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technique was used to identify ini- health care providers, and tobacco
tial questions and to eliminate ob- interventionists in identifying as-
vious duplications. Phase 2 uti- pects of smoking addiction that are
lized multiple statistical methods behavioral in nature. The need for
(principal components analysis, future research is discussed.
cluster analysis, stepwise multiple Key words: smoking cessation,
linear regression, cross tables, behavioral questionnaire, to-
Mantel-Haenzel χ 2 -test, and a bacco, smoking
Gamma test) to evaluate and re- Am J Health Behav. 2005;29(5):443-455
T
obacco use has been cited as the eases including cancer, heart disease,
chief avoidable cause of illness and stroke, complications of pregnancy, and
death in American society, respon- chronic obstructive pulmonary disease.2
sible for more than 440,000 deaths annu- Moreover, estimates indicate that ap-
ally in the United States.1 Smoking has proximately 25% of the adult population
also been known to cause a host of dis- smoke, and approximately 3200 adoles-
cents initiate smoking daily.3,4
In 1988, after examining the available
evidence, the Surgeon General’s Report
Elbert D. Glover, Professor & Chair, Public concluded that the principal pharmaco-
and Community Health, College of Health and logic agent common in all forms of tobacco
Human Performance, University of Maryland, Col- is nicotine. Specifically, the report con-
lege Park, MD. Fredrik Nilsson, MS, Senior Clini-
cal Scientist, Pfizer Consumer Healthcare,
cluded that (a) all forms of tobacco are
Helsinborg, Sweden. Åke Westin, MS, Statisti- addicting, (b) nicotine is the drug in to-
cian, Pfizer Consumer Healthcare, Helsinborg, bacco that causes addiction, and (c) the
Sweden. Penny N. Glover, Public and Community pharmacologic and behavioral processes
Health, College of Health and Human Perfor- that determine tobacco addiction are
mance, University of Maryland, College Park, MD. similar to those that determine addiction
Molly T. Laflin, Professor, School of Family & to other drugs such as heroin and co-
Consumer Sciences, Bowling Green State Univer- caine.5 Quantitative measures of physi-
sity, Bowling Green, OH. Birger Presson, Statis- cal dependence can be determined via
tician, Department of Statistics, Univesity of Lund,
Lund, Sweden
nicotine, cotinine, and thyiocynate lev-
Address correspondence to Dr Glover, Public els in saliva, urine, and plasma. Al-
and Community Health, 2387 HHP Building, Uni- though reliable, these assessments may
versity of Maryland, College Park, MD 20742. E- not be practical measures to utilize in
mail: eglover1@umd.edu general medical practice due to sample
™ 2005;29(5):443-455
Am J Health Behav.™ 443
Smoking Behavioral Questionnaire
collection, analysis, and cost. The 8-item behavioral patterns play a role in smoking
Fagerström Tolerance Questionnaire dependence. Specifically, this paper re-
(FTQ) is the most widely used measure of veals the process by which the initial ques-
nicotine dependence due to its ease of tions were developed, tested, and eventu-
administration, proven accuracy, and ally reduced to form the Glover-Nilsson
cost-effectiveness.6 Researchers use the Smoking Behavioral Questionnaire (GN-
FTQ to measure levels of physical depen- SBQ). Reliability of the instrument is not
dence based on scores ranging from 0 to addressed in this manuscript. Specifi-
11; a score greater than or equal to 6 cally, the authors wish to share the pro-
indicates a high level of dependence, and cess by which the questionnaire was de-
a score less than 6 indicates lower depen- rived. Current research is underway by
dence.6 Surprisingly, no easily adminis- others to determine reliability of the GN-
tered questionnaire has been identified to SBQ and predictive validity with regard to
consistently measure the behavioral pro- the need for behavioral treatment compo-
cesses that underlie smoking dependence. nents for smoking cessation.
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Dependence (FTND),7 have been used ex- cesses play a role in smoking depen-
tensively for years to estimate this level dence. A modified Delphi process was
of physical dependence in smokers and used in the initial phases of this study.
more recently in smokeless tobacco us- Four international tobacco treatment ex-
ers (modified version). However, there is perts were asked to develop question-
no similar instrument to consistently naire items designed to measure per-
measure the behavioral aspects of smok- ceived behavioral dependence. All items
ing addiction. These behavioral patterns were developed independently by the panel
include the rituals associated with smok- members; no items were selected from
ing, the feelings or perceptions of security any existing instruments. Round one
that smoking provides, and the relation- produced a total of 39 items.
ship between the smoker and cigarette. In the second round, the panel was
Traditionally the behavioral aspects of asked to ensure that all key components
smoking are addressed via counseling. A of behavioral dependence were adequately
quick, easily administered behavioral addressed by the questions. They were
assessment would allow clinicians to tai- also asked to reduce the total number of
lor behavioral treatments to the indi- questions by eliminating those that were
vidual needs of the patient. Ideally, by duplicative in nature and omitting those
administering both a physical (FTQ or the that were perceived to elicit physical de-
FTND) and a behavioral (GN-SBQ) ques- pendence rather than behavioral depen-
tionnaire, clinicians could match treat- dence. This procedure eliminated 21
ment to the behavioral as well as physical items, leaving 18 that could possible be
needs of the patient. We would predict used to identify behavioral dependence.
that those with high scores on the FTQ or In the next phase, the authors used a
FTND would benefit from pharmacologi- variety of statistical techniques to elimi-
cal intervention. Those with high scores nate duplicative items and retain the
on the behavioral measure would be more most critical items that address the be-
likely to require intensive behavioral in- havioral processes of smoking. Table 1
tervention. Patients who score high on presents the 18 items that were ana-
both the physical and behavioral mea- lyzed. Each question contained 5 stem
sures would probably have the most diffi- numerical options (0, 1, 2, 3, 4). A high
culty in quitting smoking and would most numerical response indicated high be-
likely require intensive support. havioral dependence, and a low numeri-
cal response indicated low behavioral de-
OBJECTIVE pendence.
The purpose of this project was to de- This phase of the study involved 2231
velop a simple, easily administered pencil- individuals from 8 tobacco research trials
and-paper questionnaire, similar to the using comparable protocols in 4 countries
FTQ/FTND, to assess the degree to which (Spain [n=1], Sweden [n=2], Switzerland
444
Glover et al
Table 1
Initial Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ)
Please indicate your choice by circling the number that best reflects your choice.
0=Not at all; 1=Somewhat; 2=Moderately so; 3=Very much so; 4=Extremely so
Please indicate your choice by circling the number that best reflects your choice.
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4. Do you keep your hands and fingers busy to distract you from smoking? 0 1 2 3 4
Copyright (c) PNG Publications. All rights reserved.
7. Do you panic if you find yourself out of cigarettes or if you cannot find your
cigarettes? 0 1 2 3 4
8. If you find yourself without cigarettes, will you have difficulties in concentrating
before attempting a task? 0 1 2 3 4
9. If you are not allowed to smoke in certain places, do you then play with your
cigarette pack or a cigarette? 0 1 2 3 4
10. Do certain environmental cues trigger your smoking, eg, favorite chair, sofa, room,
car, or drinking alcohol? 0 1 2 3 4
12. Will just holding a cigarette in your hand (without lighting up) assist you with
reducing stress? 0 1 2 3 4
13. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick,
chewing gum, etc) in your mouth and sucking to get relief from stress, tension
or frustration, etc)? 0 1 2 3 4
14. Does part of your enjoyment of smoking come from the steps (ritual) you take
when lighting up? 0 1 2 3 4
15. Does part of your enjoyment of smoking come from watching the smoke as
you exhale? 0 1 2 3 4
16. Do you light up a cigarette without realizing you have another one burning in
the astray? 0 1 2 3 4
17. When you are alone in a restaurant, bus terminal, party, etc, do you feel safe,
secure, or more confident if you are holding a cigarette? 0 1 2 3 4
™ 2005;29(5):443-455
Am J Health Behav.™ 445
Smoking Behavioral Questionnaire
[n=1], United States [n=4]. After elimi- other and relatively large distances from
nating questionnaires that contained elements outside the cluster. Among the
missing or questionable data, the au- different methods for performing a CA,
thors were left with 2032 usable ques- the authors chose a procedure in SAS
tionnaires. All of the participants were at referred to as Varclus. Varclus clusters
least 18 years of age, classified as healthy the variables (in this case, questions) by
smokers (free of disease), and expressed 2 methods: (a) principal component cluster
a desire to quit smoking. All participants analysis and (b) centroid component cluster
were recruited through physician refer- analysis. CA was used to find clusters of
rals, advertising via newsprint, televi- questions and the distance between re-
sion, radio, or antismoking clinics. All 8 sponses provided by the 2032 smokers.
clinical trials received approval from their The principal component cluster analy-
respective institutional review boards. sis uses the first 2 cluster components.
The authors used the default value in
Reducing the Number of Questions Varclus, which means splitting is not
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The average face-to-face time for phy- executed until each cluster has only a
sician office visits in the United States is single eigenvalue greater than 1. The
17.4 minutes8 and 7-16 minutes in many centroid component cluster analysis mea-
European countries; 9 therefore, to be sures the distance between a variable
widely accepted, the GN-SBQ needed to be (question) and its cluster’s center (cen-
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brief. The overall objective of this project troid). If the variable is closer to its own
was the development of a smoking behav- cluster’s centroid, it is allowed to stay
ioral dependence questionnaire that could within this cluster. Otherwise, it is moved
be self-administered, easy to understand, to another cluster with a centroid closer
and take <90 seconds to complete. to the concerned variable. The difference
To reduce the number of questions between “R-squared with own cluster”
from the 18 remaining at the end of the and “R-squared with the next closest”
Delphi process, principal components should be large for well-separated clus-
analysis, cluster analysis, stepwise mul- ters. “R-squared with the next closest”
tiple linear regression, cross tables, Man- should be a low value if the clusters are
tel-Haenzel χ2-test, and a Gamma test well separated.
were employed. These statistical meth- Stepwise multiple linear regression
ods provided an opportunity to conduct an (SMLR). To further examine the relation-
accumulated judgment of the fit and ne- ship between our variables (questions),
cessity of the various items. Questions the authors also used a regression model
that produced redundant information were in which one question at a time became
eliminated. the dependent variable, and the rest of
Principal components analysis (PCA). the questions were independent variables.
PCA is a technique that can be used when The variable with the highest F was en-
a simple representation for a set of tered into the model first and partial F-
intercorrelated variables is desired. The statistics were computed for all of the
technique can be summarized as a remaining variables. The one yielding
method of transforming original variables the highest F, in the presence of the first-
into new, uncorrelated variables. The selected variable was added to the model.
new variables are referred to as the prin- This pattern continued until there were
cipal components or factors. One mea- no variables with significant F-values.
sure of the amount of information con- The cutoff for variables entering the analy-
veyed by each principal component is its sis was set at P>0.15, the standard default
variance. For this reason the principal value when using stepwise regression as
components are arranged in order of de- an exploratory tool.
creasing variance. Thus with the PCA, Cross tables with Mantel-Haenzel χ2-
the authors analyzed principal compo- test (CTMH). Cross-tables analysis be-
nents to see which questions were mea- tween questions allowed the authors to
suring distinct underlying concepts. trace the patterns among the answers.
Cluster analysis (CA). CA is a multi- The χ2 has 1 degree of freedom where r is
variate analysis technique for grouping the Pearson correlation between the row
individuals or objects into groups referred and column variable. The Mantel-Haenzel
to as clusters. The elements in a cluster χ2-test allowed the authors to test the
have relatively small distances from each alternative hypothesis that there may be
446
Glover et al
™ 2005;29(5):443-455
Am J Health Behav.™ 447
Smoking Behavioral Questionnaire
Table 3
Oblique Principal Component Cluster Analysis
(Summary for 6 Clusters)
Variation Proportion Second
Cluster Members explaineda explainedb eigenvaluec
1 5 2.00817 0.4016 0.8804
2 2 1.42360 0.7118 0.5764
3 3 1.72336 0.5745 0.8791
4 3 1.65799 0.5527 0.7400
5 2 1.30052 0.6503 0.6995
6 3 1.83584 0.6119 0.7645
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R-squared With
Own Next
Variable Clusterf Closest g
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Cluster 1
Question 6 0.4492 0.1488
Question 10 0.3900 0.0768
Question 14 0.2427 0.1520
Question 17 0.4473 0.1137
Question 18 0.4789 0.0856
Cluster 2
Question 4 0.7118 0.0699
Question 5 0.7118 0.1207
Cluster 3
Question 2 0.7365 0.0873
Question 3 0.7399 0.0866
Question 15 0.2469 0.0919
Cluster 4
Question 9 0.4803 0.0623
Question 12 0.6156 0.0538
Question 13 0.5621 0.1688
Cluster 5
Question 11 0.6503 0.0876
Question 16 0.6503 0.0680
Cluster 6
Question 1 0.4059 0.0774
Question 7 0.7293 0.1792
Question 8 0.7006 0.1870
Note.
a Variation explained by own cluster.
b The result of dividing the variation explained with the number of cluster members.
c The second largest eigenvalue of the cluster.
d The sum across clusters of the variation explained by each cluster.
e The total explained variation divided by the total sum of members.
f Squared correlation of the variable within its own cluster.
g The next highest squared correlation with a cluster.
Table 10 displays the removed ques- to questions that provide the same or very
tions, the replacement questions, and similar information as the questions re-
the correlations. “Replacement ques- moved, thereby making removal statisti-
tions” do not refer to “new” questions, but cally acceptable.
448
Glover et al
Table 4
Oblique Centroid Component Cluster Analysis
(Summary for 6 Clusters)
Variation Proportion
Cluster Members explaineda explainedb
1 3 1.81876 0.6063
2 2 1.42360 0.7118
3 4 1.97704 0.4943
4 2 1.30052 0.6503
5 4 1.86767 0.4669
6 3 1.65551 0.5518
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R-squared With
Own Next
Variable Clustere Closestf
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Cluster 1
Question 1 0.4866 0.0753
Question 7 0.6844 0.1708
Question 8 0.6577 0.1831
Cluster 2
Question 4 0.7118 0.0761
Question 5 0.7118 0.1187
Cluster 3
Question 2 0.5590 0.0712
Question 3 0.5550 0.0666
Question 14 0.4727 0.0749
Question 15 0.3994 0.0556
Cluster 4
Question 11 0.6503 0.0882
Question 16 0.6503 0.0688
Cluster 5
Question 6 0.4694 0.1420
Question 10 0.4370 0.0754
Question 17 0.4551 0.1112
Question 18 0.5076 0.0830
Cluster 6
Question 9 0.5111 0.0620
Question 12 0.5908 0.0538
Question 13 0.5550 0.1688
Note.
a Variation explained by own cluster.
b The result of dividing the variation explained with the number of cluster members.
c The sum across clusters of the variation explained by each cluster.
d The total explained variation divided by the total sum of members.
e Squared correlation of the variable within its own cluster.
f The next highest squared correlation with a cluster.
Questions 3, 4, 7, 12, 15, 16, and 18 0.004 + 0.6 for Question 2, where 0.04 is
were removed from the original question- equivalent to the intercept and 0.6 is
naire (Table 1). The end variable was equivalent to the regression coefficient.
calculated through the linear regression Therefore, Question 2 received the weight
model where Question 3 corresponded to of 0.6 from Question 3. Question 2 had
™ 2005;29(5):443-455
Am J Health Behav.™ 449
Smoking Behavioral Questionnaire
Table 5
Stepwise Procedure for Dependent Variable Question 3 (Q3)
Step 1 Variable Question 2 Entered R-square = 0.36287009
Table 6
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Note.
All variables left in the model are significant at the 0.15 level. No other variable met the 0.15 level of
significance for entry into the model.
Table 7
Results of Regression Analyses With Different Questions
as the Dependent Variable
Independent
Dependent Variable/ Regression
Variable Variables Coefficient Correlation
3 2 0.6 0.60
4 5 0.4 0.42
7 8 0.5 0.60
12 9 0.3 0.45
13 0.3 0.45
15 14 0.3 0.36
16 11 0.4 0.30
18 6 0.2 0.44
10 0.2 0.44
17 0.2 0.44
450
Glover et al
Table 8
Cross Tabulation Between Question 2 and Question 3
Q u e s t i on 3
Frequency
Percent
Row Percent
Column Percent 0 1 2 3 4 Total
0 433 18 9 3 2 465
21.31 0.89 0.44 0.15 0.10 22.88
Q 93.12 3.87 1.94 0.65 0.43
44.18 4.80 3.06 1.09 1.87
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u
1 201 185 11 3 1 401
e 9.89 9.10 0.54 0.15 0.05 19.73
50.12 46.13 2.74 0.75 0.25
s 20.51 49.33 3.74 1.09 0.93
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Note.
Frequency missing = 199, which is the number of respondents who did not respond to both questions.
Asymptotic
Test Df Value P-value Standard Error
an original weight at 1.0, and with the end Method 1. In this method, each ques-
variable, we obtained the value 0.04 + 1.6 tion was given the value/weight of 1.0.
for Question 2. Equivalent calculations This value/weight is the capacity of the
were conducted for all questions. question to identify whether a person has
a behavioral dependence on smoking.
Methods for Evaluating Questions Seven questions were removed because
Essentially there were 2 distinct meth- the same or very similar information
ods by which we evaluated the question- could be obtained from another question
naire and questions. Both were deter- or series of questions; therefore, the re-
mined to be acceptable. maining 11 questions carried a new
™ 2005;29(5):443-455
Am J Health Behav.™ 451
Smoking Behavioral Questionnaire
Table 9
Linear Associations Between Questions
Asymptotic
Questions Test df Value P-value Standard Error
452
Glover et al
Table 11
Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ)
Please indicate your choice by circling the number that best reflects your choice.
0=Not at all; 1=Somewhat; 2=Moderately so; 3=Very much so; 4=Extremely so
Please indicate your choice by circling the number that best reflects your choice.
(Specific to Questions 3-11).
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5. If you find yourself without cigarettes, will you have difficulties in concentrating
before attempting a task? 0 1 2 3 4
6. If you are not allowed to smoke in certain places, do you then play with your
cigarette pack or a cigarette? 0 1 2 3 4
7. Do certain environmental cues trigger your smoking, eg, favorite chair, sofa, room,
car, or drinking alcohol? 0 1 2 3 4
9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick,
chewing gum, etc) in your mouth and sucking to get relief from stress, tension or
frustration, etc.)? 0 1 2 3 4
10. Does part of your enjoyment of smoking come from the steps (ritual) you take
when lighting up? 0 1 2 3 4
11. When you are alone in a restaurant, bus terminal, party, etc, do you feel safe,
secure, or more confident if you are holding a cigarette? 0 1 2 3 4
TOTAL _______
A high numerical response indicated a high behavioral dependence, and the lower numerical
response indicated a lower behavioral dependence.
can be said for the questionnaire as a estimate of the distribution scores for the
whole – the higher the sum score, the normal smoking population and, there-
higher the behavioral dependence. The fore, the best estimate for interpreting
distribution of scores at baseline for the 8 the sum scores.
studies used in these analyses is the With the FTQ, 6 is the cutoff between
™ 2005;29(5):443-455
Am J Health Behav.™ 453
Smoking Behavioral Questionnaire
high and low dependence and is taken to dence through the development of a
be the median value for the smoking simple, easily administered pencil-and-
population. Adopting the same approach paper questionnaire similar to the FTQ/
as the FTQ, the authors separated the FTND. That goal has been accomplished.
scores into the following behavioral de- The 11 item GN-SBQ can be administered
pendence groups: <12 mild, 12-22 moder- in <60 seconds, well below the upper limit
ate, 23-33 strong, >33 very strong. It is of <90 seconds we set for the question-
our recommendation that high scores on naire at the beginning of the study. The
the GN-SBQ indicate a need for greater authors hope that by administering both
emphasis by the clinician on behavioral the FTQ and the GN-SBQ, clinicians can
management and lower scores on the GN- better match pharmacological (medica-
SBQ suggests a lesser need for emphasis tion) and behavioral (counseling) treat-
on behavioral management. Finally, the ments to individual smokers. Table 11
GN-SBQ is not intended to guide clini- notes the final version of the GN-SBQ.
cians toward specific types of behavioral At the 8th annual meeting of the Soci-
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therapy that might be best for the indi- ety for Research on Nicotine and Tobacco
vidual smoker. Rather the instrument held in Savannah in 2002, a symposium
should serve as a means of estimating Reinvigorating Behavioral Therapies for
the degree to which behavioral interven- Smoking Cessation was held.10 The focus of
tion will be helpful. the symposium was to explore reasons for
Copyright (c) PNG Publications. All rights reserved.
454
Glover et al
(USA), Nina G. Schneider (USA), Cris 3.Centers for Disease Control Prevention. To-
Bolliger (Switzerland), Mats Wallstrom bacco use among high school students –
(Sweden), and Carlos Jimenez-Ruiz United States, 1997. MMWR Morb Mortal Wkly
(Spain), who administered the question- 1998. 1997;47(12):229-233.
4.Centers for Disease Control Prevention. Inci-
naire and provided data from their clini- dence of initiation of cigarette smoking –
cal trials. Also, we acknowledge with United States, 1965-1996. MMWR Morb Mortal
appreciation the work of Birger Persson Wkly. 1998;47(39):837-840.
(University of Lund, Sweden), who con- 5.Department of Health and Human Services,
ducted many of the analyses presented. Public Health Service. The Health Conse-
Finally, we wish to thank the following quences of Smoking: Nicotine Addiction. A
individuals who provided valuable sug- Report of the Surgeon General. DHHS (CDC)
gestions for improving the manuscript: Publication No.88-8406. Washington, DC:
Myra L. Muramoto MD, MPH (University of Government Printing Office, 1998.
6.Fagerström KO, Schneider NG. Measuring
Arizona); Lowell C. Dale, MD (Mayo Clinic); nicotine dependence: a review of the
Joseph Bauer, PhD (Roswell Park Cancer Fagerström Tolerance Questionnaire. J Behav
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Steven Y. Sussman, PhD (University of 8.National Center for Health Statistics. Ambula-
Southern California). tory Health Care Data. Physician Office visits.
Available at: http://www.cdc.gov/nchs/
All subjects used in this study partici- about/major/ahcd/officevisitcharts.htm. Ac-
pated in clinical trials funded by cessed March 30, 2005.
Pharmacia AB Consumer Healthcare, 9.BBC News. GPs demand more time with
Helsinborg, Sweden. Pharmacia assisted patients. Available at: http://news.bbc.co.uk/
with the collection of data and supervised 1/hi/health/2225316.stm. Accessed March
the analyses. However, since the initia- 30, 2005.
tion of this study, Pharmacia has been 10.Hughes JR, Shiffman S, Baker T, et al.
purchased by Pfizer, Inc. Reinvigorating behavioral therapies for smok-
ing cessation. Symposium presented at: An-
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Am J Health Behav.™ 455