Usage conditions apply. Copyright sits with the original publisher (Taylor & Francis); per the source publication the scale may be reproduced without permission. Reproduce it in full with attribution to Heatherton et al. (1991).
Answer each question about your current smoking pattern.
01
How soon after you wake up do you smoke your first cigarette?
Item score-
02
Do you find it difficult to refrain from smoking in places where it is forbidden (for example in church, at the library, in the cinema)?
Item score-
03
Which cigarette would you hate most to give up?
Item score-
04
How many cigarettes per day do you smoke?
Item score-
05
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Item score-
06
Do you smoke even if you are so ill that you are in bed most of the day?
Item score-
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0 of 6 answered
0 / 10
FTND0 / 6
Answer each question about your current smoking pattern.
01
How soon after you wake up do you smoke your first cigarette?
Item score-
02
Do you find it difficult to refrain from smoking in places where it is forbidden (for example in church, at the library, in the cinema)?
Item score-
03
Which cigarette would you hate most to give up?
Item score-
04
How many cigarettes per day do you smoke?
Item score-
05
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Item score-
06
Do you smoke even if you are so ill that you are in bed most of the day?
The Fagerström Test for Nicotine Dependence (FTND) is a six-item self-report measure of the physical dependence a smoker has developed on cigarettes. Rather than asking about motives or consequences, it probes the behavioural signature of dependence: how soon after waking the first cigarette is smoked, how hard it is to refrain in no-smoking settings, which cigarette would be hardest to give up, daily consumption, morning-loaded smoking, and smoking through illness. Scores run from 0 to 10, with higher scores indicating heavier physical dependence.
The FTND deliberately measures dependence on cigarettes as a delivery system, not nicotine exposure in general - a distinction its author later underlined by renaming it the Fagerström Test for Cigarette Dependence (FTCD) in 2012. The single most informative item is time to first cigarette after waking, which on its own tracks biochemical markers of intake and predicts difficulty quitting. In clinical practice the total score is used to gauge how intensive cessation support and pharmacotherapy may need to be.
02 - Origin & purpose
Where it comes from.
The FTND was published in 1991 by Todd Heatherton, Lynn Kozlowski, Richard Frecker and Karl-Olov Fagerström as a revision of the 1978 Fagerström Tolerance Questionnaire (FTQ). The revision removed psychometrically weak FTQ items (such as nicotine yield and inhaling) and re-weighted the remainder, producing a shorter scale with a cleaner relationship to biochemical measures of smoking such as cotinine and carbon monoxide.
It was designed as a quick clinical and research index of physical dependence - brief enough for routine use in cessation clinics, epidemiology and treatment trials. It has become the most widely used cigarette-dependence measure internationally, and in 2012 Fagerström proposed the current name, the Fagerström Test for Cigarette Dependence, to reflect that it measures dependence on cigarette smoking specifically. A two-item short form drawn from it, the Heaviness of Smoking Index (HSI: time to first cigarette plus cigarettes per day, scored 0-6), is recommended where even six items are too many.
03 - Scoring & cutoffs
How scoring works.
Two items (time to first cigarette and cigarettes per day) are scored 0-3; the remaining four are scored 0-1, giving a total of 0-10. The conventional bands are 0-2 very low, 3-4 low, 5 moderate, 6-7 high and 8-10 very high dependence. Scores of 6 or more are commonly used to indicate high dependence warranting more intensive pharmacological support; time to first cigarette within 30 minutes of waking is itself a strong single marker of dependence. The FTND grades physical dependence - it is not a diagnostic instrument for DSM-5 tobacco use disorder.
Score
Severity
Interpretation
0–2
Very low dependence
Very low physical dependence on nicotine.
3–4
Low dependence
Low physical dependence on nicotine.
5–5
Moderate dependence
Moderate physical dependence on nicotine.
6–7
High dependence
High physical dependence on nicotine.
8–10
Very high dependence
Very high physical dependence on nicotine. Intensive support is recommended.
04 - Validation evidence
How well it performs.
In the original validation the FTND showed clearer relationships with biochemical indices of smoking (salivary cotinine, expired carbon monoxide) than the FTQ it replaced. A 2022 systematic review of its psychometric properties found internal consistency (Cronbach's alpha) ranging from about 0.55 to 0.74 across studies - modest, reflecting the scale's mix of item formats - alongside high test-retest reliability and consistent predictive validity: higher scores, and earlier time to first cigarette in particular, predict lower quit rates at follow-up in both general-population and clinical samples. Both the full FTND and the two-item HSI predicted abstinence at six-month follow-up in clinical samples.
0.55-0.74
Internal consistency
Cronbach's alpha across studies (2022 systematic review)
up to ~0.88
Test-retest reliability
High across studies in adult smokers
Sig.
Convergent validity
Correlates with salivary cotinine and expired carbon monoxide (Heatherton et al., 1991)
Sig.
Predictive validity
Higher scores and earlier time-to-first-cigarette predict lower cessation success at 6-month follow-up
05 - How it compares
How it compares to the alternatives.
Instrument
Items
Time
When to reach for it
HSI (Heaviness of Smoking Index)
2
under 1 min
Ultra-brief dependence screen for epidemiology or busy clinics; the two highest-yield FTND items scored 0-6.
-Grading physical dependence on cigarettes to guide the intensity of cessation support and nicotine-replacement dosing
-Routine baseline measure in smoking-cessation clinics and treatment trials
-Quick risk stratification: time to first cigarette alone flags heavily dependent smokers
Reach for something else when
-Diagnosing DSM-5 tobacco use disorder - it grades dependence, it does not diagnose
-Vaping, smokeless tobacco or dual use - item wording assumes cigarette smoking (adapted versions exist, e.g. FTND-ST)
-Measuring motivation or readiness to quit - it measures dependence, not intent
-Adolescents - developed and validated in adult smokers
07 - Confidence & precision
Reading the score with care.
No standard error of measurement or minimally important change threshold is established for the FTND, and its modest internal consistency (alpha 0.55-0.74) means single-point differences should not be over-interpreted. Treat the bands, not single points, as the clinically meaningful unit, and read time to first cigarette as the strongest single indicator. It is a state measure of current smoking pattern; retest after a change in consumption reflects genuine change as well as measurement error.
08 - Limitations
What it cannot tell you.
Modest internal consistency across studies (alpha 0.55-0.74), reflecting mixed item formats and the two-factor structure (morning smoking vs daytime pattern). Item wording is cigarette-specific, so it under-measures dependence in people who vape or use smokeless tobacco; cross-cultural adaptations show variable psychometric quality. It captures physical dependence only - craving, withdrawal severity and DSM criteria need separate assessment. Self-reported cigarettes per day is prone to digit bias and under-reporting.
09 - Licensing, explained
How licensing works.
Copyright sits with the original publisher (Taylor & Francis); per the source publication the scale may be reproduced without permission. Reproduce it in full with attribution to Heatherton et al. (1991).
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