We believe there is also a need to rethink the functionality of a nicotine dependence diagnosis [10]. Under DSM-III-R diagnostic criteria and cut-offs, only about half of daily smokers earned diagnoses in some age cohorts [119]. Yet, smoking causes major health risks to all daily smokers, and even daily smokers scoring at low levels on dependence criteria have difficulty quitting [120, 121], may benefit from cessation intervention [122, 123], and suffer from the numerous costs of smoking (economic, loss of time, etc.). Thus, the current criteria and diagnostic rules may be set at too high a threshold. As opposed to agents such as alcohol, tobacco does not foster widespread, relatively innocuous use. Achieving an optimal measure cut-score for TD should be one component of a greater effort to improve the utility and clinical benefit of diagnosis.
