Using a smoking rate criterion in DSM-5 (cigarettes smoked/day) may raise concerns because smoking rates may change over time, and thereby may change the relation between the measure and dependence outcomes. While this would introduce complexity, it might not necessarily compromise the utility of such criteria or items. First, as an ebbing tide may lower all boats, relative differences in smoking heaviness might continue to predict dependence well, despite population shifts in heaviness. Of course, this would argue for periodic re-norming of cut-scores, or using items that do not require information on specific numbers of cigarettes consumed (e.g., self-perception of smoking heaviness and the automaticity of smoking [27]).
