and 5.
*p < .05; **p < .01.
Figure 1.
Convergence for the NAS Average score with the SOCRATES Recognition subscale in all participants with dependence on nicotine (n = 100).NAS = Nicotine Use Awareness and Insight Scale; SOCRATES = Stages of Change Readiness and Treatment Eagerness Scale.
Similar to the whole sample, separate analyses of participants with dependence on tobacco and e-cigarettes showed a strong correlation between NAS Average and the SOCRATES Recognition subscale scores (Supplementary Figures 1 and 2), and a weak correlation between NAS Average and the PANAS Positive and Negative Affect scale scores (Supplementary Tables 2 and 3).
Two components emerged from parallel analysis, with component 1 accounting for 45.8% of the variance and component 2 accounting for 21.8% of the variance in the NAS. Two eigenvalues emerged from the actual data (3.20, 1.53, and 0.88) that exceeded the 95th percentile eigenvalues generated from random data (1.59, 1.35, and 1.18). The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.71. Supplementary Table 4 shows the factor loadings.
Internal Consistency
The Cronbach’s alpha for NAS was 0.78 indicating strong internal consistency. The Cronbach’s alpha for NAS was 0.78 in tobacco users and 0.79 in e-cigarette users.
Test-Retest Reliability
The intra-class correlation coefficient for the one-month test-retest reliability at the 95th confidence interval was 0.86 for the NAS Average score.
Discussion
The NAS is a novel and easy-to-use scale that measures illness awareness in individuals with dependence on nicotine. The NAS consists of 7 items that are each assessed using a 10-point Likert scale. The results of this study provide preliminary support for the convergent and discriminant validity, internal consistency, and test-retest reliability of the NAS in individuals with moderate dependence on nicotine due to either tobacco or e-cigarettes.
Currently available scales that are validated for nicotine dependence only allow for the assessment of one to two of the four theoretical domains of illness awareness.23 Although the SOCRATES Recognition subscale includes items that can measure general illness awareness, need for treatment, and negative health consequences, the scale has not been validated for nicotine dependence.36 The NAS was developed to assess the four core theoretical domains of illness awareness, including items to assess accurate attribution of nicotine addiction or withdrawal symptoms to their nicotine use.14–20
The NAS Average score demonstrated good convergent and discriminant validity with the SOCRATES Recognition subscale and PANAS scores, respectively. The NAS Symptom Attribution and Negative Consequences subscales showed weak-to-moderate correlations with the SOCRATES Recognition subscale. This is expected as the SOCRATES Recognition subscale does not contain items that are symptom-related. Separate analyses of participants with tobacco and e-cigarette dependence showed similar results, suggesting that the NAS can be used in both groups.
An exploratory factor analysis of the NAS suggested the retention of two components. Factor 1 included items that measure an individual’s awareness/acceptance of being dependent on nicotine, the associated symptoms, need for cessation treatment, and the health consequences of nicotine dependence. Factor 2 included items that measure illness denial. These two factors were distinguished based on item keying. As the NAS was developed for clinical and research applications, we prioritized the use of a brief scale with a few key items for each theoretical domain of illness awareness. However, further studies evaluating the four-factor structure of the NAS using a confirmatory analysis in a larger sample may be needed to better understand the construct of illness awareness in individuals with dependence on nicotine.
This study has a few limitations. First, due to the use of a digital data collection platform, individuals who were unfamiliar with online platforms or did not have access to one were excluded. However, previous studies on clinical surveys reported no differences in reliability or validity of online and in-person surveys.37,38 Second, our selection criteria were based solely on self-report. As such, whether participants had a clinical diagnosis of tobacco use disorder cannot be confirmed. Third, the results of NAS are not generalizable to adolescents with nicotine dependence or to individuals who use other forms of inhaled (e.g., cigars, pipes, and water pipes) or non-combustible (e.g., chewing and other forms of smokeless tobacco) forms nor those e-cigarette users who use non-nicotine containing devices. Lastly, the sample size for the test-retest reliability estimates was small, and a replication in a larger sample will be useful.
Conclusion
In summary, the NAS is a novel scale designed to measure illness awareness in individuals with dependence on nicotine (http://illnessawarenessscales.com). Findings from this study provide preliminary support for the psychometric validity and reliability of the NAS. The NAS can be administered in clinical and research settings to measure the effect of impaired awareness of dependence on nicotine on treatment-seeking behavior for nicotine cessation.
Supplementary Material
A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.
Funding
This work was supported by the Centre for Addiction and Mental Health (PG), an Academic Scholars Award from the Department of Psychiatry, University of Toronto (PG), and the Canadian Institute of Health Research (CIHR) (PJT-159807 to PG).
Declaration of Interests
PG reports receiving research support from the Canadian Institutes of Health Research (CIHR), Ontario Ministry of Health and Long-Term Care, Ontario Mental Health Foundation (OMHF), Centre for Addiction and Mental Health (CAMH) Foundation, and an Academic Scholars Award from the Department of Psychiatry, University of Toronto. PS reports receiving funding from the Canadian Cancer Society Research Institute, Canadian Institutes of Health Research, Canadian Partnership Against Cancer, Cancer Care Ontario, Centre for Addiction and Mental Health, Health Canada, Medical Psychiatry Alliance, Ontario Ministry of Health and Long-Term Care, and the Public Health Agency of Canada. PS also reports funding from the following commercial organizations: Patient-Centered Outcome Research Institute, and Pfizer Incorporated. Through an open tender process, Johnson & Johnson, Novartis, and Pfizer Inc. are vendors of record for providing free/discounted smoking cessation pharmacotherapy for research studies. FC has received funding from the CIHR Post-doctoral Fellowship Award and the CAMH Foundation. AG-G has received support from the United States National Institute of Health, CIHR, OMHF, Consejo Nacional de Ciencia y Tecnología, the Instituto de Ciencia y Tecnología del DF, the Brain & Behavior Research Foundation (Formerly NARSAD), the Ontario Ministry of Health and Long-Term Care, the Ontario Ministry of Research and Innovation Early Research Award, and Janssen. All other authors have declared that there are no conflicts of interest in relation to the subject of this study.
Data Availability
The data underlying this article will be shared on reasonable request to the corresponding author.
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Data Availability Statement
The data underlying this article will be shared on reasonable request to the corresponding author.