Construction and validation of a smoking cessation

motivation questionnaire (Q-MAT).

Summary
The objective of this study was to construct and validate a smoking cessation
motivation scale. A preliminary study selected seven questions out of a total of 25
questions investigating nine dimensions of motivation, based on a semi-structured
expert evaluation. The present study was conducted in 261 smokers recruited from
30 smoking cessation centres, who completed the seven questions of the
questionnaire on two occasions: when making appointments, and at a visit.
Investigators were trained to evaluate motivation on a visual analogue scale based
on a structured interview. A multiple regression model was used to obtain a weighting
coefficient for each of seven questions. The heterogeneity of the coefficients led us to
eliminate three questions which only had a marginal impact on the final score.
Several weighting trials were performed to obtain, by successive approximations, an
easy-to-use maximum score of the scale and a harmonious weighting system for the
items of each question. The final scale comprises four questions with a maximum
score of 20. Linear regression analysis between the score of the scale and
measurement of motivation by the investigator on the visual analogue scale showed
a Spearman correlation coefficient of 0.75 (p < 0.0001). Application of the adopted
scoring system to the two self-administered motivation questionnaires completed
successively by the patient demonstrated a slight, but significant (p = 0.04) variation
in motivation. This scale therefore appears to be sensitive to change. In conclusion,
we have constructed and validated a self-administered smoking cessation motivation
scale composed of four questions: Q-MAT. The protective validity of success of the
scale is currently under evaluation.

Key Words
Smoking cessation -- motivation -- questionnaire -- Q-MAT
 Motivation is one of the principal factors that determine the success of attempts
to stop smoking (1). Several definitions of motivation have been proposed and, for
this study, we have retained that proposed by the Philosophy Studies Council in the
United States: "the probability that an individual adheres to, engages in and pursues
a specific action for change" (2). Motivation is a complex phenomenon, depending on
several factors including possession of information, belief in information provided,
ambivalence, environmental constraints, self-efficacy and the role of the entourage
(3). Many attempts to measure motivation during smoking cessation have been
reported:
 The notion of levels of readiness to change, derived from the trans-
theoretical model of change, implicitly refers to motivation but does not measure
its intensity (4).
 The motivation for stopping scale (5) allows extrinsic and intrinsic
motivation factors to be determined. This scale only measures the reasons which
smokers consider important for stopping. Self-efficacy, for example, is not taken
into account in this scale. Unfortunately, the intrinsic motivation factor is not
associated with success whilst the extrinsic factor is associated with failure.
 The Richmond scale, composed of four questions, does seem to be
associated with success but has not been validated as an instrument to measure
motivation (6).
 More simple measures with just one question exploring the desire to stop
or confidence in succeeding have also been proposed but these have not been
validated (7,8).

The objective of our study was to construct and validate a motivation scale for
smoking cessation. In a first step (3,9), we constructed a self-administered
questionnaire with 25 questions which explored nine dimensions. These dimensions
were: agreement with the postulate that smoking is dangerous for health in general
(three questions), agreement with the postulate that smoking is dangerous for one's
own health (three questions), readiness to change according to the trans- theoretical
model (six questions), perceived ability to succeed in stopping smoking (three
questions), the responsibility of external versus internal factors in successfully
stopping smoking (four questions), the perceived advantages of stopping smoking
(two questions), the perceived disadvantages of stopping smoking (one question)
and personal attitudes towards relapse (two questions). This questionnaire was
proposed to 266 smokers consulting their physician. Of these subjects, 30 were
randomly selected to undergo a structured interview with a psychiatrist in order to
explore motivation for stopping smoking. A motivation score of between zero and 100
was assigned to each smoker by the psychologist at the end of the interview. At this
stage, eight items which appeared to have little discriminant power or to be
redundant were eliminated. A series of statistical analyses (principal component
analysis, ranking questions by degree of correlation with the overall trend, correlation
of individual questions with motivation score) allowed us to make a final selection of
seven questions (Appendix 1).

The present article describes the result of a subsequent study whose objective
was to weight replies to the motivation questionnaire in order to construct a coherent
motivation scale for stopping smoking.
Methods
The study aimed to recruit 280 smokers in 30 tobacco addiction clinics in
France (10 patients per centre). Each investigator was trained to evaluate motivation
for stopping smoking using a structured interview established by the authors. Data
was collected by interview during a single consultation. Background information was
collected on sociodemographic variables, tobacco-related variables (age when
started smoking, current cigarette consumption, previous quit attempts,
cardiovascular risk factors, consultation trajectory, complications or comorbidities
motivating the consultation and psychiatric antecedents). Eight dimensions of
motivation to stop smoking were explored:
 the intention of the patient to stop smoking.

 Advantages and disadvantages of smoking.

 Awareness of the dangers of smoking.

 The desire to stop smoking.

 The advantages and disadvantages of stopping smoking.

 The attitude of the smoker’s entourage.

 Self-efficacy with respect to smoking cessation.

 Anticipated success in stopping smoking.

Following exploration of each of these dimensions, investigators were required

to evaluate each smoker on a visual analogue scale (VAS) for the given dimension.
The investigators were provided with an interview manual in which a certain number
of obligatory open questions were listed for each dimension, and these questions
were required to be asked. For example, to evaluate the intention of the patient to
stop smoking, investigators were expected to ask: "What are your current intentions
concerning stopping smoking?".

If the reply seemed inadequate, the investigator could probe further with the
following question: "What do you intend to do about your smoking?".

If the patient seemed to be intending to stop smoking, the investigator was

required to ask: "When are you going to stop (or cut down)?"; "how do you intend to
go about stopping?". If the patient did not appear to be intending to give up, the
investigator was to ask: "In the future, do you think that you will decide to give up?".

Once all the dimensions of motivation had been explored, the investigator was
required to make an overall evaluation of the motivation of the patient to stop
smoking using a ninth VAS. This last VAS was considered a measure of expert
judgment concerning the motivation of the smoker to stop.

On the day of the consultation, smokers were required to fill in the prototype
motivation to stop smoking questionnaire (as proposed at the end of the first
validation phase) (3) and to complete the Fagerström Nicotine Dependence Test (10)
as well as the Hospital Anxiety and Depression Scale (HAD; 11). Subjects were also
required to provide the investigator with another completed copy of the motivation to
stop smoking questionnaire which they had previously been addressed by post when
the appointment had been made by telephone.

Statistical analysis

To construct the motivation scale, responses to the questionnaire obtained on

the consultation day were weighted in order to obtain an overall score S which
corresponded to the sum of the seven individual questions (S = Q1 + Q2 + Q3 + Q4
+ Q5 + Q7). Multiple regression analysis identified seven weighting coefficients a to g
for each of the seven questions such that the sums of the individual weighted scores
added up to the overall VAS motivation score (overall score = aQ1 + bQ2 + cQ3 +
dQ4 + eQ5 + fQ6 + gQ7). The weighting coefficients were adjusted to match as
closely as possible the following model: a = b = c = d = e = f = g = 1. The minimum
possible score was zero.

The questionnaire was completed twice, once when the appointment was made
and secondly at the time the consultation. The scores obtained were compared in
order to measure whether motivation could change significantly over this time period.
If this was the case, psychological and sociodemographic factors that could influence
this change were assessed. The motivation scores were calculated with the
questionnaire from the previous study (3) and compared with the investigators
evaluation in this study.
Results
The study included a total of 261 smokers. In three centres, the investigators
did not follow the required training for the structured interview and the twelve
smokers included in these centres were therefore excluded from the analysis. Finally,
249 smokers from 27 participating centres, were thus retained for the analysis. Of
these subjects, 49% were male and 51% female, and the mean age was 42 years
(SD: 11); 62% of subjects had completed secondary education and 25% a higher
level of education. Mean cigarette consumption was 25 cigarettes per day (SD: 12),
and subjects had been smoking for an average of 24 years (SD: 10), nicotine
dependence scores on the Fagerström test were 5.8 (SD: 2.5). Only 22% of subjects
had never tried to give up smoking. One quarter had made one unsuccessful
attempt, one-sixth two attempts,15% three attempts and a further sixth more than
three attempts. A third of subjects had at least one cardiovascular risk factor,
predominantly hypercholesterolaemia (18%), diabetes (6.5%) and arterial
hypertension (12.5%; the total is somewhat higher than 33% since more than one
risk factor could be found in the same subject).

With respect to reasons for consulting a smoking clinic, 68% of subjects claimed
to have done so on their own initiative, 5% on the recommendations of the entourage
and 23% on medical advice. The consultation was motivated by a complication in
14% of cases and by comorbidity in 24 % of cases, notably cardiovascular disease
(11%), respiratory insufficiency (3.6%) and neoplastic disease (4%); other conditions,
in particular upper respiratory tract pathologies, made up the remaining 7%. A
psychiatric history was observed in 21% of cases, which involved hospitalisation in
6.8%; 18.5% of subjects had been treated for a psychiatric disorder and 8% had
stopped work for this reason. On the HAD test, the mean anxiety and depression
scores were 9.1 (SD: 4.5) and 4.8 (SD: 3.7) respectively. These scores indicate a
moderately anxious but not depressed population.

The VAS scores obtained for the eight dimensions of the global motivation scale
are presented in Table 1. The distribution of replies to the self-administered
motivation questionnaire are presented in Figures 1 to 6.

In order to derive a scale from the questionnaire, the different items were
weighted. A multiple regression analysis was performed using the VAS score for
global motivation as the dependent variable and the scores on the seven items of the
self-administered motivation questionnaire as independent variables. The scores
were first of all assigned a priori using a linear progression from 0 for the first reply, 1
for the second reply and so on. The weighting coefficients obtained for the seven
items were following: Q1: 10.4; Q2: -1.3; Q3: 4.9; Q4: 8.5; Q5: 0.6; Q6: 5.0; Q7: 2.2.
An estimation of residual variance demonstrated that such a linear model of score
attribution was acceptable.

Due to the heterogeneity of the weighting coefficients, we could eliminate the

three questions with the lowest coefficients which thereby contributed only marginally
to the final score. We thus retained the questions Q1, Q3, Q4 and Q6. A new multiple
regression analysis was performed with just these four independent variables. The
weighting coefficients obtained from this analysis were 10.2 for Q1, 5.0 for Q3, 8.4 for
Q4 and 5.2 for Q6.

Several iterations of item scoring were then performed in order to obtain a

simple maximal score for the scale (a round number like 10 or 20) and an evenly-
distributed weighting between the different response modalities possible for each
question. The final model retained yielded a maximal score of 20 and is presented in
Appendix 2. Multiple regression analysis revealed a correlation coefficient r² of 0.32
between the VAS score of global motivation and the score derived from the four
questionnaire items with their final item score attributions. The linear regression
analysis between the total score derived from the questionnaire and the VAS score of
global motivation yielded a Spearman's correlation coefficient of 0.75 (p < 0.0001).

The motivation score was calculated from the two self-administered motivation
questionnaires completed by the patients when the appointment was made and then
at the time of the consultation. The mean motivation score increased from 15.3 (SD:
4.2) at the time of the appointment to 15.6 (SD: 4.2) at consultation, a small but
significant (p = 0.04) change. Stepwise multiple regression analysis failed to identify
any sociodemographic, tobacco-related or psychopathological variable significantly
associated with this increase in motivation score (data not shown).

Motivation scores were also generated from the self-administered

questionnaires completed by the patients in our previous study (3). Linear regression
analysis of the association between these scores and the motivation score assigned
by the psychologist following a semi-structured interview generated a correlation
coefficient of 0.82 (p < 0.001).
Discussion and Conclusions
We have generated a motivation scale (Q-MAT) for smoking cessation made up
of four questions whose response modalities generated a score that could range
from 0 to 20. The Q-MAT scale was constructed from an original questionnaire
including 25 questions exploring nine dimensions of motivation. Analyses performed
during a preliminary study (3,9) allowed the number of items to be reduced to seven.
The item weighting performed by multiple regression analysis in the current study led
to the elimination of a further three questions which contributed only marginally to the
total motivation score. These were Q2 (Do you think that stopping smoking would be
good for your self-image?), Q5 (Have you already tried to stop smoking?) and Q7
(Do you think that smoking is bad for your health?).

The final scale generated a score which correlated well with overall motivation
as measured by the investigator in a semi structured interview. The robustness of the
scale is supported by the very similar correlation coefficients for the association
between Q-MAT score and overall motivation according to the physician that
obtained with data generated in this and in a previous (3) study (r = 0.75, p < 0.001
and r = 0.82, p < 0.001 respectively). Moreover, motivation scores measured with the
Q-MAT scale were sensitive to change, since scores increased significantly between
the time at which an appointment was made and the first consultation at the smoking
cessation clinic. This change in motivation score, although modest, appears logical,
since attending a consultation represents a stronger commitment to change than just
making appointment and it is therefore not surprising to observe an increase in
motivation during the weeks preceding quitting. This finding supports the construct
validity of the scale. The predictive validity of the score in terms of smoking cessation
success is currently being evaluated in a sample of 505 patients giving up smoking.

Finally, the first three items retained in the Q-MAT questionnaire explore the
stages of readiness for change proposed in the trans-theoretical model (4), as well as
self-efficacy for questions 1 and 3 (concept of success). Question 4 addresses
agreement with the postulate that smoking is bad for one's own health. The six other
dimensions explored in the original proto-questionnaire (3) do not contribute to the
motivation scale. These were agreement with the postulate that smoking is
dangerous for health in general, the responsibility of external versus internal factors
in successfully stopping smoking, the perceived advantages of stopping smoking, the
perceived disadvantages of stopping smoking and personal attitudes towards
relapse.
 In conclusion, we have constructed and validated a self-administered scale to
assess motivation for smoking cessation made up of four questions. The predictive
validity of the scale with respect to giving up smoking successfully is currently being
evaluated in a dedicated study.
Acknowledgements
The authors would like to express their gratitude to all the physicians who
participated in this study:

Dr Kamel ABDENNBI - Centre Cardiologique du Nord (Saint-Denis)

Dr Laure-Anne BECQUART et Dr Bruno PICAVET - CH Maison Blanche (Reims)
Dr Anne BORGNE - Hôpital Jean Verdier (Bondy)
Dr Nathalie BOUVET-DELORD - "Les Charmilles" (Fontaine-Lès-Dijon)
Dr Gérard de L'HOMME - American Hospital of Paris (Neuilly s/Seine)
Dr Christelle DUBOCAGE - Service Local de la Promotion de la Santé (Arras)
Dr Patrick DUPONT - Cabinet Médical (Evry)
Dr Daniel GARELIK - Hôpital Bichat (Paris)
Dr Jérôme GARIEPY - Hôpital Broussais (Paris)
Dr Claudine GILLET - Hôpital Villemin (Nancy)
Dr Marie-Pierre HUMEAU-CHAPUIS - Dispensaire Jean V (Nantes)
Dr Martine KUPERMINC-LE BER - Centre de Tabacologie (Paris)
Pr Gilbert LAGRUE Gilbert - Hôpital Albert Chenevier (Créteil)
Dr Gabrielle LALANDE - IRSA (La Riche)
Dr Annick LANTEAUME-VAILLANT (Marseille)
Dr Béatrice LE MAITRE - CHU Côte de Nacre (Caen)
Dr Jacques LESCS (Poissy)
Dr François LETOURMY - Hôpital de RANGUEIL (Toulouse)
Dr MAILLON - COLUMBUS (Saint-Etienne)
Dr François MARTIN - Centre hospitalier (Dreux)
Dr Gérard PEIFFER - Centre de Tabacologie (Metz)
Dr Véronique PEIM-BOUJENAH (Paris)
Dr Jean PERRIOT - Dispensaire Emile Roux (Clermont-Ferrand)
Pr François RUFF - Hôpital Européen Georges Pompidou (Paris)
Appendix 1
Smoking Cessation Motivation Questionnaire

Q1. In six months time, do you think that:

 You will still be smoking as much?
 You will have cut down your cigarette consumption a little?
 You will have cut down your cigarette consumption a lot?
 You will have stopped smoking?

Q2. Do you think that stopping smoking would be good for your self-image?
 Not at all
 A little
 A lot
 Enormously

Q3. At the moment, do you want to stop smoking?

 Not at all
 A little
 A lot
 Enormously

Q4. In the next four weeks, do you think that:

 You will still be smoking as much?
 You will have cut down your cigarette consumption a little?
 You will have cut down your cigarette consumption a lot?
 You will have stopped smoking?

Q5. Have you already tried to stop smoking?

 Never
 Once
 Several times

Q6. Do you ever feel unhappy about smoking?

 Never
 Sometimes
 Often
 Very often

Q7. Do you think that smoking is bad for your health?

 Not at all
 A little
 A lot
 Enormously
Appendix 2
Final Q-MAT Smoking Cessation Motivation Questionnaire

Item Score

Q1. In six months time, do you think that:

 You will still be smoking as much? 0
 You will have cut down your cigarette consumption a little? 2
 You will have cut down your cigarette consumption a lot? 4
 You will have stopped smoking? 8

Q2. At the moment, do you want to stop smoking?

 Not at all 0
 A little 1
 A lot 2
 Enormously 3

Q3. In the next four weeks, do you think that:

 You will still be smoking as much? 0
 You will have cut down your cigarette consumption a little? 2
 You will have cut down your cigarette consumption a lot? 4
 You will have stopped smoking? 6

Q4. Do you ever feel unhappy about smoking?

 Never 0
 Sometimes 1
 Often 2
 Very often 3
Table 1

Dimensions of motivation m sd min max med

Intention to stop smoking 75.94 19.40 14.29 100.00 80.71
Advantages and disadvantages of smoking 74.75 19.83 11.43 100.00 78.57
Awareness of the dangers of smoking 77.97 19.54 2.86 100.00 83.57
Desire to stop smoking 76.89 18.73 9.29 100.00 80.00
Advantages and disadvantages of stopping smoking 73.32 18.66 0.00 100.00 77.14
Attitude of the smoker’s entourage 77.20 19.11 7.14 100.00 82.86
Personal effectiveness and self-confidence with respect to stopping 60.96 22.10 1.43 100.00 61.43
Anticipated success in stopping smoking 70.41 19.53 10.00 100.00 75.00
Global motivation 71.15 21.00 12.86 100.00 88.21
Figure 1

In six months time, do you think that:

100%

When making the appointment

80% At the time of the consultation
76.2% 76.3%

60%

40%

20%
13.4% 12.7%
8.6%
6.5%
3.9%
2.5%
0%
You will still You will have cut You will have cut You will have
be smoking down your cigarette down your cigarette stopped smoking?
as much? consumption a little? consumption a lot?
Figure 2

Do you think that stopping smoking would be good for your self-image?

100%

80% When making the appointment

At the time of the consultation

60%

40.3%
40% 36.8%
34.2% 33.5%

20% 17.1%
15.3%
12.0% 10.9%

0%
Not at all A little A lot Enormously
Figure 3

At the moment, do you want to stop smoking?

100%

When making the appointment

80% At the time of the consultation

60%

46.2%
42.2%
40% 37.8%
32.9%

20.9% 19.3%
20%

0.0% 0.8%
0%
Not at all A little A lot Enormously
Figure 4

In the next four weeks, do you think that:

100%

80% When making the appointment

At the time of the consultation

60% 55.9%
49.8%

40%
33.2%
27.4%

20%
11.4% 12.2%
5.7% 4.5%

0%
You will still be You will have cut You will have cut You will have
smoking as much? down your cigarette down your cigarette stopped smoking?
consumption a little? consumption a lot?
Figure 5

Do you ever feel unhappy about smoking?

100%

80% When making the appointment

At the time of the consultation

60%

43.2%
40.6%
40%
31.2%
29.5%
24.6% 24.4%

20%

3.9% 2.8%

0%
Never Sometimes Often Very often
Figure 6

Do you think that smoking is bad for your health?

100%

When making the appointment

80%
At the time of the consultation
71.4%
68.2%

60%

40%

27.4%
22.2%
20%

6.4%
4.4%
0.0% 0.0%
0%
Not at all A little A lot Enormously