(Nicotine Dependence Syndrome Scale) and Assessment of
Contents
1. 56 Also the correlation between the NDSS T with the number of cigarettes smoked per day was high r 46 but it was low when correlated with the CO level r 29 These results indicated that different scales as well as cigarette consumption and smokers CO scores have important elements in common and that the NDSS T is highly related to all of them Perhaps the most important finding was that the correlation of the SCID was equivalent to the NDSS T and the FTND The main conclusion of this study was that in this Spanish sample the NDSS T had both adequate reliability and discriminative power However the scales derived factorially did not The NDSS T 12 items proved to be a brief and useful instrument for nicotine dependence assessment As Kassel 2000 pointed out the operationalization of the construct of nicotine dependence is still a work in progress and as such there is no gold standard with respect to its assessment p 32 The present study demonstrates the truth of this assertion We need to understand nicotine dependence to have adequate assessment instruments preferably brief de Leon et al 2003 and to explore their predictive capacity Hence there is a need to continue research in this area both at the theoretical level and at the level of developing new assessment instruments Brandon Herzog Irwin amp Gwaltney 2004 There are three major limitations in the present study The first limita2. using a MicroSmokerlyser Bedfont Technical Instruments Sittingbourne Kent United Kingdom We used this physiological measure because it is the preferred method for the detection of recent smoking West Hajek Stead amp Stapleton 2005 Results Factor analysis of the NDSS Given the adequate sample size used N 637 the Kaiser Meyer Olkin measure of sampling adequacy 77 indicated that it was appropriate to proceed to a factor analysis The principal components of factor analysis indicated that the ideal number of factors to extract is 6 using the criterion of 1 or more of explained variance or 6 or 2 according to the graphic representation of the sedimentation matrix However extracting and rotating 5 and 6 factors by means of varimax orthogonal rotation it was observed that with 5 factors the interpretation was correct This fits almost perfectly with the results of Shiffman et al 2004 regarding the validation of this questionnaire using U S samples The five factors explained 52 55 of the variance Table 1 Thus the factors obtained through varimax orthogonal rotation are perfectly interpretable such as I Drive II Continuity Stereotypy IV Priority and V Tolerance These factors were retained for subsequent analyses We used a score of 30 or more in the factor loading for retaining the items in each factor Kline 1984 Thus the first scale has 8 items and the rest had 4 5 3 and 4 respectively For th
3. 1020 Shiffman S Waters A J amp Hickcox M 2004 The Nicotine Dependence Syndrome Scale A multidimensional measure of nicotine dependence Nicotine amp Tobacco Research 6 327 348 960 BECO A LOPEZ FERNANDEZ DEL R O M GUEZ AND CASTRO United States Department of Health and Human Services 1988 West R Hajek P Stead L amp Stapleton J 2005 Outcome The health consequences of smoking Nicotine addiction A criteria in smoking cessation trials Proposal for a common report of the Surgeon General Rockville MD United States standard Addiction 100 299 303 Department of Health and Human Services World Health Organization 1992 CD 10 The ICD 10 United States Department of Health and Human Services 2004 Classification of Mental and Behavioural Disorders Geneva The health consequences of smoking A report of the Surgeon World Health Organization General Atlanta GA United States Department of Health and Human Services Centers for Disease Control and Prevention Received May 13 2009 National Center for Chronic Disease Prevention and Health Revision received December 3 2009 Promotion Office on Smoking and Health Accepted February 13 2010
4. 1481 1486 Donny E C 8 Dierker L 2007 The absence of DSM IV nicotine dependence in moderate to heavy daily smokers Drug and Alcohol Dependence 89 93 96 Etter J F 2005 A comparison of the content contruct and predictive validity of the Cigarette Dependence Scale and the Fagerstr m Test for Nicotine Dependence Drug and Alcohol Dependence 77 259 268 Fagerstr m K O 1978 Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment Addictive Behaviors 3 235 241 Fagerstr m K O Kunze M Schoberberger R Breslau N Hughes J R Hurt R D et al 1996 Nicotine dependence versus smoking prevalence Comparisons among countries and categories of smokers Tobacco Control 5 52 56 First B Spitzer L Gibbon M Williams J B amp Smith Benjamin L 1998 Gu a del usuario de la entrevista cl nica estructurada para los trastornos del eje I del DSM IV SCID I Structured Clinical Interview for DSM IV Axis I Disorders Clinician Version Barcelona Masson Franco M 2007 An lisis de curvas ROC principios b sicos y aplicaciones Analysis of ROC curves Basic principles and applications Madrid La Muralla Hamblenton K Merenda P F amp Spielberger C D 2005 Adapting educational and psychological tests for cross cultural assessment London Lawrence Eribaum Associates Heatherton T F Kozlowski L T
5. 16 Whenever I go without a smoke for a few hours I experience craving 144 027 178 083 18 748 Siempre que estoy sin fumar durante algunas horas siento unas ganas muy fuertes de hacerlo 17 My cigarette smoking is fairly regular throughout the day 286 109 723 059 187 373 Mi consumo de cigarrillos es bastante regular a lo largo del dia 18 After not smoking for a while I need to smoke to relieve feelings of restlessness and irritability 780 074 082 063 001 735 Despu s de estar un tiempo sin fumar necesito hacerlo para aliviar las sensaciones de inquietud e irritabilidad 19 I smoke about the same amount on weekends as on weekdays 042 161 523 194 235 187 Fumo la misma cantidad de tabaco durante la semana que en el fin de semana SPANISH ADAPTATION OF THE NDSS 955 have 10 items with two of them approaching the limit of 30 29 and 28 Each scale was calculated by assigning items to scales according to their highest factor loading as suggested by Clark et al 2005 Reliability of the scales We assessed the internal consistency ofthe overall NDSS subscales and the NDSS T scale by computing Cronbach s a coefficient for the sample The results indicated adequate reliability for the total scale NDSS T a 76 which is formed by 12 items ofthe first unrotated factor With respect to the reliability of the rest of the scales it is adequate for Drive 74 and moderate or low for the remainder 6
6. 45 gg M 838 828 1027 8 59 826 739 770 Mean 12 94 14 09 m 1426 12 82 ex 1427 13 29 1291 Continuity SD 451 423 3 295 414 455 4 189 417 438 4 78 4 671 16 59 14 91 14 41 17 11 14 83 15 91 16 82 St 3 92 1 6 470 5 044 5 32 sp 504 542 97 517 5 42 5 60 2 Mean 4 73 472 4 58 4 89 4 72 4 56 5 38 IV Priorit 064 1 54 3 449 Meo 2 65 2 33 2 19 276 2 43 227 3 18 9 11 63 12 22 12 06 11 86 12 31 11 50 12 89 e AS uf 431 agp 9 415 9 427 437 PS Mean 32 59 32 73 31 96 33 53 32 72 32 04 35 10 APSE sD 1024 1032 17 1005 1053 1914 1045 1005 1045 2786 Note Significant between single and married Significant between single and others Significant between married and others ek lt 05 p lt 01 5 Aspects related to smoking the NDSS scale Daily number of cigarettes Have you tried to give up smoking in the last year 1 19 20 or more t Yes No t a Mean 20 71 26 84 9 95 7H 24 50 23 52 T SD 7 97 7 54 8 68 8 19 Mean 13 93 13 31 13 39 13 70 II Continuit 1 793 804 Continuity SD 4 56 4 18 12 4 17 4 46 0 Mean 14 37 16 84 m 1541 15 69 III Stereotypy SD 5 26 523 5 941 5 39 5 39 591 Mean 4 12 5 32 4 13 4 95 i T IV Priority SD 1 92 2 78 6 319 2 04 2 58 3 801 Mean 11 06 12 88 11 82 12 04 V Tol 5383 585 SD 4 14 4 37 4 29 4 38 Mean 28 68 36 60 32 81 32 62 NDSS T SD 9 33 9 66 10 517 9 78 10 48 205 p
7. cigarrettes per day 4444 03 ERE IU 26 46 CO Level SITE 09 l6 09 299 I Drive 1 00 03 pets Jer 298 ODETE II Continuity 03 1 00 43 01 36 01 Stereotypy qe 43 1 00 19779 19 e IV Priority IAE 01 ESE 1 00 10 N V Tolerance 20 5 36 19 10 1 00 369 Total NDSS IINE 01 Spe 36 1 00 Note FTND Fagerstr m Test for Nicotine Dependence SCID The Structured Clinical Interview for DSM IV p lt 001 956 BECO A L PEZ FERNANDEZ DEL R O M GUEZ AND CASTRO Table 3 Dependence non dependence with the SCID and the FTND on the NDSS T and subscales FTND SCID Non dependence Dependence t Non dependence Dependence t Mean SD Mean SD Mean SD Mean SD I Drive 21 86 7 90 29 42 6 90 10 865 17 23 6 38 26 41 7 56 14 419 II Continuity 13 55 4 40 13 79 4 31 599 12 32 4 92 14 13 4 08 4 773 Stereotypy 15 13 5 37 17 00 5 20 3 844 15 84 5 34 15 52 5 40 678 IV Priority 4 23 2 05 6 17 2 95 9 244 3 97 1 91 5 02 2 60 4 919 V Tolerance 11 52 4 30 13 32 4 22 4 635 10 81 4 55 12 44 4 18 4 333 NDSS T 30 08 9 47 40 20 8 76 11 992 25 33 7 62 35 59 9 74 12 706 lt 001 Table 4 Differences in various sociodemographic characteristics Sex Age Marital status Males Females t 18 40 gt 40 t Single Married Others F Mean 23 42 24 06 23 43 24 23 23 88 23 53 24 64 TS SD 8
8. dependent smokers in our study may be due to the fact that smokers are more likely to fall ill precisely because they smoke U S D H H S 2004 which leads them to visit their GP more often The ROC curves indicated that only the first two factors of the NDSS were adequate for predicting nicotine dependence vs non dependence according to the SCID These were the two scales with the highest reliability levels and those that worked best in relation to the other scales a coefficients of 74 and 60 If we use the NDSS T the prediction level is good with a value of 79 under the curve and better than the FTND This also indicated that both the NDSS T and the FTND assess a substantial part of the variance of nicotine dependence as evaluated with the SCID Another relevant result of this study was the predictive capacity of the NDSS T in relation to others traditionally used for determining the nicotine dependence level or the level of smoking A multiple regression analysis indicated the utility of the NDSS because of its high level of prediction of nicotine dependence It was also a better predictor than the other criteria such as the number of smoked cigarettes per day the CO level and the FTND scale Correlation analysis of the different variables of the study indicated that the correlation between the NDSS T and other scales or variables related to smoking were high and always significant with the FTND r 58 and with the SCID
9. moderada o baja para el resto de los factores La NDSS T y sus escalas correlacionan significativamente con el Test de Dependencia de la Nicotina de Fagerstr m FTND con los criterios de dependencia de la nicotina del Manual Diagn stico y Estad stico de los Trastornos Mentales IV DSM IV evaluados mediante la Entrevista Clinica Estructurada para el DSM IV SCID IV con el nivel de mon xido de carbono en aire espirado CO y con el n mero de cigarrillos fumados al d a La curva ROC indica que la NDSS T tiene una puntuaci n de 79 bajo la curva 69 para el FTND lo que indica que la predicci n de la dependencia de la nicotina es adecuada Se concluye que este instrumento es til en relaci n a la puntuaci n total NDSS T para evaluar la dependencia de la nicotina en fumadores espa oles en Espa a tal y como se ha encontrado en otros pa ses lenguas y culturas Palabras clave fumar evaluaci n dependencia nicotina NDSS This study was partially funded by a grant for research projects awarded by the Comit Nacional para la Prevenci n del Tabaquismo CNPT The present study was conducted within the framework of the collaboration agreement between the University of Santiago de Compostela Spain Tobacco Addiction Unit and the Servicio Andaluz de Salud Distrito Sanitario M laga We would like to thank Saul Shiffman for authorizing our use of the NDSS in Spain We also thank those who made it possible to carry out the study at
10. 0 for Continuity 56 for Stereotypy 43 for Priority and 39 for Tolerance The analysis of reliability by items on each of the scales confirmed the previous results All items of the total scale had very good reliability from 72 to 77 Reliability was also adequate for the Drive factor from 68 to 76 but low for the rest of the factorially derived scales In the present sample the reliability obtained for the FTND by means of Cronbach s a coefficient was 65 Concurrent validity The concurrent validity assessment of the same construct with different methods of the NDSS was evaluated by correlating the NDSS measures with the FTND the DSM IV criteria and the smoking rate The results indicated that the correlation between the NDSS T and the FTND and SCID is high and significant with values of 58 p lt 001 between the NDSS T and FTND and 56 p lt 001 between the NDSS T and SCID In turn the correlation between the FTND and the SCID was Table 2 38 p lt 001 The correlation between the NDSS T and the number of cigarettes smoked per day was significant r 46 p lt 001 as was the assessment of the CO level 7 29 p lt 001 A more detailed analysis of each of the NDSS items indicated that almost all of the 19 items correlated significantly with the NDSS T the FTND the SCID the assessment of CO level and the number of cigarettes smoked per day Table 2 In turn using the SCID criteria of d
11. 6 Suppl 2 201 226 Beco a E amp V zquez F 1998 The Fagerstr m Test for Nicotine Dependence in a Spanish sample Psychological Reports 83 1455 1458 Brandon T H Herzog T A Chad J E amp Gwaltney J 2004 Cognitive and social learning models of drug dependence Implications for the assessment of tobacco dependence in adolescents Addiction 99 Suppl 1 51 77 Breslau N Johnson E O Hiripi E amp Kessler 2001 Nicotine dependence in the United States Prevalence trends and smoking persistence Archives of General Psychiatry 58 810 816 Broms Y U Madden P A Heath A C Pergadia M L Shiffman S amp Kaprio J 2007 The Nicotine Dependence Syndrome Scale in Finnish smokers Drug and Alcohol Dependence 89 42 51 Clark D B Wood D S Martin C S Cornelius J R Lynch K G amp Shiffman S 2005 Multidimensional assessment of nicotine dependence in adolescents Drug and Alcohol Dependence 77 235 242 Costello D Dierker L Sledjeski E Flaherty B Flay B amp Shiffman S 2007 Confirmatory factor analysis of the Nicotine Dependence Syndrome Scale in an American college sample of light smokers Nicotine Tobacco Research 9 811 819 De Leon J D az F J Beco a E Gurpegui M Jurado D amp Gonz lez Pinto A 2003 Exploring brief measures of nicotine dependence for epidemiological surveys Addictive Behaviors 28
12. Frecker R C amp Fagerstr m K O 1991 The Fagerstr m Test for Nicotine Dependence A revision of the Fagerstr m Tolerance Questionnaire British Journal of Addictions 85 1119 1127 Hughes J R Helzer J E amp Lindberg S A 2006 Prevalence of DSM ICD defined nicotine dependence Drug and Alcohol Dependence 85 91 102 Hughes J R Oliveto A H Riggs R Kenny M Kiguori A amp MacLaughlin M A 2004 Concordance of different measures of nicotine dependence Two pilot studies Addictive Behaviors 29 15277 1539 Kassel J D 2000 Are adolescent smokers addicted to nicotine The suitability of the nicotine dependence construct as applied to adolescents Journal of Child and Adolescent Substance Abuse 9 27 49 Kline P 1994 An easy guide to factor analysis London Routledge Nunnally J C amp Bersnstein I H 1994 Psychometric theory New York McGraw Hill Okuyemi K S Pulvers K M Cox L S Thomas J L Kaur H Mayo M S et al 2007 Nicotine dependence among African American light smokers A comparison of three scales Addictive Behaviors 32 1989 2002 Piper M E McCarthy D E Bolt D M Smith S S Lerman C Benowitz N et al 2008 Assessing dimensions of nicotine dependence An evaluation of the Nicotine Dependence Syndrome Scale NDSS and the Wisconsin Inventory of Smoking Dependence Motives WISDM Nicotine amp Tobacco Research 6 1009
13. IV American Psychiatric Association 2000 and the International Statistical Classification of Diseases and Related Health Problems 10th Revision ICD 10 World Health Organization 1992 the most widely used procedures for assessing nicotine dependence are the Fagerstr m scales The original Fagerstr m Tolerance Questionnaire Fagerstr m 1978 is more than 30 years old but more recently the Fagerstr m Test for Nicotine Dependence FTND Heatherton Kozlowski Frecker amp Fagerstr m 1991 has become the most widely used in the field of smoking assessment The reliability of this six item test is low between 56 and 80 for the original version and 66 for the Spanish adaptation Beco a amp Vazquez 1998 The reliability for a good questionnaire is 70 or more Nunnally amp Bernstein 1994 In recent years it has been recommended to assess nicotine dependence with scales that are more comprehensive and more closely in line with DSM IV criteria in view of the low reliability of the FTND Actually there are several new scales such as the Cigarette Dependence Scale CDS Etter 2005 and the Nicotine Dependence Syndrome Scale NDSS Shiffman Waters amp Hickcox 2004 that address the low reliability of the Fagerstr m scales and adhere to the DSM IV criteria The NDSS is the most utilized of the two This questionnaire is composed of 19 items and includes five dimensions Drive craving withdrawal and subjective compulsi
14. The Spanish Journal of Psychology Copyright 2010 by The Spanish Journal of Psychology 2010 Vol 13 No 2 951 960 ISSN 1138 7416 Spanish Adaptation of the NDSS Nicotine Dependence Syndrome Scale and Assessment of Nicotine Dependent Individuals at Primary Care Health Centers in Spain Elisardo Becofia Ana L pez Elena Fern ndez del Rio M Carmen M guez and Josefina Castro Universidad de Santiago de Compostela Spain Servicio Andaluz de Salud Spain The availability of adequate instruments for the assessment of nicotine dependence is an important factor that is relevant in the area of tobacco addiction In this study we present a Spanish validation of the Nicotine Dependence Syndrome Scale NDSS Shiffman Waters amp Hickcox 2004 The sample was composed of patients all daily smokers who visited their General Practitioner GP at five Primary Health Care Centers in different cities of Spain N 637 The results indicated adequate reliability for the general factor that assesses nicotine dependence NDSS Total Cronbach s 76 Factor analysis confirms the five factors of the original validation Drive Continuity Stereotypy Priority and Tolerance It must be noted that reliability is adequate for the first and moderate or low for the rest The NDSS T and its scales correlate significantly with the Fagerstr m Test for Nicotine Dependence FTND with the nicotine dependence criteria of the Diagnostic and Statistica
15. c 001 SPANISH ADAPTATION OF THE NDSS and Others 78 separated divorced or widowed we detected differences on the following factors Single people scored significantly higher on Continuity than did Married people Others scored higher on Stereotypy than Singles and Others produced higher scores on Tolerance than did Married Table 4 With respect to cigarette consumption smokers of 1 19 cigarettes vs smokers of 20 or more per day we found significant differences on the NDSS T and on four of the five scales Drive Stereotypy Priority and Tolerance Smokers of 20 or more cigarettes per day scored highest on all scales There were no significant differences between those who smoked to 19 cigarettes per day and those who smoked 20 or more per day on Continuity There were only differences on the Priority scale between participants who had attempted to give up smoking in the previous year and those who had not Smokers who didn t try to give up obtained higher scores Table 5 Prediction of nicotine dependence SCID with the NDSS using ROC curves A ROC Relative Operating Characteristic curve is a graphic method that determines the optimum point of classification based on the differentiation functions between two groups In addition the ROC curves make it possible to determine the optimum cut off point in the 1 0 0 8 Sensitivity e e T 0 2 0 0 0 0 0 2 0 4 Specificity 957 assignmen
16. e I wouldn t be 204 086 016 668 051 437 allowed to smoke Si tengo que hacer un viaje largo no me planteo viajar en avi n porque s que no est permitido fumar 4 Sometimes I decline offers to visit with my non smoking friends because I know feel 010 008 037 766 074 299 uncomfortable if I smoke A veces dejo de visitar a mis amigos no fumadores porque s que me sentir inc modo si fumo 5 I tend to avoid restaurants that don t allow smoking even if I would otherwise enjoy the food 266 154 103 589 115 474 Tiendo a evitar los restaurantes donde no se permite fumar incluso aunque me guste su comida 6 I smoke consistently and regularly throughout the day 372 100 674 148 053 549 Fumo de forma constante y regular a lo largo del d a 7 I smoke at different rates in different situations 4027 aT 047 120 110 003 Fumo distinta cantidad de cigarrillos en funci n de la situaci n en la que est 8 Compared to when I first started smoking I need to smoke a lot more now in order to get what 470 186 089 146 465 524 I really want out of it Comparado con cuando empec a fumar necesito fumar mucho m s ahora para conseguir el mismo efecto 9 Compared to when I first started smoking I can smoke much much more now before I start 202 181 009 007 705 283 to feel nauseated or ill Comparado con cuando empec a fumar ahora puedo fumar mucho m s sin llegar a sentir n useas o malesta
17. e first unrotated factor of the factor matrix NDSS T we retained those items with a loading above 25 As a result we have 12 items on the total scale Using the criteria of 30 we 954 BECO A L PEZ FERNANDEZ DEL R O M GUEZ AND CASTRO Table 1 Factor analysis principal components rotated factor matrix varimax 5 factors Spanish primary care patients N 637 Varimax Varimax Varimax Varimax Varimax Unrotated rotated rotated rotated rotated rotated Wi first factor factors factors factors factors factors ON I IV V Spanish version in brackets Drive Continuity Stereotypy Priority Tolerance NDSS Total 1 My smoking pattern is very irregular throughout the day It is not unusual for me to smoke 155 458 331 056 384 157 many cigarettes an hour then not have another one until hours later Mi forma de fumar es muy irregular a lo largo del d a No es extra o que fume muchos cigarrillos durante una hora y luego no fume ninguno hasta horas despu s 2 My smoking is not much affected by other things I smoke about the same amount whether Pm 158 272 211 006 616 015 relaxed or working happy or sad alone or with others etc Mi forma de fumar no se ve muy afectada por otras cosas Fumo m s o menos lo mismo si estoy relajado o si estoy trabajando contento o triste solo o en compa a de otros etc 3 Even if traveling a long distance I d rather not travel by airplane becaus
18. ependence 3 or more or non dependence 0 2 or the FTND criteria 6 or more dependent less than 6 non dependent we found that the NDSS T and the scales of Drive Stereotypy Priority and Tolerance differentiated between dependent and non dependent smokers with the FTND with scores always higher in dependents In accordance with the SCID dependent smokers scored significantly higher on the NDSS T Drive Continuity Priority and Tolerance Table 3 Characteristics of the smokers according to the NDSS assessment The NDSS T and the different scales are good discriminators of smokers demographic and cigarette consumption characteristics Using the raw scores we found significant differences in the factors of Continuity and Stereotypy according to sex and age Females scored higher on Continuity than males Males 12 94 Females 14 09 t 3 294 p lt 01 while males scored higher in Stereotypy than females M 16 59 F 14 91 t 3 921 p 001 By age groups the youngest scored higher in Continuity 14 26 vs 12 82 t 4 189 p 001 and the eldest scored higher in Stereotypy 14 41 vs 17 11 t 6 470 p lt 001 Considering marital status Single people n 242 Married people n 317 Correlations between scales CO level and cigarette consumption II Drive Continuity HI Stereotypy ty V Tolerance NDSS T FTND ote 01 24 37 M d 80 SCID IDEA ges 00 279 22 E N
19. even if the NDSS T offers the best prediction Origin of the curve FTND NDSS T 0 6 0 8 1 0 Figure 1 ROC curves of the FTND and NDSS T in relation to dependence non dependence assessed with the SCID 958 BECO A L PEZ FERNANDEZ DEL R O M GUEZ AND CASTRO Prediction of dependence We included the five factors of the NDSS its total score NDSS T the FTND the daily number of cigarettes and the CO level all continuous in stepwise multiple regression for predicting the number of symptoms on the SCID The results indicated that the only significant variables were the first and second factors of the NDSS Drive Beta 579 and Continuity Beta 167 R 608 When we used the number of cigarettes smoked per day the FTND the NDSS T and CO level the only significant variable was the NDSS T R 56 Beta 56 Discussion The results of our study provided support for our expectations as stated in the Introduction With a representative sample of daily smokers attending Spanish primary health care centers we obtained five factors similar to those of Shiffman et al 2004 Drive Continuity Stereotypy Priority and Tolerance Only the first factor Drive showed adequate reliability higher than 70 The first unrated factor NDSS T included 12 of the 19 items of the scale and it had adequate reliability a 76 These findings are similar to the Piper et al 2008 study that used three different sam
20. he cut off point Fagerstr m et al 1996 Procedure We contacted the Administrators of the Health Care Centers in which the study was to be carried out in order to obtain their permission They were provided with an explanation of the study a copy of the questionnaire and a copy of the authorization of the study by the Bioethics Committee of the University of Santiago de Compostela Once the Administrator of each Health Care Center authorized the study he or she informed the other professionals of the center and requested their cooperation The questionnaires were administered individually by center personnel to patients who were daily smokers 1 or more cigarettes per day for at least the previous month who were visiting their General Practitioners GP They were contacted by interviewers while they were in the waiting room At that time the subjects agreed to participate in the study or not participants had an appointment with their doctor on the day of the assessment The patients companions were not admitted to the study even if they were smokers of the participants in the study signed the informed consent document A psychologist trained for the study read and completed the questionnaire and resolved their doubts if any Approximately 10 15 minutes were required to complete the questionnaire Once the questionnaire had been completed the psychologist assessed the level of carbon monoxide in expired air CO
21. l Manual of Mental Disorders DSM IV as assessed through the Structured Clinical Interview for DSM IV SCID with carbon monoxide levels in expired air CO and with the number of cigarettes smoked The ROC curve indicates that the NDSS T has a score of 79 which is under the curve 69 for the FTND thus the prediction of nicotine dependence is adequate We conclude that this instrument is useful in terms of its total score NDSS T for assessing nicotine dependence for Spanish smokers in Spain as has been found in other countries language groups and cultures Keywords smoking assessment dependence nicotine NDSS Disponer de adecuados instrumentos de evaluaci n de la dependencia de la nicotina es un aspecto relevante en el area de la adicci n al tabaco En este estudio se presenta la validaci n espa ola de la Escala del S ndrome de la Dependencia de la Nicotina NDSS Shiffman Waters y Hickcox 2004 La muestra estuvo formada por fumadores diarios de cigarrillos que acudieron a su m dico de Atenci n Primaria en cinco centros de salud de diferentes ciudades de Espa a N 637 Los resultados indican una adecuada fiabilidad para el factor general que eval a dependencia de la nicotina NDSS Total a de Cronbach 76 El an lisis factorial confirma los cinco factores obtenidos en la validaci n original de la escala Impulso Continuidad Estereotipia Prioridad y Tolerancia La fiabilidad es adecuada para el primer factor y
22. la and 210 from M laga All participants in the present study smoked one or more cigarettes per day The exclusion percentage was 25 1 n 213 People were excluded for various reasons when they could not talk nor respond at that time when they were ill when they declined to respond to the questionnaire due to lack of time or for other reasons when they refused to sign the informed consent and when they declined to take the test for carbon monoxide in expired air Occasional and ex smokers were also excluded The mean age of this sample was 39 26 years SD 12 81 with a range from 18 to 81 Of these 265 41 6 were male and 372 58 4 were female Data were collected between February and May 2008 SPANISH ADAPTATION OF THE NDSS 953 Questionnaire In addition to the assessment of sociodemographic variables smoking characteristics and previous attempts to quit smoking the following additional assessment instruments were used DSM IV nicotine dependence criteria through the SCID The Structured Clinical Interview for DSM IV First Spitzer Gibbon amp Williams 1998 The SCID is a semi structured diagnostic interview that includes as many diagnostic modules as there are diagnostic categories in the DSM According to the DSM IV the diagnostic criteria for substance dependence are the same for all substances Dependence is defined as a maladaptive pattern of the use of a substance that involves clinically significa
23. led the nicotine dependence criteria of the DSM IV We have three principle objectives The first is to validate the NDSS in Spain for the assessment of nicotine dependence This measure is extremely useful both for adults Shiffman et al 2004 and adolescents Clark et al 2005 as evidenced by its validation in the United States and its adaptation to other countries languages and cultures e g Broms et al 2007 Our expectation is to obtain similar results as the original validation of the NDSS in the U S A Shiffman et al 2004 The second is to determine the percentage of nicotine dependence in the population This is a concern of great relevance and it has received considerable attention in recent years Hughes Heltzer amp Lindberg 2006 The present study assesses the percentage of Spanish smokers with nicotine dependence attending Primary Health Care Centers Finally the third is to analyze the relationship between the DSM IV the FTND and the NDSS with respect to the diagnosis of nicotine dependence Method Participants The sample was obtained from five Primary Health Care Centers in different cities of Spain two in Madrid Vicente Muzas and Garcia Noblejas Madrid Health Area 4 one in Bayona Pontevedra province one in Santiago de Compostela Vite and one in Malaga Trinidad Jesus Cautivo The total sample was composed of 637 daily smokers 105 from Madrid 155 from Bayona 171 from Santiago de Composte
24. nt deterioration or distress expressed through three or more of a total of seven items at some point during an uninterrupted 12 month period The Nicotine Dependence Syndrome Scale NDSS Shiffman et al 2004 The NDSS contains 19 items and assesses a general factor of nicotine dependence and various factors derived from it The original validation includes the factors of Drive Priority Tolerance Continuity and Stereotypy This questionnaire uses a 5 point Likert scale not at all true somewhat true moderately true very true extremely true scores ranging from to 5 respectively Through a back translation procedure Hamblenton Merenda amp Spielberger 2005 the Spanish version of the NDSS that we used was obtained from the 19 item version of Shiffman et al 1994 Three different persons translated it from English to Spanish Three different persons who were experts in the field of tobacco and other addictions revised the translation and agreed on a single version of the scale Finally two translators confirmed the Spanish translation of the English version in order to check for equivalence Fagerstr m Test for Nicotine Dependence FTND Heatherton et al 1991 Spanish version by Beco a and Vazquez 1998 This scale is the most widely used instrument for assessing nicotine dependence although its reliability is moderate 60 in studies in Spain see amp Lorenzo 2004 We utilized six 6 as t
25. ons to smoke Tolerance reduced sensitivity to the effects of smoking Continuity regularity of smoking rate Stereotypy invariance of smoking and Priority preference for smoking over other reinforcers Moreover we obtained a total score NDSS T with good reliability Cronbach s a 85 Shiffman et al 2004 The factors proposed by the NDSS are relevant to assess nicotine dependence Therefore the NDSS would assess the nicotine dependence syndrome better than the FTND because it evaluates various dimensions the five proposed while the FTND evaluates only one dimension The first studies by Shiffman et al 2004 with the NDSS confirmed the five factors or dimensions proposed and the utility of the scale which showed both concurrent and predictive validity Other studies such as those of Costello et al 2007 with adolescents Okuyemi et al 2007 with Afro American light smokers and Piper et al 2008 with smokers of 10 or more cigarettes per day have found good reliability for the total scale and for several of the factorially derived scales A relevant concern is the percentage of smokers with nicotine dependence Hughes et al 2004 found that the percentage of nicotine dependents identified by the DSM IV criteria was between 63 and 86 in their different samples Donny and Dierker 2007 used a sample of 8000 daily smokers in the U S between the ages of 18 and over It was determined that 60 6 of the sample fulfil
26. ples of cigarette smokers 10 or more per day and the Okuyemi et al 2007 study of light smokers although the reliability levels were lower than those obtained by Shiffman et al 2004 However in all of the studies cited including the present one the reliability of the total scale was adequate An analysis of the total scale and the five NDSS factors indicated their discriminative utility as a function of daily cigarette consumption CO level nicotine dependence FTND and dependence assessment SCID except on the Continuity and Stereotypy scales Specifically using the SCID criteria the NDSS T and four of five scales Drive Continuity Priority and Tolerance discriminated well between smokers A high percentage 71 58 of daily smokers in the present sample was nicotine dependent according to the SCID criteria Depending upon the type of sample used research has indicated different percentages of nicotine dependence Due to the type of sample employed in this study smokers visiting their GP and representative of the general population our results are similar to those of Hughes et al 2004 who found 63 and 86 of dependents in two different studies These were higher values than those obtained in other epidemiological studies such as Breslau Johnson Hiripi amp Kessler 2001 and Donny amp Dierker 2007 that determined 62 8 and 60 6 of nicotine dependence respectively The identification of a high percentage of
27. r 10 After not smoking for a while I need to smoke in order to keep myself from experiencing 712 010 039 167 044 675 any discomfort Tras pasar un tiempo sin fumar necesito hacerlo para no sentirme mal 11 It s hard to estimate how many cigarettes I smoke per day because the number often change 075 527 032 104 137 148 Es dif cil saber cu ntos cigarrillos fumo al d a porque el n mero suele variar 12 I feel a sense of control over my smoking I can take it or leave it at any time 576 030 029 009 076 506 Tengo sensaci n de control sobre el tabaco Puedo cogerlo o dejarlo en cualquier momento 13 The number of cigarettes I smoke per day is often influenced by other factors how Pm 030 818 061 048 026 074 feeling what I m doing etc El n mero de cigarrillos que fumo al d a var a seg n distintos factores c mo me siento qu estoy haciendo etc 14 When I m really craving a cigarette it feels like Pm in the grip of some unknown force that 583 067 056 207 190 636 I cannot control Cuando realmente deseo un cigarrillo parece que estoy bajo el control de alguna fuerza desconocida que no puedo dominar 15 Since the time when I became a regular smoker the amount I smoke has either stayed the 391 108 583 072 054 216 same or has decreased somewhat Desde que me he convertido en un fumador habitual la cantidad que fumo ha sido la misma o ha disminuido un poco
28. t of cases to groups The ROC curve is a graphic plot of sensitivity vs specificity for a binary classification system due to the fact that the discrimination threshold is varied Franco 2007 The ROC can also be represented by plotting the fraction of true positives true positive rate vs the fraction of false positives FPR false positive rate This is also known as a ROC curve because it is a comparison between two operating characteristics TPR amp FPR as the criteria change We use the dependence criterion ofthe SCID 3 or more positive items as a predictive variable The five scales of the NDSS and the NDSS T scale were predicted variables The results of the SCID indicated that 456 smokers were nicotine dependent 71 5896 and 181 were non dependent 29 4196 Both the NDSS T with a value of 79 and the scores for four of the five scales were greater than 50 under the curve Drive with 82 Continuity with 60 Priority with 62 and Tolerance with 61 Only Stereotypy was below 50 48 Therefore the prediction was significant in all cases except for Stereotypy Figure 1 When we compared the functioning of the NDSS T scale with the FTND we found that both provided good predictions of dependence But the NDSS T scale with a score of 79 under the curve has a better level of prediction than the FTND 69 under the curve This indicates that both are good discriminators of dependent and non dependent smokers
29. the primary health care centers involved Dr Manuel Bacariza Corti as Centro de Salud de Vite Santiago de Compostela Dr Lorenzo Pousa Est vez Centro de Salud de Bayona Pontevedra Dra Sonia Manget Velasco Centros de Salud de Madrid Dr Maximiliano Vilaseca Fortes Director of the Servicio de Salud de M laga and Dr Santos Agrela Torres Centro de Salud Trinidad Jes s Cautivo Servicio de Salud de M laga Finally we express our gratitude to all of the professionals who participated in the application of the questionnaires and in particular to Carmela Martinez Vispo and Gema D az Alonso Correspondence concerning this article should be addressed to Elisardo Beco a Unidad de Tabaquismo Universidad de Santiago de Compostela Facultad de Psicolog a Departamento de Psicolog a Cl nica y Psicobiolog a Campus sur 15782 Santiago de Compostela Spain E mail elisardo becona usc es 951 952 BECO A LOPEZ FERNANDEZ DEL R O M GUEZ AND CASTRO The assessment of nicotine dependence is important in the analysis of smoking behavior The addictive power of nicotine explains why many smokers repeatedly fail in their attempts to quit smoking This power has been consistently shown in a large number of studies for example the United States Department of Health and Human Services 1988 2004 Despite the existence of the nicotine dependence criteria of the Diagnostic and Statistical Manual of Mental Disorders fourth edition DSM
30. tion is the type of sample used It is always desirable to have as large and varied a sample as possible although the one used here represents a type of smoker of great relevance in terms of intervention because smokers visit their GP most frequently The second limitation concerns the number of measures used for assessing SPANISH ADAPTATION OF THE NDSS 959 nicotine dependence It would be ideal to use a larger number of them And the third limitation concerns the need for more detailed information on people s smoking history In summary we have used the method of factor analysis in order to assess the validity of the NDSS in a Spanish sample Our results confirm the five factors of the original validation We also found that reliability is adequate for the first factor and that the NDSS T is an adequate predictor of nicotine dependence Therefore we conclude that the NDSS is useful for assessing nicotine dependence in smokers attending on Spanish health care centers We believe that the results are heuristic and provide a useful instrument for the assessment of nicotine dependence in a variety of clinical and investigation contexts References American Psychiatric Association 2000 Diagnostic and statistical manual for mental disorders 4th ed revised text Washington D C American Psychiatric Association Beco a E amp Lorenzo 2004 Evaluaci n de la conducta de fumar Smoking behavior assessment Adicciones 1
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