Traditionally, smoking cessation was viewed as a dichotomy: an individual either smoked or did not. Individuals were categorized as either smokers, ex-smokers or non-smokers.
This perspective was in line with a biomedical model of addictions and emphasized the
‘all or nothing nature’ of smoking behaviour. In addition, alcoholics were encouraged to abstain and to become non-drinkers. However, early attempts at promoting total abstinence were relatively unsuccessful and research now often emphasizes cessation as a process. In particular, Prochaska and DiClemente (1984; see Chapter 2) adapted their stages of change model to examine cessation of addictive behaviours. This model
highlighted the processes involved in the transition from a smoker to a non-smoker and from a drinker to a non-drinker. They argued that cessation involves a shift across five basic stages:
1 precontemplation: defined as not seriously considering quitting;
2 contemplation: having some thoughts about quitting;
3 preparation: seriously considering quitting;
4 action: initial behaviour change;
5 maintenance: maintaining behaviour change for a period of time.
Prochaska and DiClemente maintain that individuals do not progress through these stages in a straightforward and linear fashion but may switch backwards and forwards (e.g. from precontemplation to contemplation and back to precontemplation again).
They call this ‘the revolving door’ schema and emphasize the dynamic nature of cessa- tion. This model of change has been tested to provide evidence for the different stages for smokers and outpatient alcoholics (DiClemente and Prochaska 1982; 1985; DiClemente and Hughes 1990), and for the relationship between stage of change for smoking cessa- tion and self-efficacy (DiClemente 1986). In addition, DiClemente et al. (1991) examined the relationship between stage of change and attempts to quit smoking and actual cessation at one- and six-month follow-ups. The authors categorized smokers into either precontemplators or contemplators and examined their smoking behaviour at follow-up.
They further classified the contemplators into either contemplators (those who were smoking, seriously considering quitting within the next six months, but not within the next 30 days) or those in the preparation stage (those who were seriously considering quitting smoking within the next 30 days). The results showed that those in the prepara- tion stage of change were more likely to have made a quit attempt at both one and six months, that they had made more quit attempts, and were more likely to be not smoking at the follow-ups. This study is described in detail in Focus on research 5.1, page 115.
Research has also used the health beliefs and structured models outlined in Chapter 2 to examine the predictors of both intentions to stop smoking and successful smoking cessation. For example, individual cognitions such as perceptions of susceptibility, past cessation attempts and perceived behavioural control have been shown to relate to reductions in smoking behaviour (Giannetti et al. 1985; Cummings et al. 1988; Godin et al. 1992). In addition, the theory of planned behaviour (TPB) has been used as a framework to explore smoking cessation in a range of populations, including those following a worksite ban (Borland et al. 1991), pregnant women and the general population (Godin et al. 1992).
Along these lines, one study examined the usefulness of the TPB at predicting inten- tion to quit smoking and making a quit attempt in a group of smokers attending health promotion clinics in primary care (Norman et al. 1999). The results showed that the best predictors of intentions to quit were perceived behavioural control (i.e. ‘How much control do you feel you have over not smoking over the next six months?’) and perceived susceptibility (i.e. ‘How likely do you think it might be that you will develop any of the following problems in the future if you continue to smoke?’). At follow-up, the best predictors of making a quit attempt were intentions at baseline (i.e. ‘How likely is it that
you will not smoke during the next six months?’) and the number of previous quit attempts. Therefore, the process of smoking cessation can be explored using either a stages of change perspective, individual cognitions or structured models such as the TPB.
F O C U S O N R E S E A R C H 5 . 1 : T E S T I N G A T H E O RY – S TA G E S O F S M O K I N G C E S S AT I O N
A study to examine the stages of change in predicting smoking cessation (DiClemente et al. 1991).
Traditionally addictive behaviours were viewed as ‘either/or’ behaviours. Therefore, smokers were considered either smokers, ex-smokers or non-smokers. However, DiClemente and Prochaska (1982) developed their transtheoretical model of change to examine the stages of change in addictive behaviours. This study examined the validity of the stages of change model and assessed the relationship between stage of change and smoking cessation.
Background
The original stages of change model describes the following stages:
I Precontemplation: not seriously considering quitting in the next six months.
I Contemplation: considering quitting in the next six months.
I Action: making behavioural changes.
I Maintenance: maintaining these changes.
The model is described as dynamic, not linear with individuals moving backwards and forwards across the stages. In this study, the authors categorized those in the con- templation stage as either contemplators (not considering quitting in the next 30 days) and those in the preparation stage (planning to quit in the next 30 days).
Methodology
Subjects A total of 1466 subjects were recruited for a minimum intervention smok- ing cessation programme from Texas and Rhode Island. The majority of the sub- jects were white, female, had started smoking at about 16 and smoked on average 29 cigarettes a day.
Design The subjects completed a set of measures at baseline and were followed up at one and six months.
Measures The subjects completed the following set of measures:
I Smoking abstinence self-efficacy (DiClemente et al. 1985), which measures the smokers’ confidence that they would not smoke in 20 challenging situations.
I Perceived stress scale (Cohen et al. 1985), which measures how much perceived stress the individual has experienced in the last month.
I Fagerstrom Tolerance Questionnaire which measures physical tolerance to nicotine.
I Smoking decisional balance scale (Velicer et al. 1985), which measures the perceived pros and cons of smoking.
I Smoking processes of change scale (DiClemente and Prochaska 1985), which measures the individual’s stage of change. According to this scale, subjects were defined as precontemplators (n = 166), contemplators (n = 794) and those in the preparation stage (n = 506).
I Demographic data, including age, gender, education and smoking history.
Results
The results were first analysed to examine baseline difference between the three subject groups. The results showed that those in the preparation stage smoked less, were less addicted, had higher self-efficacy, rated the pros of smoking as less and the costs of smoking as more, had made more prior quitting attempts than the other two groups. The results were then analysed to examine the relationship between stage of change and smoking cessation. At both one and six months, the subjects in the preparation stage had made more quit attempts and were more likely to not be smoking.
Conclusion
The results provide support for the stages of change model of smoking cessation and suggest that it is a useful tool for predicting successful outcome of any smoking cessation intervention.
I N T E R V E N T I O N S T O P R O M O T E C E S S AT I O N
Interventions to promote cessation can be described as either (1) clinical interventions, which are aimed at the individual; (2) self-help movements; or (3) public health inter- ventions, which are aimed at populations.