Substance Use & Misuse

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Fagerström Test and Heaviness Smoking Index.

Are they Interchangeable as a Dependence Test for
Nicotine?

José Ignacio de Granda-Orive, José Francisco Pascual-Lledó, Santos Asensio-

Sánchez, Segismundo Solano-Reina, Marcos García-Rueda, Manuel Ángel
Martínez-Muñiz, Lourdes Lázaro-Asegurado, Daniel Bujulbasich, Rogelio
Pendino, Susana Luhning, Isabel Cienfuegos-Agustín & Carlos A. Jiménez-
Ruiz

To cite this article: José Ignacio de Granda-Orive, José Francisco Pascual-Lledó, Santos
Asensio-Sánchez, Segismundo Solano-Reina, Marcos García-Rueda, Manuel Ángel Martínez-
Muñiz, Lourdes Lázaro-Asegurado, Daniel Bujulbasich, Rogelio Pendino, Susana Luhning, Isabel
Cienfuegos-Agustín & Carlos A. Jiménez-Ruiz (2019): Fagerström Test and Heaviness Smoking
Index. Are they Interchangeable as a Dependence Test for Nicotine?, Substance Use & Misuse,
DOI: 10.1080/10826084.2019.1660680

To link to this article: https://doi.org/10.1080/10826084.2019.1660680

Published online: 13 Sep 2019.

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SUBSTANCE USE & MISUSE
https://doi.org/10.1080/10826084.2019.1660680

ORIGINAL ARTICLE

€ m Test and Heaviness Smoking Index. Are they Interchangeable as

Fagerstro
a Dependence Test for Nicotine?
Jos
e Ignacio de Granda-Orivea , Jose  Francisco Pascual-Lledo
b, Santos Asensio-Sanchezb,
c d 
Segismundo Solano-Reina , Marcos Garcıa-Rueda , Manuel Angel ~ize,
Martınez-Mun
Lourdes Lazaro-Asegurado , Daniel Bujulbasich , Rogelio Pendino , Susana Luhningh,
f g g

Isabel Cienfuegos-Agustına, and Carlos A. Jimenez-Ruizi

a
Servicio de Neumologıa, Hospital Universitario 12 de Octubre, Madrid, Spain; bServicio de Neumologıa, Hospital General Universitario
de Alicante, Alicante, Spain; cServicio de Neumologıa, Hospital General Universitario Gregorio Maran~on, Madrid, Spain; dServicio de
Neumologıa, Hospital Carlos Haya de Malaga, Malaga, Spain; Servicio de Neumologıa, Hospital San Agustın de Aviles, Asturias, Spain;
e
f
Servicio de Neumologıa, Hospital Universitario de Burgos, Burgos, Spain; gServicio de Neumologıa, Sanatorio Nuestra Sen~ora Del
Rosario, Centro Medico IPAM, Rosario, Santa Fe, Republica Argentina; hNeumologa Instituto Medico Humana, Centro Asistencial de
Consulta Externa, Cordoba, Republica Argentina; iUnidad Especializada de Tabaquismo de la Comunidad de Madrid, Madrid, Spain

ABSTRACT KEYWORDS
Objective: The purpose of this study was to evaluate the degree of agreement between the Tobacco dependence;
Fagerstro€m Test for Cigarette Dependence (FTCD) and the Heaviness of Smoking Index (HSI) smoking; scales;
in daily smokers admitted to smoking cessation clinics from National Healthcare System in epidemiology; smoking
cessation; regression
Spain and Argentine Republic. Material and methods: An observational, longitudinal, multi- analysis
center study (prospective cohort) conducted in smoking clinics in daily clinical practice. The
patients were consecutively included as they attended the consultations. The statistical ana-
lysis was descriptive, and correlation and concordance tests as well as analysis and regres-
sion models were used. Results: In total, 308 subjects were included [161 women (52.3%)],
with a mean age of 51.4 (10.8) years. We found an absence of agreement and the existence
of a proportional difference between both tests [Regression coefficient for global series: 0.55
(0.52–0.59) p < .001]. This difference increased as the value of the FTCD score increased; that
is, the higher the value of the FTCD score was, the greater the difference in relation to the
value of the HSI score. Likewise, Cohen’s kappa concordance coefficient, according to vari-
ous combinations of categorization of both tests, showed that the agreement between
these variables was only good. Approximately 20% of the subjects were not classified with
the same degree of dependence by the two tests. Thus, a classification mismatch existed.
Conclusions: We found an absence of agreement between both tests. These data imply that
we should not substitute one test for the other when we analyze nicotine dependence in a
population of smokers.

Introduction
The Fagerstr€om Test (Fagerstr€ om Test for Cigarette
Dependence, FTCD) (Fagerstr€ om, 2012) is the most
widely used tool for the measurement of nicotine
dependence, it is a non-invasive and easy-to-obtain
self-report tool that conceptualizes dependence
through physiological and behavioral symptoms. The
FTCD consists of six questions, and a score
6 indi-
cates a high dependence on nicotine (Fagerstr€ om,
Heatherton, & Kozlowski, 1990). The two most
important questions to establish dependence are “How
soon after you wake up do you smoke your first ciga-
rette?” and “How many cigarettes per day do you
smoke?” (Kozlowski, Porter, Orleans, Pope, &
Heatherton, 1994). The combination of these two
questions constitutes the Heaviness of Smoking Index
(HSI) (Heatherton, Kozlowski, Frecker, Rickert, &
Robinson, 1989), which is used as an adequate and
quicker alternative to the FTCD. A score
4 in the
HSI indicates a high dependence on nicotine. The HSI
has shown only good agreement (kappa 0.72–0.78)
with the FTCD in several population studies (Burling
& Burling, 2003; Chabrol, Niezborala, Chastan, & de
Leon, 2005; Diaz et al., 2005; de Leon et al., 2003;
Kozlowski et al., 1994; Perez-Rıos et al., 2009), which
suggests that this dependence test is at least as good

CONTACT Dr. Jose Ignacio de Granda-Orive igo01m@gmail.com Respiratory Department, Hospital Universitario 12 de Octubre, C/Cavanilles 43,
7 E, 28007 Madrid, Spain.
ß 2019 Taylor & Francis Group, LLC
2 J. I. de GRANDA-ORIVE ET AL.

as the FTCD (Burling & Burling, 2003; de Leon et al., Table 1. Categories of the heaviness of smoking index (HSI)
2003; Kozlowski et al., 1994). and the Fagerstr€om test (FTCD) according to different versions.
Though the specificity, accuracy and concordance Version and categories Punctuation
Version 1 HSI
between the two tests were high in males and females, Very low dependence 0–2
the HSI sensitivity for the latter was relatively low Low dependence 3
Moderate dependence 4
(Perez-Rıos et al., 2009). Indeed, Perez-Rıos et al. High dependence >4
(2009) found that HSI performs degree of dependence Versi
on 2 HSI
Low dependence 0–1
as well as FTCD when both sexes are analyzed, but Moderate dependence 2–4
when sex is taken into account his results differ: the High dependence 5–6
Versi
on 3 HSI
agreement between the two tests showed limitations, Low dependence <4
especially applied to female smokers, sensitivity ana- High dependence
4
Versi
on 4 HSI
lysis in females did not show good agreement. So, Low-moderate dependence 4
they concluded that for populations or subpopulations High dependence >4
Versi
on 1 FTCD
having low nicotine dependence, such as women, the Low dependence 3
FTCD is more reliable. Moderate dependence 4a7
High dependence >7
In several of these studies (Chabrol et al., 2005; de Versi
on 2 FTCD
Leon et al., 2003; Diaz et al., 2005; Perez-Rıos et al., Low-moderate dependence 7
High dependence >7
2009) authors found a discordance of classification
between both tests (smokers have not being classified
with the same degree of dependence), this and the Ethical committees
fact that in all these studies the agreement between The present work was presented in each one of the
both tests remains in good moved us to analyze this ethical committees of the participating centers, all of
data in our smoking patients. them being apt (ethically and methodologically cor-
The aim of this study was to evaluate the degree of
rect). The different certificates that corroborate this
agreement between the FTCD and HSI in smokers
compliance are available.
who wanted to quit smoking and who were included
in a multicenter study conducted in daily clin-
ical practice.
Statistical analysis
Quantitative variables were described by their mean,
Methods standard deviation (SD) and range of values. The
Design qualitative variables were described by their absolute
value and percentage. Within this description, a com-
An observational, longitudinal (prospective cohort), parison of the variables by sex was carried out. In the
multicenter study was conducted in smoking clinics in case of quantitative variables, the Student t-test was
daily clinical practice in Spain and the Argentine used, and in the case of not fulfilling the normal dis-
Republic in five tertiary hospitals, three secondary tribution assumptions and homogeneity of the varian-
hospitals and a community specialized smoking unit. ces, the Mann–Whitney U non-parametric test was
The patients were consecutively included as they used. For the qualitative variables, the v-square test
attended the consultations from 1 October 2014 to 31 was used.
October 2015 and were followed for a year. The concordance analysis between the FTCD and
the HSI was carried out in two ways. The first ana-
lysis which included the determination of the
Variables collected
Pearson and Spearman correlation coefficients, the
The variables collected were sex, age, cigarette con- linear regression between the HSI and FTCD, consid-
sumption per day (as a continuous variable and cat- ering the HSI as a dependent variable and the FTCD
egorical variable from 0 to 10, from 11 to 20, from 21 as an independent variable, the determination of the
to 30 and > 30 cigarettes per day), number of years Lin correlation-concordance coefficient, the construc-
of smoking, cumulative consumption valued as packs- tion of the Bland–Altman graphs, mountain graph
year, and the FTCD and HSI scores, both as continu- (“mountain plot”), and concordance-survival graph
ous and categorical variables (Table 1). (“survival-agreement plot”) and the realization of the
 SUBSTANCE USE & MISUSE 3

Table 2. Mean of the different quantitative variables for the global series and by gender.
Global series (Mean) Males (Mean) Females (Mean) Significance
Variables (SD) (Range) (SD) (Range) (SD) (Range) (p)
Age 51.4 (10.8) (25–77) 51.9 (10.9) (27–77) 51.0 (10.9) (25–76) .472
Cigarettes per day consumption 22.9 (10.4) (4–60) 24.5 (11.4) (5–60) 21.5 (9.2) (4–60) .014
Number of years smoking 35.0 (10.4) (7–66) 35.7 (11.3) (12–66) 34.3 (10.6) (7–61) .250
Cumulative consumption value (packs/years) 40.8 (24.2) (4.2–141.0) 44.6 (26.2) (4.7–141.0) 37.4 (21.7) (4.2–132) .019
Fagerstr€om test 6.1 (2.1) (0–10) 6.1 (2.2) (0–10) 6.0 (2.1) (0–10) .809
HSI 3.6 (1.4) (0–6) 3.7 (1.4) (0–6) 3.5 (1.4) (0–6) .239
HSI: Heaviness of Smoking Index; SD: standard deviation.

Table 3. Frequency distribution (absolute value and percentage) of some of the quantitative variables categorized.
Variables Global series Males Females Significance (p)
Cigarettes per day consumption
 10 30 (9.7) 13 (8.8) 17 (10.6)
Between 11 and 20 177 (57.5) 76 (51.7) 101 (62.7)
Between 21 and 30 58 (18.8) 32 (21.8) 26 (16.1)
> 30 43 (14.0) 26 (17.7) 17 (10.6) .114
Fagerstr€om test
Low-moderate dep. (7 pt) 228 (74.0) 105 (71.4) 123 (764)
High dep. (> 7 pt) 80 (26.0) 42 (28.6) 38 (23.6) .321
HSI – version 1
Very low dep. (0–2) 51 (16.6) 25 (17.0) 26 (16.1)
Low-moderate dep. (3) 99 (32.1) 43 (29.3) 56 (34.8)
Moderate dep. (4) 82 (26.6) 36 (24.5) 46 (28.6)
High dep. (>4) 76 (24.7) 43 (29.3) 33 (20.5) .304
HSI – version 2
Low dep. (0–1) 23 (7.5) 11 (7.5) 12 (7.5)
Moderate dep. (2–4) 209 (67.9) 93 (63.3) 116 (72.0)
High dep. (5–6) 76 (24.7) 43 (29.3) 33 (20.5) .196
HSI – version 3
Low dep. (<4) 150 (48.7) 68 (46.3) 82 (50.9)
High dep. (
4) 158 (51.3) 79 (53.7) 79 (49.1) .412
HSI – version 4
Low-moderate dep. (4) 232 (75.3) 104 (70.7) 128 (79.5)
High dep. (>4) 76 (24.7) 43 (29.3) 33 (20.5) .075
Dep.: Dependence; HSI: Heaviness of smoking index.
In the column “Global series”, enter () the percentage against the total. In the “men” and “women” columns, the () indicates the percentage in columns.

Deming regression model, considered both variables
as quantitative.
The second form of the analysis was to evaluate the
concordance between the FTCD and the HSI, consid-
ered as categorical variables of 2 or 3 categories, by
means of the Cohen weighted kappa statistic with lin-
ear weighting, since it was considered that the FTCD
and the HSI categories were ordered categories and
that the importance between categories was the same
(combinations are indicated in Table 6).
The analyses were carried out with the statistical
programs SPSS 15.0 for Windows v.15.0.1 [(22
November 2006) SPSS Inc., 1996–2006] and MedCalc
Statistical Software version 18 (MedCalc Software
bvba, Ostend, Belgium; //www.medcalc.org; 2018). A
value of p < .05 was considered statistically significant.
variables for the global series and by sex. Males con-
sumed on average 3 (standard deviation 1.2) cigarettes/
day (95% CI: 0.6 to 5.3 cigarettes/day) more than
women. Men had a cumulative consumption of 7.2
(standard deviation 2.7) pack years (95% CI: 1.8 to
12.5 pack years) higher than the cumulative consump-
tion by women.
Table 3 showed the frequency distribution of the
categorical variables for both the global series and by
gender. Although the consumption of cigarettes per
day showed substantial differences between sexes in
terms of average consumption, these differences are
not appreciated when categorizing such variable; the
percentages of men and women who smoke 10,
between 11 and 20, between 21 and 30 or > 30 ciga-
rettes/day were similar.

Results Analysis of concordance between the FTCD

Descriptive analysis and the HSI
We included 308 subjects [161 women (52.3%)]. (a) Correlation analysis. Determination of Pearson and
Table 2 shows the descriptive values of the quantitative Spearman correlation coefficients: Table 4 shows the
4 J. I. de GRANDA-ORIVE ET AL.

Table 4. Pearson and Spearman correlation coefficients, Lin correlation-concordance coefficient and regression analysis between
the Fagerstr€om Test and Heaviness of Smoking Index variables, as well as the parameters of the Bland–Altman graphs in the
lower part.
Correlation coefficients Global series Males Females
Pearson (precision) 0.87 0.86 0.88
(<.001) (<.001) (<.001)
(0.84–0.89) (0.82–0.90) (0.84–0.91)
Spearman 0.86 0.86 0.856
(<.001) (<.001) (<.001)
(0.83–0.89) (0.81–0.90) (0.81–0.89)
Lin correlation-concordance coefficient. 0.40 0.41 0.39
(0.36–0.44) (0.35–0.48) (0.32–0.44)
Bias correction factor Cb (accuracy) 0.46 0.48 0.44
Regresion
Ordered at the origin 0.22 0.42 0.02
(0.01 to 0.44) (0.08–0.75) (0.29 to 0.34)
Regresion coefficient 0.55 0.53 0.57
(<.001) (<.001) (<.001)
(0.52–0.59) (0.48–0.58) (0.52–0.62)
In each box is indicated, in this order: (1) the correlation coefficient, ordered at the origin or regression coefficient; (2) The degree of significance (p) (this
is not shown for the ordinate at the origin, as it lacks interpretation); (3) The 95% confidence interval.

Parameters of Bland–Altman graphs

Global series Males Females
Differences
Mean 2.49 2.43 2.55
(2.36–2.62)a (2.22–2.63)a (2.38–2.72)a
(<.001)b (<.001)b (<.001)b
Lower limit of concordance 0.20 0.02 0.42
(0.02 to 0.43)c (0.37 to 0.33)c (0.13–0.71)c
Upper limit of concordance 4.78 4.88 4.69
(4.56–5.01)d (4.53–5.23)d (4.40–4.98)d
Regression equation of the differences
Ordered at the origin 0.21 (0.15)e 0.04 (0.22)e 0.43 (0.19)e
(0.08 to 0.49)f (0.47 to 0.39)f (0.04–0.81)f
Pending 0.47 (0.03)g 0.50 (0.04)g 0.44 (0.04)g
(<.001)h (<.001)h (<.001)h
(0.48–0.53)i (0.42–0.59)i (0.37–0.52)i
a
Confidence interval at 95% for the mean of the differences.
b
Degree of significance for the null hypothesis that the difference of means is equal to 0.
c
95% confidence interval for the lower limit of agreement.
d
Confidence interval at 95% for the upper limit of concordance.
e
Standard error for the estimation of the ordinate at the origin of the regression equation of the differences.
f
Confidence interval at 95% for the ordinate at the origin.
g
Standard error of the estimation of the pending of the regression equation of the differences.
h
Degree of significance of the null hypothesis that the pending of the regression equation of the differences is different from 0.
i
95% confidence interval for the estimation of the regression pending of the differences.

values of the Pearson and Spearman correlation coeffi-
cients regarding the relationship between the FTCD
and the HSI for the global series and by gender.
Although significant, they do not exceed 0.90, which
is expected in concordance studies.(b) Linear regres-
sion analysis. Determination of the ordinate at the ori-
gin and the regression coefficient: Table 4 shows values
of the ordinate at the origin and regression coefficient
in the linear regression analysis between the FTCD
and HSI both for the global series and by gender. The
regression analysis shows that regression lines between
the HSI and the FTCD are quite far from the identity
line, both for the global series and for both sexes,
indicating the absence of agreement and the existence
of a proportional difference between both methods of
measurement. (c) Correlation-concordance coefficient
of Lin (Lin, 1989, 2000): As Table 4 shows, all the
values of the correlation coefficients of Lin, both for
the global series and for both sexes, had values well
below 0.90, indicating an inferior match strength
(McBride, 2005). (d) Study of the concordance between
the FTCD and HSI using the Bland–Altman graphs:
Figure 1 shows the Bland–Altman graphs, and the
parameters of the Bland–Altman graphs for the global
series and by gender are shown in Table 4. The
Bland–Altman graphs show that the differences
between both measurement methods were above zero,
that is, they were always positive. The means of the
differences were statistically significant, different from
0, both for the global series and gender, indicating the
presence of a significant systematic difference between
FTCD and HSI variables, which can be estimated at
just over two points. On the other hand, the ordinate
at the origin of the regression line of the differences
 SUBSTANCE USE & MISUSE 5

Figure 1. Bland–Altman graphs between Fagerstr€om and heaviness of smoking index tests for global series and by gender. FTCD:
Fagerstro€m test of cigarette dependence; HSI: Heaviness of Smoking Index; SD: Standard deviation.

Figure 2. “Mountain-plot” graph between Fagerstr€om and Heaviness of Smoking Index tests. FTCD: Fagerstr€om test of cigarette
dependence; HSI: Heaviness of Smoking Index.

only contained 0 for the global series and males, but
not for females, indicating that there was a difference
between both methods by an amount constant in
females. The slope was also different from 1 in a stat-
istically significant way since none of the confidence
intervals (for the global series and by gender) included
that value, which indicated the presence of at least a
proportional difference between both methods. In
addition, the slope of the regression line of the differ-
ences was also statistically significantly different from
0 and was positive, which indicates that the propor-
tional difference increased as it increased in value,
when considering the FTCD score as an independent
variable. This finding can be observed in the
Bland–Altman graphs (Figure 1), in which the regres-
sion line (dashed line) ascended, for both the global
series and gender, indicating that as the value of the
FTCD score increased, so did the difference between
the FTCD and HSI scores. (e) Study of the concord-
ance between the FTCD and the HSI by means of the
“mountain-plot” and the “survival-agreement plot”
(Krouwer & Monti, 1995; Luiz, Costa, Kale, &
Werneck, 2003): The study of concordance between
the FTCD and HSI, for the global series and by gen-
der using the “mountain” graphs shows (Figure 2)
that the mountains were not centered on 0, signaling
a lack of concordance. Likewise, the graph for the
“survival-agreement plot” (Figure 3) for concordance
between the FTCD and HSI, for the global series and
by gender, shows curves quite far from the origin of
the axes. In all cases, it is appreciated that in order to
achieve an 80% agreement ratio (20% discordance
6 J. I. de GRANDA-ORIVE ET AL.

Figure 3. “Agreement-survival plot” graph for the study of the concordance between Fagerstr€om and Heaviness of Smoking Index
tests. FTCD: Fagerstr€om test of cigarette dependence; HSI: Heaviness of Smoking Index.

Table 5. Deming regression model in the evaluation of the Table 6. Concordance values using Cohen’s kappa index for
concordance between the FTCD and HSI. various combinations between categories of the Fagerstr€om
Parameters of the Test and the Heavyness of Smoking Index.
deming regression Combinationa Global series Males Females
equation Global series Males Females
(1) 0.66 (0.04) 0.64 (0.06) 0.67 (0.06)
Ordered at the origin 0.28 (0.13) 0.36 (0.19) 0.46 (0.19) (0.58–0.74) (0.52–0.75) (0.56–0.79)
(0.54 to 0.03) (0.74 to 0.03) (0.85 to 0.08) (2) 0.50 (0.04) 0.51 (0.06) 0.49 (0.06)
Pending 0.64 (0.02) 0.66 (0.03) 0.65 (0.03) (0.42–0.58) (0.39–0.63) (0.37–0.60)
(0.60–0.67) (0.60–0.72) (0.60–0.71) (3) 0.69 (0.05) 0.65 (0.07) 0.73 (0.06)
In each box it is indicated in this order: Parameter estimation; first (), (0.60–0.78) (0.52–0.79) (0.60–0.86)
standard error of parameter estimation; second (), 95% confidence inter- Cohen’s kappa coefficient is indicated; first (), the standard error; second
val of the parameter estimate. (), the 95% confidence interval of Cohen’s kappa coefficient.
FTCD: Fagerstr€om test; HSI: Heaviness of Smoking Index. Percentages of good and bad classifications for the combinations (1), (2),
and (3), for the global series and by gender.

ratio), the difference between the FTCD and HSI is 3 Combinationa Global series Males Females
or more points, which results an inadmissible from Good classifications
(1) 80.8 (2.2) 78.2 (3.4) 83.2 (2.9)
the point of view of clinical interpretation. (f) Deming (75.9–85.0) (70.5–84.4) (76.4–88.5)
regression model (Armitage, Berry, & Matthews, 2002; (2) 74.7 (2.5) 74.8 (3.6) 74.5 (3.4)
(69.4–79.4) (66.9–81.4) (67.0–80.9)
Cornbleet & Gochman, 1979): Table 5 shows the (3) 88.3 (1.8) 85.7 (2.9) 90.7 (2.3)
results of Deming regression for the concordance (84.1–91.6) (78.8–90.7) (84.8–94.5)
Bad classifications
study between the FTCD and the HSI. Unlike ordin- (1) 19.2 (2.2) 21.8 (3.4) 16.8 (2.9)
ary linear regression, in Deming regression, only for (15.0–24.1) (15.6–29.5) (11.5–23.6)
(2) 25.3 (2.5) 25.2 (3.6) 25.5 (3.4)
males, the ordinate at the origin includes 0. Therefore, (20.6–30.6) (18.5–33.1) (19.1–33.0)
according to this method of analysis in women, the (3) 11.7 (1.8) 14.3 (2.9) 9.3 (2.3)
(8.4–15.9) (9.3–21.2) (5.5–15.2)
methods differed by at least a constant amount of
In each box it is indicated in this order: Estimation of the percentage;
0.46 points (95% CI: 0.08–0.85). Analogous to ordin- between first () the standard error of the percentage estimate; between
ary linear regression, none of the estimates of the second () the 95% confidence interval of the percentage estimate.
a
Combination: (1): HSI Low 0–1, Moderate 2–4, High 5–6 vs. FTND Low 
regression slope (global series and both sexes) 3, Moderate 4–7, High> 7, (2): HSI Low–Moderate <4, High
4 versus
included 1, which indicates a proportional difference FTND Low–Moderate  7, High> 7, (3): HSI Low–Moderate  4, High>
4 versus FTND Low–Moderate  7, High> 7.
between both methods of measurement, which can be
estimated between 0.60 and 0.70 points for each
increase in the value of the FTCD score. Therefore, proportional difference between both measurement
the Deming regression model is concordant with the methods was observed and, for women, both methods
linear regression analysis in the sense that a differed by a constant amount. (g) Study of the

concordance between the FTCD and the HSI, with both
considered as qualitative variables, by means of
Cohen’s kappa concordance coefficient: Table 6 shows
values of Cohen’s kappa index and percentages of
good and bad classifications for combinations (1), (2),
and (3) for the global series and by gender. The
results show agreement between these variables was
very good (Altman, 1991) and that approximately 80%
of subjects were correctly classified (same degree of
dependence in both tests), depending on the configur-
ation considered; however, there were approximately
20% that were misclassified (discordance between
both tests).
Discussion
The most important result of our study was the lack
of agreement and the existence of a proportional dif-
ference between both measurement methods since the
higher the value of the FTCD score, the greater the
difference in relation to the value of the HSI score.
We have used different statistical tests of correlation-
concordance that confirm our findings, and we
obtained the same results with all of them. According
to our study, neither test measures nicotinic depend-
ence the same way, and consequently, they are not
interchangeable. This finding is probably because one
test is included in the other, which makes concord-
ance impossible when the FTCD questions not
included in the HSI are answered affirmatively. This
fact explains why the differences between the FTCD
and HSI are always
0 (always positive) and that the
more the FTCD score increases, the greater the dis-
cordance with the HSI, which, in turn, explains and
justifies the presence of systematic error. In addition,
approximately 20% of subjects were not classified with
the same degree of dependence by the two tests. Thus,
there is a discordance of classification. We think,
therefore, that comparative tests cannot be substituted
for one another.
Other studies have previously compared the HSI
and FTCD. De Le on et al. (2003) proposed that a
score
6 on the FTCD, identifying high nicotine
dependence, was comparable with three briefer classi-
fications: (1) Item 4: heavy smoking (more than 30
cigarettes per day); (2) Item 1: high early smoking
(smoking within 30 min of waking up); and (3) a
score
4 by combining items 1 and 4 (that is, the
HSI). They found that heavy smoking had low sensi-
tivity; high early smoking had low specificity; and a
score
4 by combining items 1 and 4 had relatively
good sensitivity (94%) and specificity (88%). The
SUBSTANCE USE & MISUSE 7
authors found that a value
4 in the HSI provides a
good quick measure of the high dependence on nico-
tine, but agreement found between the tests in no
case was good. There was a significant percentage of
subjects misclassified when both tests were used (per-
centage of disagreement: (1) identified by the HSI and
not by the FTCD, 8%; range 7–12% and (2) identified
by the FTCD and not by the HSI: 2%; range 1–3%).
Chabrol et al. (2005), in a study whose objective
was to compare the HSI and FTCD, found only a
good agreement (Cohen’s kappa: 0.78) and a good
correlation between both tests, both in men and
women, so they concluded that the HSI is a good
measurement tool in high dependence, especially in
epidemiological surveys. In their analysis, they also
found a lack of an adequate classification of depend-
ence between the HSI and FTCD although the differ-
ence was not statistically significant (identified by the
HSI and not by the FTCD: 3% and identified by the
FTCD and not by the HSI: 3%). Dıaz et al. (2005)
performed a new study, broader than the previous
one (de Le on et al., 2003), in which they compared
the effectiveness of the HSI with the same questions
as the FTCD, if the cutoff point of
4 of the HSI
truly indicates high dependence, and sensitivity and
specificity of four binary indices for high dependence:
high HSI, “short time since they rise up to smoking”,
“large smokers”, and “high dependence on any previ-
ous item”. The authors found that HSI better detects
high dependence than the same questions when con-
sidered separately. The cutoff point for high depend-
ence of
4 was a good indicator of it, and this cutoff
point corresponds with best agreement measured with
Cohen’s kappa index (0.71), not reaching again a very
good agreement between both tests (percentage of dis-
agreement: (1) identified by the HSI and not by the
FTCD: 7% and (2) identified by the FTCD and not by
the HSI: 3%).
The same group of authors (Perez-Rıos et al., 2009)
once more compared the validity of the HSI versus
the FTCD. Again, the agreement between both tests
remained just adequate, unable to fulfill a total and
correct classification by dependence, adding in its
conclusions that for some subpopulations, such as
women, the FTCD is more reliable. They found a
good agreement between measures (Kappa ¼ 0.7) and
specificity values were also high (Sp ¼ 96.2%), but
sensitivity analysis in females (Se ¼ 62.3%) did not
show good agreement. His explanation of the differen-
ces found for men and women is that women tend to
smoke fewer cigarettes per day and the time until the
first cigarette in the morning is longer. We found that
8 J. I. de GRANDA-ORIVE ET AL.
males consumed on average more cigarettes than
women and had a cumulative consumption higher
than the cumulative consumption by women (these
differences are not appreciated when categorizing
such variable), but we did not found gender differen-
ces in terms of tests agreement. Burling and Burling
(2003) investigated psychometric properties and valid-
ity of the Fagerstr€om Tolerance Questionnaire, FTCD,
and HSI when used as measures of nicotine depend-
ence in subjects with alcohol dependence. The authors
found that the three measurement tools show medi-
ocre psychometric properties, and the magnitude of
the relationships between these measures and their
independent indicators (pack years, symptoms, carbon
monoxide and cotinine) were generally modest. Even
so, they considered the three tools as valid measures
of nicotine dependence, with the HSI being the best
of the three to use in this population, this result being
the reason why they recommend it. The authors end
by suggesting we should strive to develop better test
scores for nicotine dependence.
Lim et al. (2012) compared the HSI and number of
cigarettes smoked per day, as a measure of nicotine
dependence, with the FTCD and again found a fair
(but not perfect) concordance between the HSI and
FTCD (Cohen’s kappa 0.63), with a moderate sensitiv-
ity and high specificity indicating it can be used as an
alternative to the FTCD. Conversely, the agreement
between the FTCD and the number of cigarettes
smoked per day was low, so they do not recommend
it as an alternative. The agreement found between
both tests was even lower in the study by John et al.
(2004) (0.55–0.60), although it is still recommended as
a valid substitute for the FTCD.
The present work presents several limitations. (1) A
possible limitation could be that findings were
obtained in smokers who voluntarily attended smok-
ing cessation clinics, and the survey was performed in
different scenarios and geographical locations which
might not reflect the ones regarding the general popu-
lation. (2) Both dependency tests were developed to
be answered face to face. In some cases, the question-
naires were delivered to be completed at home and
brought back later in time. (3) Analysis of Cohen’s
kappa index is influenced by prevalence. (4) Another
limitation could be related to the use of questionnaires
in patients because it is not always accurate. (5)
Another limitation would be in relation to the sam-
pling strategy and the dimensions of the sample. This
variability could lead to other results.
Among the aspects that give strength to our work
are both coherence of the results independent of the
statistical analysis used and coherence of our results
with those present in similar published studies.
In conclusion, we found an absence of agreement
between both tests, and approximately 20% of the
subjects were not classified with the same level of
dependence by these two tests. These data imply that
we should not substitute one test for the other when
we analyze nicotine dependence in a population of
smokers. We think that the FTCD should be used in
smokers who attend to a clinic to stop smoking,
because it is the most widely used tool for the meas-
urement of nicotine dependence, while the HSI could
be performed, due to its simplicity and rapidity of
use, in large population-based studies. For planning
purposes, it is preferable to use tests with high sensi-
tivity, and this supports the use of the FTCD instead
of HSI. We should not use one or the other test in
the same population to assess dependence on nicotine
because, as we have found, they are not interchange-
able, so in a population we will use only one of the
two until the end. We think that efforts to develop a
short self-report measure of nicotine dependence for
epidemiological studies should continue.
Disclosure statement
J.I.G.-O. has received honoraria for lecturing, scientific
advice, participation in clinical studies or writing for publi-
cations for (alphabetical order): AstraZeneca, Chiesi, Esteve,
Faes, Gebro, Menarini, and Pfizer. C.A.J.R.: has received
honoraria for advisory and talks for pharma companies
trading smoking cessation medications. L.L.-A. has received
honoraria for lecturing, participation in clinical studies and
writing for publications for (alphabetical order): Astra-
Zeneca, Boehringer, Chiesi, Esteve, Ferrer, Grifols, GSK,
Menarini, Novartis y Pfizer. S.S.-R. has received honoraria
for lecturing, participation in clinical studies and writing for
publications for (alphabetical order): Boehringer, Esteve,
Pfizer y Sandoz. Rest of authors do not have a conflict
of interest.
Author’s contributions
All authors have introduced patients in the study in our
smoking cessation clinics. J.I.G.-O.: Conception and design
of the study, writing the core content of the study, analysis
and interpretation of data, drafting the article and revising
it critically for important intellectual content. J.F.P.-L.:
Statistics analysis and interpretation of data, preparation
and critical review of the manuscript. S.A.-S., S.S.-R., M.G.-
R., M.A.M.-M., L.L.-A., D.B., R.P., S.L., I.C.-A., & C.A.J.-R.:
critical review of the manuscript. All authors declare their
approval for the current version of the manuscript.

Funding
This work was supported by the Spanish Respiratory
Society (SEPAR) under Grant [146/2013]
ORCID
Jose Ignacio de Granda-Orive https://orcid.org/0000-
0002-5433-0561
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