Success in stopping smoking depends on the balance between the individual's motivation to quit and their degree of nicotine dependence, and clinicians should be able to evaluate both aspects.1 The Fagerström Test for Cigarette Dependence (FTCD)2 is the most widely used tool for measuring nicotine dependence. It consists of 6 questions, and a score≥6 indicates a high level of dependence.3 Motivation to quit is important because the treatments that have been shown to help subjects stop smoking do not work as well in smokers who are not highly motivated.1 Motivation can be assessed qualitatively, by asking the smoker directly about their interest and intention to give up, and this approach often works in clinical practice.1 A semiquantitative method, the visual analog scale, can also be used, and quantitative methods1 are also available, including the Richmond test (RT), the Henri Mondor Paris test (HMP), and the Khimji–Watts test (KW). Motivation and the number of previous attempts to quit have been shown as predictors of effort, while a low level of dependence4,5 and a high level of self-efficacy6 have been shown to be predictors of abstinence after the attempt. When motivation is separated into its different components, “desire” and “intention” have been shown as independent predictors of the attempt to quit, while “duty” mitigates the predictive value of the previous two.7 Another aspect to bear in mind is that motivation and dependence are related: motivation varies over time and is heavily influenced by circumstances. When smokers tell us about their desire to quit in the clinical interview, they may not be accurately reflecting their true feelings.1

It has been reported that an increased motivation to change correlates negatively with the level of dependency, and that these factors, together with age, predict relapse.8 Gantiva et al.9 found a significant negative correlation between the level of dependency and motivation in a group of college students.

Our hypothesis is that subjects with greater reliance on nicotine are less motivated to stop smoking. The aim of this study was to evaluate the existence of an association between the degree of nicotine dependence measured by the FTCD and tests of motivation to quit smoking conducted in this study.

The most important finding of our study is that no association was observed between dependence measured by the FTCD and the various motivation tests. At this point, the question we must ask is whether the motivation tests really measure motivation to quit smoking. It is of the utmost importance to have health measurement scales that can be used in clinical practice and research, and it is imperative that these instruments undergo a validation process to ensure the quality of their measurements. This process consists of adapting the instrument to the cultural environment where it will be administered, and verifying its psychometric characteristics, including reliability, validity, sensitivity, and feasibility. If we are to use a scale with any degree of confidence, we must be sure that it provides an accurate and reliable measurement under the same circumstances, that it is sensitive to changes in the clinical situation, and that it is easy to use in practice. This process of testing the characteristics of an instrument is called validation.10 None of the motivation tests used in this study has been validated in their original language nor, of course, in Spanish (aside from language differences, there are cultural differences between different populations that make these procedures essential). In addition, the cut-off point indicating when motivation for quitting smoking can be considered high is unknown. An analysis of the psychometric properties of the FTCD confirmed its reliability for the assessment of nicotine dependence in different environments and populations.11 The FTCD was developed after the previous 10-question version showed psychometric disadvantages, low criterion validity and a multifactorial structure.12 Becoña and Vazquez13 studied a group of Galician smokers to assess the applicability of the Spanish version of the FTCD and its relationship with age, sex, and the consumption of cigarettes. The authors found that the value of the test increases with age and tobacco consumption, and that its value is greater in men than in women. The authors suggest that the Spanish version of the FTCD is useful for measuring dependency and identifying smokers with an increased risk of developing smoking-related diseases.

The widespread use of the different questionnaires used in this study has led them to be considered appropriate for measuring dependence and motivation. Richmond et al.14 conducted a study in a primary care setting to identify characteristics that predicted continuous abstinence in a group of smokers. In this study, they evaluated participants’ motivation to quit smoking by designing a rating scale, with a range of 0–10 (10: high motivation), based on the 4 questions that are currently included in the test known as the RT. In the discussion, the authors indicated that a significant proportion of smokers responded positively to the 4 questions of the RT, indicating that many of them wanted to quit smoking. Those who obtained the highest score in the scale were up to 4.5 times more likely to remain abstinent for 12 months than those with a minimum score. According to the authors, these results supported the robustness of this scale as a predictor of abstinence. The RT includes 2 questions that were previously used by Russell15 to determine the respondent's motivation to quit smoking, and these were used to build a simple model of smoking cessation based on the degree of motivation to quit smoking and on the degree of nicotine dependency among the smokers. The greater the motivation, the higher the chances of quitting smoking; and the greater the dependence, the lower the possibility.

The HMP motivation questionnaire is easy to complete and relatively short, but poorly validated.16 The HMP has been used in various studies to determine the degree of motivation to quit smoking,16–21 with low motivation categorized as a score of equal to or less than 12, and high motivation when the value is greater than 12. Layoun et al.,21 in a study to establish predictors of attempts to quit among Lebanese smokers, found that the HMP and FTCD showed acceptable reliability as measured by Cronbach's alpha statistic (HMP [0.757] and FTCD [0.789]), and that smokers with high motivation as measured by the HMP were twice as likely to quit smoking (P=0.007, OR=1.98; 95% CI: 1.21–3.26) In another study,20 the same group aimed to determine the predictors of prior attempt and time of abstinence, and found that a longer period of abstinence (more than one month) was associated with low dependence on nicotine and with high motivation as measured by the HMP; subjects with a high score on the motivation test were twice as likely to maintain a longer period of abstinence. Similarly, Mannocci et al.17 conducted a study aimed at determining whether the photographs and health alerts printed on cigarette packets helped achieve greater abstinence or a reduction in the number of cigarettes smoked, stratified by demographic characteristics, dependence on nicotine, and motivation as measured by the HMP. They found that the more motivated group of smokers was better informed than the less motivated group and believed that warnings on cigarette packets increased awareness and motivation to reduce consumption and quit smoking. All these studies cite La Torre et al.22 whenever the HMP test is mentioned; however, this reference is merely a review of the available tests for measuring motivation.

The KW test appears in a French website to help quit smoking (Tabac info Service, in French)23 which cites a study published in 199424 as the source of the test, but that has not been validated either. With regard to the analog scales, these have been considered by most authors as reliable and valid measurement tools, although they have their limitations.25 Lindberg et al.26 evaluated factors associated with smoking cessation and compared the characteristics and nicotine dependence of smokers with and without chronic obstructive pulmonary disease. The authors used analog scales to measure motivation and self-efficacy, and found that they were perfectly valid for discriminating between high or low motivation and self-efficacy.

It seems therefore that we can answer the question posed at the beginning of this discussion by saying that, with the exception of the KW (for which there is no written evidence), these motivation scales can distinguish between individuals with more chance of quitting or a greater number of attempts to give up, since this group scores higher in these scales. Motivation is key to change; it is a multidimensional, dynamic and fluctuating state that is interactive and can be modified: a patient's motivation may be affected by the personal style of their treating physician.27 All of these elements could explain why motivation to quit smoking measured by these tests has no correlation with the degree of nicotine dependence measured by the FTCD.

Another finding of our study was that the average daily consumption of cigarettes and the cumulative consumption of tobacco were higher in men than in women. This fact has already been established, as several previous studies have shown that men and women differ in their smoking habits: women smoke fewer cigarettes per day, start smoking later in life, and have a lower accumulated consumption, they tend to use cigarettes with a lower nicotine content, and do not inhale as deeply as men. Women smokers, moreover, become dependent quicker, and have serious difficulties giving up.28,29

Our study has some limitations. 1) The findings were obtained from a routine clinical practice population who came voluntarily to the smoking cessation clinic to make a serious attempt to quit smoking, and might not reflect the situation had these test scores been obtained from a general population of smokers. 2) The results cannot be extrapolated to the general population, and replicating this study in different scenarios and geographical locations could produce other results. 3) The use of questionnaires in patients is not always accurate due to potential problems in understanding the questions, or the possibility that some questions are understood implicitly, others are downplayed, and others are just omitted, which could result in certain information biases. 4) It has been established that the scores obtained on patient questionnaires differ, depending on whether they are administered by the healthcare professional or are self-administered, and the moment at which the information is collected should also be uniform, as this factor could also affect the final results. This variability could lead to different results.

We believe, therefore, that it would be advisable to perform a more ambitious study in a greater number of patients, in order to complement the information obtained in this study, and to confirm whether or not there is a relationship between the degree of dependency and the motivation to quit smoking.

In conclusion, we found no association between the degree of dependency and the motivation to quit smoking as measured with the tests used here, so the proposed hypothesis cannot be supported.

This study was supported with a SEPAR 2013 grant.

The authors state that they have no conflict of interests.