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Sleep Hygiene Practices in Population Based Sample of Insomniacs

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					  INSOMNIA

Sleep Hygiene Practices in a Population-Based Sample of Insomniacs
Catherine D. Jefferson, BS;1 Christopher L. Drake, PhD;1,2 Holly M. Scofield, BA;1 Eric Myers, BS;1 Tara McClure, BA;1 Timothy Roehrs, PhD;1,2 Thomas Roth, PhD1,2

¹Henry Ford Hospital Sleep Disorders and Research Center and ²Wayne State University Department of Psychiatry & Neurosciences, Detroit, MI

  Study Objectives: The present study was designed to assess selected                Measurements and Results: Insomniacs reported poorer sleep hygiene,
  aspects of sleep hygiene from a population-based sample of individuals             as evidenced by an increase in prevalence of smoking close to bedtime
  with insomnia compared to age- and sex-matched controls.                           and increased use of alcohol. They also reported more naps per week
  Design: A random-sample phone survey of 258 individuals meeting Diag-              and sleeping in on days not worked. Caffeine use did not differ between
  nostic and Statistical Manual of Mental Disorders, Fourth Edition-based            groups. Time in bed was also comparable between insomniacs and con-
  criteria for insomnia was compared to age- and sex-matched normal                  trols.
  sleepers on specific measures of sleep hygiene. Sleep hygiene practices             Conclusion: Insomniacs do engage in specific poor sleep hygiene prac-
  measured included cigarette smoking, smoking near bedtime, alcohol                 tices, such as smoking and drinking alcohol just before bedtime. These
  use, caffeine use, napping, time in bed, and reported likelihood of sleep-         particular aspects of sleep hygiene may be important components that
  ing in on weekends.                                                                exacerbate or perpetuate insomnia.
  Setting: Detroit tricounty population.                                             Key Words: Insomnia, sleep hygiene, alcohol
  Participants: 258 individuals 18 to 65 years old with insomnia and 258             Citation: Jefferson CD; Drake CL; Scofield HM et al. Sleep hygiene prac-
  age- and sex-matched controls.                                                     tices in a population-based sample of insomniacs. SLEEP 2005;28(5):611-
  Interventions: N/A.                                                                615.


INTRODUCTION                                                                         as a therapy is contingent upon poor basal sleep hygiene. There
                                                                                     are few representative community-based data evaluating spe-
INSOMNIA IS AMONG THE MOST PREVALENT SYMP-                                           cific sleep hygiene practices in individuals with insomnia. Thus,
TOMS ASSOCIATED WITH SLEEP-WAKE DYSFUNCTION,                                         within the multiple components of sleep hygiene, it is not known
AFFECTING MORE THAN 10% OF THE GENERAL POPU-                                         which, if any, specific behaviors should be targeted in insomnia
LATION.1 Studies have shown that insomnia can have a signifi-                         treatment programs.
cant negative impact on an individual’s work, physical, and social                      Sleep hygiene involves behavioral practices based on our un-
performance, as well as overall quality of life.2,3 The economic                     derstanding of sleep physiology and pharmacology, which have
costs of insomnia have been estimated to be more than $77 bil-                       been identified to promote good sleep. First introduced by Pe-
lion per year;4,5 this is likely due in part to the chronic nature of                ter Hauri8 in 1977, sleep hygiene has become a common tool
the disorder. Severe insomnia has been shown to last for a median                    of clinicians in the treatment of insomnia. Most insomnia treat-
of 4 years,6 with 44% of insomniacs continuing to report severe                      ment programs have incorporated sleep hygiene as 1 facet of a
sleep disturbance ten years later.7                                                  multicomponent approach.9 There have been several studies that
   There has been debate over the efficacy of sleep hygiene for                       have tested the effectiveness of general sleep hygiene practices
the treatment of chronic insomnia. The efficacy of sleep hygiene                      as a single component in comparison to other specific sleep treat-
                                                                                     ments; however, these studies have produced inconsistent results.
                                                                                     One study evaluated meditation, stimulus control, and sleep hy-
Disclosure Statement                                                                 giene treatments for sleep-maintenance insomnia. They found
This was not an industry funded project. Dr. Drake has received research             that sleep hygiene was effective, as were the other treatments,
support from Cephalon, Pfizer, and Neurocrine; has participated in speak-
                                                                                     although this study had no control group for comparison.10 Har-
ing engagements supported by Sepracor, Sanofi-Aventis; and has received
                                                                                     vey et al used a cognitive behavioral treatment intervention over
equipment from Vivometrics. Dr. Roehrs has received research support
from Sanofi-Aventis, Sepracor, Xenoport, Cephalon, Neurocrine, and Pfizer;
                                                                                     6 sessions. These sessions included information on sleep educa-
and has participated in speaking engagements supported by Sanofi-Aven-                tion, sleep hygiene, stimulus control, and sleep restriction.11 The
tis and Sepracor. Dr. Roth has received research support from Cephalon,              results showed that sleep scheduling and cognitive restructuring
Pfizer, Neurocrine, Sanofi, Syrex, Takeda, GlaxoSmithKline, and Sepracor;              methods were more likely to produce significant improvements in
has received consulting fees from Cephalon, Pfizer, Neurocrine, Sanofi,                sleep latency and nighttime wakefulness than was a combination
Somaxon, Syrex, Takeda, GlaxoSmithKline, Aventis, Sepracor, Transoral,               of broad education techniques such as sleep hygiene, relaxation,
Merck, Vivometrics, Eli Lilly, Wyeth, Roche, Organanon, AstraZeneca, Mc-             or thought-blocking methods. However, the study did not exam-
Neil, Lundbeck, Hypnion, and King Pharmaceutical; and has participated in            ine sleep hygiene as a single component.
speaking engagements supported by Sanofi. Jefferson, Scofield, Myers,                     Another study surveyed university students using the Sleep
and McClure have indicated no financial conflicts of interest.                         Hygiene Awareness and Practice Scale and the Pittsburg Sleep
                                                                                     Quality Index and showed that the practice of proper sleep hab-
Submitted for publication October 2004                                               its was related positively to good sleep quality.12 Thus, although
Accepted for publication January 2005                                                sleep hygiene as a single component has produced mixed results,
Address correspondence to: Catherine Jefferson, BS, 2799 West Grand                  there are some data to indicate a relationship between sleep hy-
Blvd. CFP-3, Detroit, MI 48202; Tel: (313) 916-2265; Fax: (313) 916-5167;            giene and sleep quality in normal sleepers. The question remains
E-mail: Cjeffer2@hfhs.org                                                            as to whether specific aspects of sleep hygiene are differentially
SLEEP, Vol. 28, No. 5, 2005                                                    611                                    Sleep Hygiene and Insomnia—Jefferson et al
practiced in insomniacs relative to noninsomniacs. If differences              ten experiencing difficulty getting to sleep, staying asleep, or hav-
are identified, they may help explain some of the discrepant find-               ing nonrefreshing sleep for at least 1 month during their lifetime.
ings related to sleep hygiene as an independent component in the               In addition, an insomnia severity of more than 6 (scale = 0 [not at
behavioral treatment of insomnia. The current study was designed               all severe] through 10 [severe as possible]) over the past 3 months
to assess selected aspects of sleep hygiene practices in a popula-             was required. Each insomniac was paired with an age- and sex-
tion-based sample of insomniacs and age- and sex-matched con-                  matched control who did not meet insomnia criteria. Shift work-
trols in order to determine if specific practices are encountered               ers were excluded from the study. Demographic characteristics
more frequently in insomniacs than in controls. The sleep hygiene              were similar between groups (Table 2). Selected aspects of sleep
practices assayed were only those related to commonly used sub-                hygiene were measured by several questions eliciting information
stances and sleep habits, as these components are frequently en-               on typical cigarette use. Regular smokers were defined as those
gaged-in behaviors and often cited as potential targets for sleep              individuals who reported smoking over the past year. Aspects of
hygiene targets.13                                                             sleep hygiene were measured by several questions eliciting infor-
                                                                               mation on cigarette use, regular smokers (defined as those indi-
METHODS                                                                        viduals who reported smoking over the past year), alcohol, caf-
                                                                               feine use, napping, time in bed, and total sleep time (Appendix).
   A representative sample of 516 individuals was selected from
the Detroit tricounty population based on answers provided dur-
                                                                               RESULTS
ing a 20-minute phone interview. Subjects were paid 25 dollars
for participation. The protocol was approved by the institutional              Sleep Variables
review board of Henry Ford Hospital. Individuals participating
                                                                                  Data regarding both the self-reported sleep habits and selected
in this study were assessed in conjunction with a larger ongo-
                                                                               sleep hygiene behaviors for the insomnia and control groups are
ing epidemiologic study investigating the prevalence of daytime
                                                                               shown in Table 3. As expected, total sleep time was significantly
sleepiness. Participants were drawn from the general population
                                                                               lower for insomniacs than controls (P < .001). Number of hours
of tricounty metropolitan Detroit using random-digit dialing tech-
                                                                               spent in bed did not differ between groups for either weekdays (P
niques. For eligibility, the calling address had to be a residence,
                                                                               > .6) or weekends (P > .3). Sleep efficiency was significantly low-
and the participant an adult between the ages of 18 and 65 years.
                                                                               er for insomniacs versus controls (P < .001). Despite comparable
A random-probability selection procedure was used to determine
                                                                               times in bed, insomniacs were more likely to report sleeping in
the sex of the target adult. If 2 or 3 adults within a target sex were
                                                                               on days not worked (P = .02). Insomniacs also reported a higher
present in a household, random-probability selection procedure
                                                                               frequency of naps per week (P < .02).
(oldest/second, oldest/youngest) was used to determine the treat-
ment respondent. If 4 or more adults with the target sex were pres-
                                                                               Substance Use
ent in the household, last birthday method was used to determine
the target respondent. In order to maintain an unbiased sample,                   Insomniacs had an increased prevalence of regular smoking
only individuals who couldn’t answer the questionnaire due to                  compared to controls (P < .001). Within regular smokers, in-
sensory or mental impairment were excluded from the sample.                    somniacs more often smoked within 5 minutes of bedtime (P =
From 4,682 eligible participants, 3,283 interviews were obtained               .004). Insomniacs engaged in more social drinking, as measured
(response rate 70.1%). The demographic details of the sample,                  by number of alcoholic drinks per week, (P = .003). More impor-
including race status, is shown in Table 1 and are nearly identical            tantly, insomniacs used alcohol to induce sleep more frequently
to the 2000 Census data for the area.                                          (P < .001). Within those who reported drinking alcohol in the past
   Criteria for insomnia included a response of sometimes or of-               2 weeks, insomniacs consumed alcohol within 30 minutes of bed-
                                                                               time more often than did controls (P < .05). In contrast, caffeine
  Table 1—2000 US Census data                                                  intake (drinks per day) did not differ between groups (P > .26).
                                                                                  A secondary analysis using multiple logistic regression was
  Sociodemographic                       Population (No.)
  Characteristics, %                                                           undertaken to determine which sleep hygiene variables were in-
                               Sample       Tricounty       US                 dependent predictors of insomnia. The use of alcohol for sleep
                               (3,283)     (4,043,467) (281,421,906)           (P < .001, odds ratio [OR] = 2.99, 95% confidence interval [CI]
  Sex                                                                          = 1.74-5.14) and smoking within 5 minutes of bedtime (P < .05,
    Men                         49.1           48.5         49.1               OR= 2.69, 95% CI = 1.2-2.03), sleeping in on days not worked (P
    Women                       50.9           51.5         50.9               < .05, OR = 1.54, 95% CI = 1.03-2.28) were significant indepen-
  Race/ethnicity                                                               dent predictors. Use of alcohol within 30 minutes of bedtime and
    Caucasian                   68.6           68.9         75.1
    African American            24.9           25.0         12.3                Table 2—Study Sample Demographics
    Asian or Pacific Islander     1.9            2.5          3.7
    Native American              .9            0.3           0.9                                     Insomniacs                     Controls
    Other or refused             3.5            3.3          7.9                                       n = 258                      n = 258
  Age, y                                                                        Mean age, y            43 ± 11                      43 ± 11
    18-24*                      10.7           18.7         21.0                Women, %                 62                            62
    25-34                        21            22.5         21.4                Race, %
    35-44                        25            25.0         24.3                 Caucasian               63.6                          72.9
    45-54                       24.7           21.0         20.2                 African American        27.5                          20.9
    55-64                        18            12.7         13.0                 Other                    8.9                           6.2


SLEEP, Vol. 28, No. 5, 2005                                              612                                Sleep Hygiene and Insomnia—Jefferson et al
                                                                              sleep hygiene variable. Treatment programs routinely include this
 Table 3—Summary of Results                                                   as a sleep hygiene target but do not quantify its effect or patient
                                                                              adherence to specific behaviors. Previous studies have explored
 Sleep Hygiene Variable               Insomniac           Control
                                      n = 258             n = 258
                                                                              the relationship between nicotine and sleep. One population-
 Total sleep time, h                  5.9 ± 1.7***        6.9 ± 1.2           based study found a relationship between cigarette smoking, dif-
 Time in bed, h                                                               ficulty initiating sleep, and symptoms associated with sleep frag-
   Weekdays                           7.3 ± 1.9           7.4 ± 1.2           mentation.16 Another study showed similar results; smokers were
   Weekends                           7.8 ± 2.0           8.03 ± 1.4          significantly more likely to report difficulty sleeping.17 In that
 Sleep efficiency, %                   79.9***             90.8                study, smokers also reported a high daily caffeine intake, suggest-
 “Sleeping in,” %                     42.7*               32.4                ing an inclination for individuals who engage in one unhealthy
 Naps, no./wk                         3.5 ± 4.5*          2.7 ± 3.5           sleep behavior to also engage in others. This raises the question
 Regular smokers, %                   40.7***             22.9
                                                                              as to whether these behaviors are specific disturbers of sleep or
 Smoke within 5 minutes of            45.3**              21.8
   bedtime(regular smokers), %
                                                                              simply reflective of a cognitive lifestyle that might be associated
 Alcoholic beverages, no./wk          **4.7 ± 11.0        2.3 ± 4.8           with insomnia. A study on smokers and age, ethnicity, and sex-
 Use alcohol to sleep, %              ***29.1             11.2                matched nonsmokers, recorded information on cigarette, alcohol,
 Alcohol within 30 minutes of         *12.9               5.6                 and caffeine intake, as well as daily stress and sleep quality. The
   bedtime (regular drinkers), %                                              results showed that smokers were more likely to report poor sleep
 Caffeine, no./d                      3.0 ± 4.0           2.7± 3.3            and use more alcohol than were nonsmokers.18 Results from the
                                                                              present study are consistent with these data, as we found that in-
 Results are presented as mean ± SD for each variable in insomniacs           somniacs smoke more often and closer to bedtime than controls.
 and controls. See text for definition of “regular” smokers and “regu-
                                                                                  The negative effect of alcohol on sleep and the use of alco-
 lar” drinkers.
 *P < .05
                                                                              hol to self-medicate in insomniacs have been extensively studied.
 **P < .01                                                                    Johnson et al19 found that 13% of the general population use al-
 ***P < .001                                                                  cohol to promote sleep. Of these individuals, those with difficulty
                                                                              falling asleep were more likely to use alcohol in order to improve
overall cigarette smoking approached significance (P < .1), while              sleep. Approximately 30% of insomniacs self-medicate with al-
the remainder of the sleep hygiene variables were not independent             cohol or over-the counter medications.20 Furthermore, insomniacs
predictors of insomnia (P > .1).                                              who use alcohol have greater levels of daytime sleepiness than do
                                                                              insomniacs who do not use alcohol. The present results show that
DISCUSSION                                                                    13% of insomniacs consume their last alcoholic beverage within
   The results of this study demonstrate that individuals with                30 minutes of bedtime. It has been shown that tolerance to the
insomnia engage in some inappropriate sleep practices, such as                sleep-inducing effects of alcohol develops within several nights.21
smoking, alcohol use, and compensatory sleep (ie, naps and sleep-             Consequently, individuals who use alcohol to promote sleep not
ing-in on weekends), more frequently than do normal sleepers.                 only increase their social use, but also increase their intake after
These sleep-related health practices could potentially exacerbate             several nights of exposure.22 In the present study, insomniacs re-
or perpetuate an existing sleep disturbance. Our findings are simi-            ported an average frequency of alcohol use of 5 days per week
lar to previous studies of sleep hygiene, which have demonstrated             in comparison to 2 days per week in controls. These lines of evi-
an association between smoking, alcohol use, and compensatory                 dence suggest the possibility that individuals with insomnia who
sleep. Our results are also consistent with existing behavioral               self-medicate with alcohol may be at a higher risk for the devel-
treatment regimens (e.g., cognitive behavioral treatments) that               opment of alcohol dependence, but further research in this area is
frequently employ a general component addressing sleep hygiene                clearly needed before such a conclusion can be made.
for insomnia patients.9                                                           Since caffeine has been known to disturb sleep, we chose to
   It is important to emphasize that while previous studies have              evaluate its use as a component of sleep hygiene.23,24 Though
demonstrated the disruptive sleep effects of some of the poor                 caffeine consumption was found to be slightly increased for the
sleep practices assessed in the present study (e.g., caffeine con-            insomnia group compared to controls, the difference was not sta-
sumption) the data do not provide information regarding causal-               tistically significant. While the present data do not provide sup-
ity.14 Although, these data provide useful information regarding              port for caffeine consumption as a target for treatment, we did not
the population prevalence of these behaviors in insomniacs and                specifically differentiate the time of caffeine consumption. Thus,
matched controls, the direction of any potential causality also               it is difficult to make a definitive conclusion in this regard. It is
remains unknown. For example, the current data do not inform                  possible that insomniacs consume caffeine in the morning in re-
whether a reduction in smoking prior to bedtime would improve                 sponse to poor sleep the previous night. In contrast, because caf-
sleep or potentially disrupt sleep due to possible nicotine with-             feine is widely used and known to adversely effect sleep, perhaps
drawal effects close to sleep onset. While the behaviors assessed             insomniacs deliberately avoid such substances. Finally, individu-
are considered important aspects of sleep hygiene,12,15 continued             als with insomnia may not consume more caffeine, but they may
research is necessary to test the potential therapeutic effects of            be more sensitive to it than are other people. These questions need
alterations in each of these specific sleep hygiene components.                to be addressed in future studies.
What the present data do suggest is that there are diverse and                    Daytime napping has also been associated with poor sleep hy-
highly relevant targets for sleep hygiene in the insomnia popula-             giene, in so far as frequent naps may decrease the homeostatic
tion.                                                                         drive for nocturnal sleep. Generally, it has been accepted that
   There have been few studies that include smoking as a specific              sleep need is approximately 8 hours per 24-hour period. As a re-

SLEEP, Vol. 28, No. 5, 2005                                             613                                Sleep Hygiene and Insomnia—Jefferson et al
sult, any sleep accumulated during the day may decrease an indi-               studies will need to determine where inappropriate sleep hygiene
vidual’s sleep drive at night, thereby producing sleep disturbance.            fits within the purposed multifactoral model of insomnia. Specif-
The present data, demonstrating a greater frequency of naps per                ically, many individuals may unknowingly utilize inappropriate
week in insomniacs, are consistent with this notion. However, it               sleep practices for the purpose of minimizing sleep disturbance.
must be recognized that polysomnographic data on the napping                   For example, a person may smoke or have a drink just prior to
behavior of insomniacs are sparse and inconsistent.25-27 Because               bedtime in order to relax and hence to facilitate sleep. Though
the majority of literature regarding napping is based on the sleep             some individuals may believe these behaviors improve sleep,
of normal individuals, controlled studies are needed to more sys-              they are likely to prolong sleep latency and exacerbate sleep dis-
tematically understand the potential impact of daytime naps on                 turbance over time.
nocturnal sleep in individuals with insomnia.                                     Previous studies have shown that individuals will often en-
   While individuals with insomnia in our study report less total              gage in multiple unhealthy behaviors.17 In the multivariate
sleep time on both weekdays and weekends, there was no differ-                 analysis, naps per week were not a significant predictor, sug-
ence in nightly time in bed compared to controls. Interestingly,               gesting that other sleep hygiene behaviors covary with daytime
insomniacs report more frequently sleeping in on nonwork days.                 nap frequency. Indeed, a posthoc correlation matrix using all of
Sleep efficiency was lower in the insomniacs than in control par-               the sleep hygiene parameters measured shows that napping is
ticipants. Sleep efficiency in our data is consistent with previous             closely associated with sleeping-in on weekends (r = .14, P <
findings commonly of < 80% in both self-reported and polysom-                   .005). Similarly, the fact that drinks per week were no longer
nograph data.28 One might speculate that such excess time in bed               a significant predicator of insomnia in the multivariate model
may contribute to elevated arousal associated with the bedroom                 suggests that the differences found (increased drinks per week
environment, as has been suggested by previous investigators.29                in insomniacs) is likely mediated by alcohol use specific to sleep
This possibility is also supported by studies showing that sleep               near bedtime.
restriction therapy, where time in bed is reduced to approximate                  In conclusion, this population-based study demonstrated that
habitual total sleep time and then slowly extended as sleep effi-               insomniacs exhibit poor sleep behaviors. Insomniacs are more
ciency improves, is an effective treatment for improving sleep in              likely to smoke and drink alcohol and do so close to bedtime.
patients with insomnia.30                                                      Furthermore, they are also more likely to “sleep in,” possibly
   There were several limitations to this study that should be ac-             in an attempt to compensate for their disturbed sleep at night.
knowledged. Because this was a population-based sample, clini-                 Finally, while some insomniacs may engage in these activities
cal evaluations were not used to assess insomnia; thus, our results            with the aim of improving their sleep, such behaviors may be
may not generalize to clinical populations. However, the crite-                exacerbating or perpetuating their sleep disturbance.
ria employed for identifying insomniacs in the current study was
based on the Diagnostic and Statistical Manual of Mental Disor-                ACKNOWLEDGMENTS
ders, Fourth Edition and included a standardized and conserva-
                                                                                  This research was supported by the National Institute of Men-
tive measure of severity over the past 3 months. Therefore, the
                                                                               tal Health Grant K23-068372, 59338 to Drs. Drake and Roth
current sample is not likely to be biased in the direction of milder
                                                                               respectively.We would like to give a special thanks to Zoe Anne
insomnia. In addition, the prevalence of insomnia using this cri-
                                                                               Gibson.
terion is consistent with other population-based studies.31,32 Caf-
feine use was measured only by the number of caffeinated bever-
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                                                                     Appendix
  1) Overall cigarette smoking: “during the 12 months, did you ever smoke tobacco regularly?”
  1a)“During the last 2 weeks, how many cigarettes per day did you usually smoke?”
  2) Smoking near bedtime: “in the last 2 weeks, how close to the time you went to bed did you usually finish your last cigarette?” (within 5, 6-
     30,31-60 minutes, or more than one hour before bed).
  *3)Overall alcohol use: “during the last 12 months, about how often did you drink alcohol?” (every day, nearly every day, 3-4 days a week, 1 or 2
     days a week, 2 or 3 a month, once per month, less than once a month, never/did not drink alcohol in last 12 months).
  *4)Alcohol uses for sleep: “in the past year, did you ever drink alcohol to help you fall asleep?”
  *4a)“When you drank an alcoholic beverage in the last 2 weeks, how close to the time you went to bed did you usually finish your last drink?”
     (less than 30 minutes before bed, 30 to just under and hour, 1 to just under 2 hours, 2 to just under 4 hours, or 4 or more hours before bed).
  **5)Caffeine use: “in the past two weeks, on average, how many cups of caffeinated coffee did you drink per day?”
  **5a)“In the past two weeks, on average, how many cups of other caffeinated beverages did you drink per day, such as pop or tea?”
  6) Napping: “How many days during the past two weeks did you nap?”
  7) Time in bed: “Thinking about your average weekday, how many hours did you actually sleep, each day, during the past two weeks?”
  7a)“Thinking about your average weekend, how many hours did you actually sleep, each day, in the past two weeks?”
  8) Reported likelihood of sleeping in on weekends: “in the past two weeks, did you sleep in on days you didn’t work?” (often, sometimes, rarely,
     or never true for you).
  9) Time in bed: “At what time did you typically get up on weekdays (during the past two weeks)? And, at what time did you typically go to bed on
     weekdays (during the past two weeks)?”
  10)“Thinking about your average weekday, how many hours did you actually sleep, each day (during the past two weeks)?”
  11)“At what time did you typically get up on weekends (during the past two weeks)?”
  12)“And, at what time did you typically go to bed on weekends (during the past two weeks)?”
  13)“Thinking about your average weekend, how many hours did you actually sleep, each day (during the past two weeks)?”

  *Combined questions to get an assessment of the number of drinks per week.
  **Combined the two questions to get a total caffeine use per day.


SLEEP, Vol. 28, No. 5, 2005                                               615                                 Sleep Hygiene and Insomnia—Jefferson et al

				
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