Do Transtheoretical Model Measures Predict the Transition from Preparation to Action in Smoking Cessation?

Understanding the role of e-cigarette use in smoking cessation based on the stages of change model

Objective

We explored the role of e-cigarette use in smoking cessation based on the stages of change (SOC) model, which is a framework for describing the process of smoking cessation.

Methods

We used nationwide, cross-sectional data on adults (19+ years) from the seventh Korea National Health and Nutrition Examination Survey (KNHANES, 2016–2018) and restricted the participants to 3,929 recent smokers, consisting of current smokers and recent quitters (≤2 years). A multinomial logistic regression analysis was performed to reveal the relationships between e-cigarette use and cigarette quitting behaviors (e.g., current quitting status, past quit attempts, intention to quit, and duration of quitting) and all stages in smoking cessation, with adjustment for sociodemographic and smoking-related factors.

Results

E-cigarette use was positively related to past quit attempts, while not having quit, intention to quit, and longer duration of quitting. Based on the cessation stages, current and former e-cigarette users were significantly more likely to be in the ‘Precontemplation’ and ‘Contemplation’ stages than never users, while not to be in the ‘Preparation’ and ‘Action’ stages. Current users were particularly less likely to be in the ‘Maintenance’ stage compared to never users.

Conclusion

E-cigarette use was closely linked with early-stage behavior than late-stage behavior in the smoking cessation process. E-cigarettes might promote quit attempts and short-term quitting in some smokers, but the negative role of inducing smokers to continue cigarette smoking with no immediate quit-intention for future attempts is dominant in the real world.

Theoretical constructs of smoking cessation among current tobacco smokers in India: a secondary analysis of Global Adult Tobacco Survey-2 (2016-2017)

BACKGROUND

Quitting tobacco smoking is a complex process, and the transtheoretical model describes the various stages of behaviour change that smokers experience to stop smoking. Predictors of intention to quit and stage of behavioural change could assist policy-makers in establishing tailor-made strategies to offer support.

OBJECTIVE

In the current study, we analysed the determinants of cessation among 9499 current smokers of India recorded during the second Global Adult Tobacco Survey (2016-2017).

METHODS

Bivariate analysis, multivariate analysis (binary logistic regression was performed for past quit attempts and intention to quit smoking in the future; multinomial logistic regression to understand predictors of various stages of change determining cessation behaviour of current smokers) was undertaken.

RESULTS

The majority of the smokers was men (91.0%), in 25-44 years age group, (42.3%), daily wagers (37.4%) and resided in the rural area (73.3%), with bidi being the most commonly smoked product (72%). Nearly 72% tried to quit without any assistance with 36.6% (precontemplation), 27% (contemplation), 28% (preparation (or action)) and 8.1% in (relapse) stage. Men ((1.049); 95% CI 1.047 to 1.051), the primary (1.192; 95% CI 1.190 to 1.193) as well as higher education, being married (1.231; 95% CI 1.229 to 1.234) and urban residence (1.167; 95% CI 1.1.65 to 1.168) were found to be associated with higher prevalence of previous quit attempts. The regression modelling found out that intent to quit reduced with increasing age and was similarly prevalent with any level of education.

CONCLUSION

Understanding stages of behavioural change could assist the stakeholders in developing individualised interventions along with the development of intensive cessation protocols in clinical and public health settings.

Changes in the reach of a smoking cessation program in Ontario, Canada, during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

Given the harms associated with tobacco use, continuing the provision of smoking cessation treatment during the COVID-19 pandemic is critical. The aim of this study was to examine pandemic-related changes in enrolment, total treatment use and participant characteristics in a large, publicly funded smoking cessation program in Ontario, Canada.

METHODS

We conducted a secondary data analysis of patients who enrolled in the program between Jan. 1, 2018, and Dec. 7, 2020. We used descriptive statistics to examine changes in treatment use. To test for differences in sociodemographic and health variables, we used segmented mixed-effects regression with a break point on Mar. 17, 2020, when Ontario declared a state of emergency. We tested 25 variables, using Holm's correction for multiplicity.

RESULTS

We analyzed 60 373 enrolments. In the month after the break point, enrolments fell 69% and total visits fell 42% relative to previous years. After Mar. 17, 2020, those who enrolled were less likely to report employment in the previous week (absolute expected difference -12.4%, 95% confidence interval [CI] -15.0% to -9.8%); were more likely to be occasional (1.3%, 95% CI 0.6% to 1.9%) or noncurrent smokers (1.7%, 95% CI 0.8% to 2.6%); were less likely to have set a target quit date (-4.8%, 95% CI -7.0% to -2.6%); and were more likely to have a physical health (6.6%, 95% CI 4.0% to 9.2%), mental health (4.6%, 95% CI 1.9% to 7.2%) or substance use diagnosis (3.5%, 95% CI 1.3% to 5.6%).

INTERPRETATION

Sharp decreases in new enrolments and subsequent visits to smoking cessation programs were seen when pandemic restrictions were implemented in Ontario, but the characteristics of the people who accessed the programs did not change markedly. Incorporating an equity perspective is essential when new models of care for smoking cessation are developed.

Longitudinal Care Improves Cessation in Smokers Who Do Not Initially Respond to Treatment by Increasing Cessation Self-Efficacy, Satisfaction, and Readiness to Quit: A Mediated Moderation Analysis

BACKGROUND

The Tobacco Longitudinal Care study was a randomized controlled trial for smoking cessation. It demonstrated that longitudinal care for smoking cessation, in which telephone-based counseling and nicotine replacement therapy were offered for 12 months, was more effective than the standard 8-week treatment.

PURPOSE

This study aims to identify for whom and how longitudinal care increased the likelihood of abstinence.

METHODS

Mediated moderation analyses were utilized across three time points.

RESULTS

There was a trend towards smokers who did not respond to treatment (i.e., were still smoking) by 21 days being more likely to be abstinent at 6 months if they received longitudinal care rather than usual care. Similarly, those who did not respond to treatment by 3 months were more likely to be abstinent at 12 months if they received longitudinal care. At both time points, the likelihood of abstinence did not differ across treatment conditions among participants who responded to treatment (i.e., quit smoking). The effect on 6-month outcomes was mediated by satisfaction and readiness to quit. Cessation self-efficacy, satisfaction, and readiness to quit mediated the effect on 12-month outcomes. The effect of treatment condition on the likelihood of abstinence at 18 months was not moderated by response to treatment at 6 months.

CONCLUSIONS

Smokers who did not respond to initial treatment benefited from longitudinal care. Differential effects of treatment condition were not observed among those who responded to early treatment. Conditional assignment to longitudinal care may be useful. Determining for whom and how interventions work over time will advance theory and practice.

The views and experiences of smokers who quit smoking unassisted. A systematic review of the qualitative evidence

BACKGROUND

Unassisted cessation - quitting without pharmacological or professional support - is an enduring phenomenon. Unassisted cessation persists even in nations advanced in tobacco control where cessation assistance such as nicotine replacement therapy, the stop-smoking medications bupropion and varenicline, and behavioural assistance are readily available. We review the qualitative literature on the views and experiences of smokers who quit unassisted.

METHOD

We systematically searched for peer-reviewed qualitative studies reporting on smokers who quit unassisted. We identified 11 studies and used a technique based on Thomas and Harden's method of thematic synthesis to discern key themes relating to unassisted cessation, and to then group related themes into overarching concepts.

FINDINGS

The three concepts identified as important to smokers who quit unassisted were: motivation, willpower and commitment. Motivation, although widely reported, had only one clear meaning, that is 'the reason for quitting'. Willpower was perceived to be a method of quitting, a strategy to counteract cravings or urges, or a personal quality or trait fundamental to quitting success. Commitment was equated to seriousness or resoluteness, was perceived as key to successful quitting, and was often used to distinguish earlier failed quit attempts from the final successful quit attempt. Commitment had different dimensions. It appeared that commitment could be tentative or provisional, and also cumulative, that is, commitment could be built upon as the quit attempt progressed.

CONCLUSION

A better understanding of what motivation, willpower and commitment mean from the smoker's perspective may provide new insights and direction for smoking cessation research and practice.

Adolescents' movement towards cessation of smoking: role and relative value of the processes of change and nicotine dependence

The present study addresses the applicability of the Transtheoretical Model's processes of change in explaining adolescents' readiness to quit smoking. Furthermore, the association between nicotine dependence and readiness to quit was assessed both directly, as well as indirectly through the processes of change. A cross-sectional survey was conducted, identifying 1547 weekly smokers aged 14-18 years. Structural equation modelling showed that the processes of change were only marginally associated with readiness to quit. Adding nicotine dependence to the model showed a direct association between nicotine dependence and readiness to quit. Only one process of change, self-liberation (i.e. choice/commitment to change and belief in the ability to change), was found to mediate this association. Nicotine dependence appeared to be highly important in adolescents' readiness to quit.

Developmental pathways to smoking cessation

Purpose

– To a great extent research about smoking cessation has focussed on effects from different support programs and means, in spite of that several studies have shown that over 90 percent quit smoking without such help. Factors that are important for the individual in the process from being a smoker to becoming smoke-free is less examined and also how these factors interact. The purpose of this paper is to describe typical careers or pathways that end up with a successful smoking cessation.

Design/methodology/approach

– Respondents were recruited during Oct 2009-May 2010 via screening-questions in the so-called Monitor – project. By the turn of each month 1,500 individuals, aged 16-84, from a representative sample in the Swedish population, were interviewed via telephone. Respondents who stated being previous daily smokers, but smoke-free for at least 12 months, and agreed to participate were asked to answer a postal survey (n=1,683) concerning their process to a smoke-free life. The analyses of data included the linking of individuals between different states in the stages toward becoming smoke-free.

Findings

– Several typical pathways were described and respondents with more severe smoking habits followed different pathways than individuals with milder problems. Nicotine replacement therapys or Swedish smoke-free tobacco was not found to be a component in any of the typical pathways.

Originality/value

– Smoking cessation is a heterogeneous phenomenon and individuals can follow several pathways to become smoke-free, therefore this study adds to a more nuanced picture of smoking cessation and also expands the knowledge concerning smoking cessation in individual long-term processes.

Quit now? Quit soon? Quit when you're ready? Insights about target quit dates for smoking cessation from an online quit date tool

BACKGROUND

Setting a target quit date (TQD) is often an important component in smoking cessation treatment, but ambiguity remains concerning the optimal timing (ie, quitting spontaneously versus delaying to prepare).

OBJECTIVE

We examined four questions about the timing of TQDs and smoking outcomes in secondary analyses of The iQUITT Study, a randomized trial of Internet and telephone treatment for cessation: (1) What are the characteristics of TQDs set using an online interactive quit date tool?, (2) What are the characteristics of individuals who use a quit date tool and do they differ from those who do not?, (3) Are there differences in smoker characteristics, treatment utilization, and cessation outcomes based TQD timing?, and (4) Is maintenance of an initial TQD predictive of abstinence or do changes to TQDs lead to cessation?

METHODS

A total of 825 adult current cigarette smokers were randomized to enhanced Internet or enhanced Internet plus telephone counseling. Latency to TQD in days was calculated as the date difference between the initial TQD and enhanced Internet registration; prospective TQD setters were stratified into four latency groups (0, 1-14, 15-28, 29+ days). Baseline variables, website utilization, and 3-month cessation outcomes were examined between prospective TQD groups. Desire and confidence to quit, number of TQDs, and website logins were tested as predictors of 30-day point prevalence abstinence (ppa) at 3 months (responder-only analyses). Classification and regression tree (CART) analysis explored interactions among baseline variables, website utilization, and latency to TQD as predictors of 30-day ppa.

RESULTS

There were few baseline differences between individuals who used the quit date tool and those who did not. Prospective TQDs were set as follows: registration day was 17.1% (73/427), 1-14 days was 37.7% (161/427), 15-28 days was 18.5% (79/427), and 29+ days was 26.7% (114/427). Participants with a TQD within 2 weeks had higher baseline self-efficacy scores but did not differ on smoking variables. Individuals whose TQD was the same day as registration had the highest logins, page views, number of TQDs set using the tool, and messages sent to other members. Logistic regression revealed a significant interaction between number of TQDs and website logins for 30-day ppa (P=.005). Among those with high logins, 41.8% (33/79) with 1 TQD were abstinent versus 25.9% (35/135) with 2+TQDs. Logins and self-efficacy predicted 30-day ppa in the CART model.

CONCLUSIONS

TQD timing did not predict cessation outcomes in standard or exploratory analyses. Self-efficacy and an apparent commitment to an initial TQD were the components most highly related to abstinence but only via interactions with website utilization. Findings highlight the importance of feeling efficacious about handling specific smoking situations and engaging with treatment. Additional research focused on increasing engagement in Web-based cessation studies is needed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00282009; http://clinicaltrials.gov/show/NCT00282009 (Archived by WebCite at http://www.webcitation.org/6Kt7NrXDl).

Testing the transtheoretical model in predicting smoking relapse among Malaysian adult smokers receiving assistance in quitting

The role of The Transtheoretical Model (TTM) in predicting relapse is limited. We aimed to assess whether this model can be utilised to predict relapse during the action stage. The participants included 120 smokers who had abstained from smoking for at least 24 hours following two Malaysian universities' smoking cessation programme. The smokers who relapsed perceived significantly greater advantages related to smoking and increasing doubt in their ability to quit. In contrast, former smokers with greater self-liberation and determination to abstain were less likely to relapse. The findings suggest that TTM can be used to predict relapse among quitting smokers.

Psychosocial predictors of four health-promoting behaviors for cancer prevention using the stage of change of Transtheoretical Model

OBJECTIVES

The present study aimed to examine whether demographic as well as psychosocial variables related to the five stages of change of the Transtheoretical Model can predict non-clinical adults' cancer preventive and health-promoting behaviors. This study specifically focused on cancer, one of the major chronic diseases, which is a serious threat of national health.

METHODS

A total of 1530 adults participated in the study and completed questionnaires. Collected data were analyzed by using multinominal logistic regression.

RESULTS

The significant predictors of later stages varied among the types of health-promoting behaviors. Certain cancer preventive health-promoting behaviors such as well-balanced diet and exercise were significantly associated with psychosocial variables including cancer prevention-related self-efficacy, personality traits, psychosocial stress, and social support. On the other hand, smoking cessation and moderate or abstinence from drinking were more likely to be predicted by demographic variables including sex and age.

CONCLUSIONS

The present study found that in addition to self-efficacy-a relatively well-studied psychological variable-other personality traits and psychological factors including introversion, neuroticism, psychosocial stress, and social support also significantly predicted later stages of change with respect to cancer preventive health-promoting behaviors. The implications of this study are also discussed.

Effects of timing of initiation and planning on smoking cessation outcomes: study protocol for a randomised controlled trial

BACKGROUND

Recent theoretical and empirical work has led to debate over the benefit of delaying the implementation of a decision to quit smoking in order to plan the attempt. These two need not be linked, planning can occur before a commitment to quit is made, or after it is implemented, as well as in between. This study will test whether there are independent benefits for encouraging smokers to act immediately on a definite decision to quit smoking, and to engage in structured planning.

METHODS/DESIGN

A complex randomised controlled trial with a factorial design, testing the presence of a recommendation to quit immediately (or not) and encouragement to structured planning (or not) as additions to standard care, a web-based automated tailored advice program (QuitCoach). Participants are recruited from users of the QuitCoach who reside in Australia, do not report a mental health condition for which they are taking medication, are adult daily smokers, and at least open to the possibility of quitting. For the Immediate arm they could not have committed to quit within 2 days, while the Planning arm included all these and those quit within the last 4 days. This creates 6 groups: 2 × 3, with 2 × 2 fully randomised, and 2 only randomised for the planning arm. Follow-up assessments are conducted around 1 month (targeting two weeks after the quit attempt started), and 6 months later. The primary outcome is 6-month sustained abstinence at 6 months. Secondary outcomes include point-prevalence abstinence at both follow-ups, and making quit attempts during the intervention period. We will also explore differences in actual behaviour (timing and planning) by intervention, and relate this to outcomes.

DISCUSSION

This study will result in a better understanding of the roles of planning and delay in influencing the success of quit attempts.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry http://ACTRN12612000613808.

The transtheoretical model as applied to dietary behaviour and outcomes

The transtheoretical model (TTM) is a behavioural theory that describes behaviour change as occurring in five stages, ranging from precontemplation to maintenance. The purpose of the present paper is to review and synthesise the literature published since 1999 on applications of the TTM to dietary behaviour so that the evidence for the use of assessment tools and interventions based on this model might be evaluated. Six databases were identified and searched using combinations of key words. Sixty-five original, peer-reviewed studies were identified and summarised in one of three tables using the following categories: population (n 21), intervention (n 25) and validation (n 19). Internal validity ratings were given to each intervention, and the body of intervention studies as a whole was rated. The evidence for using stage-based interventions is rated as suggestive in the areas of fruit and vegetable consumption and dietary fat reduction. Valid and reliable staging algorithms are available for fruit and vegetable consumption and dietary fat intake, and are being developed for other dietary behaviours. Few assessment tools have been developed for other TTM constructs. Given the popularity of TTM-based assessments and interventions, more research is warranted to identify valid and reliable assessment tools and effective interventions. While the evidence supports the validity of the TTM to describe populations and to form interventions, evidence of the effectiveness of TTM-based interventions is not conclusive.

Efficacy of a flexible quit date versus an a priori quit date approach to smoking cessation: a cross-study analysis

Most treatment guidelines recommend that smokers should set a target quit date (TQD) at treatment onset because making a public commitment to quit on a given date should increase motivation. On the other hand, allowing smokers the flexibility to choose when to stop after starting treatment might allow smokers to better tailor their quit date and might improve the acceptability of treatment among smokers not willing to set a TQD. In a recent placebo-controlled study, we found varenicline effective when smokers were not required to set a quit date a priori; i.e., with a "flexible quit date" (FQD) approach. The current analysis compares the effect sizes and quit rates in this FQD study with those of nine prior varenicline randomized controlled trials (RCTs) that used a TQD approach. The odds ratio for varenicline versus placebo in the FQD study was the 4th highest of the 10 trials and the incidence of continuous abstinence for varenicline was 5th highest. These results suggest that a FQD approach can produce quit rates similar to a TQD approach. Cross-study comparisons can have hidden bias; thus, a RCT of fixed versus flexible quit dates would provide a more valid test. Also, a study of whether different subpopulations of smokers may be more interested in or especially benefit from, one or the other approach to quitting is indicated.

Motivational factors predict quit attempts but not maintenance of smoking cessation: findings from the International Tobacco Control Four country project

AIM

To explore whether measures of motivation to quit smoking have different predictive relationships with making quit attempts and the maintenance of those attempts.

METHODS

Data are from three wave-to-wave transitions of the International Tobacco Control Four (ITC-4) country project. Smokers' responses at one wave were used to predict the likelihood of making an attempt and among those trying the likelihood of maintaining an attempt for at least a month at the next wave. For both outcomes, hierarchical logistic regressions were used to explore the predictive capacity of seven measures of motivation to quit smoking, controlling for a range of other known or possible predictors.

RESULTS

Bivariate analyses indicate that measures of motivation to quit are predictive of making quit attempts, but they predict relapse among those making attempts. Multivariate analyses identified wanting to quit and frequency of prematurely butting out cigarettes as the main positive predictors of making attempts, but this was reduced by intention and recency of last attempt. For maintenance, premature butting out was the main motivation variable predicting relapse and was essentially unaffected by other measures.

DISCUSSION

The findings show that it is wrong to suggest that all one needs to quit is to be motivated to do so. The reality is that one needs to be motivated to prompt action to stop smoking, but this is not sufficient in and of itself to ensure that cessation is maintained. These findings call attention to the importance of understanding the differential roles that prequit and postquit experiences play in smoking cessation and of providing help to smokers to stay off cigarettes.

The influence of having a quit date on prediction of smoking cessation outcome

The aim of this study was to explore whether factors predicting making a quit attempt are uniform within the preparation stage of the transtheoretical model (TTM). Participants were 283 smokers, all planning to quit in the next 30 days (preparation stage), who used a computer-generated tailored advice programme. Evidence of differences in prediction of making a quit attempt was found between smokers with and without a quit date, with the predictive power of a multivariate model markedly higher among those with a set date. In particular, one aspect of pros of smoking (smoking helps you feel better when things are bad) was predictive of progression among those with a quit date, but not among those without. The results suggest that factors predicting stage progression are not uniform within the preparation stage. The results complement other recent research that has questioned the stage definitions used in the TTM and provide evidence in support of an alternative stage boundary defined by the commitment of setting a quit date.

Do risk-minimizing beliefs about smoking inhibit quitting? Findings from the International Tobacco Control (ITC) Four-Country Survey

OBJECTIVE

To replicate findings that risk-minimizing and self-exempting beliefs lower quit intentions, and to extend this by testing their capacity to prospectively predict smoking cessation.

METHOD

13,324 adult (> or =18 years) cigarette smokers from the USA, Canada, UK, and Australia from one of the first three waves (2002-2004) of the International Tobacco Control 4-Country survey were employed for the predictive analysis where beliefs measured in one wave (1-3) of a cohort were used to predict cessation outcomes in the next wave (2-4).

RESULTS

Both types of belief were negatively associated with both intention to quit in the same wave and making a quit attempt at the next wave. When taken together and controlling for demographic factors, the risk-minimizing beliefs continued to be predictive, but the self-exempting belief was not. Some of the effects of risk-minimizing beliefs on quit attempts seem to be independent of intentions, but not consistently independent of other known predictors. There were no consistent predictive effects on sustained cessation among those who made attempts to quit for either measure.

CONCLUSIONS

Countering risk-minimizing beliefs may facilitate increased quitting, but this may not be so important for self-exempting beliefs.

Do the Transtheoretical Model processes of change, decisional balance and temptation predict stage movement? Evidence from smoking cessation in adolescents

AIMS

To examine the effects of processes of change (POC) on forward stage movement directly, indirectly through decisional balance and temptation, and total effects as a test of the key hypothesis of the Transtheoretical Model (TTM).

DESIGN

Prospective cohort study.

SETTING

United Kingdom.

PARTICIPANTS

A total of 1160 adolescents aged 13-14 years who were current or former smokers at baseline.

MEASUREMENTS

Stage was assessed with the standard algorithm three times, once every 3 months. On each occasion the POC, decisional balance and temptation were measured with the standard questionnaires. Path analysis was used to examine the direct, indirectly mediated and total contribution of POC and the other constructs to stage movement 3 months later.

FINDINGS

Four of the 24 analyses showed evidence that the theoretically appropriate POC predicted stage transition, with statistically significant total effects. Effect sizes were small. When the POC were summarized to experiential and behavioural process means, one transition from pre-contemplation was predicted by experiential processes and, contrary to the TTM, one transition predicted by behavioural processes. There was slightly more evidence that decisional balance (attitudes towards smoking) and temptation (ability to resist the urge to smoke) was associated with stage transition.

CONCLUSIONS

POC use was not associated generally with stage transition and evidence that effects, if missed, must be modest, giving no support to the central tenet of the TTM.

Evaluation of a pregnancy prevention programme using the Contraceptive Behavior Change model

AIM

This paper is a report of the findings of a study to examine the effects of application of the Contraceptive Behavior Change model on knowledge, attitudes, perceived benefits and barriers, self-efficacy (SE), stages of change (SOC) and contraceptive behaviours.

BACKGROUND

Unintended pregnancy is a global issue; it is also a concern for the military, as it impacts on mission readiness. Effective sexuality education programmes are needed but, to date, an evaluation of existing programmes using a conceptual model is lacking in the health literature.

METHOD

A sample of 198 single, junior enlisted females was randomly recruited from United States of America Navy ships. An experimental design was adopted. The experimental group received two class sessions, 2 months apart, while the control group received none. The variables measured were: knowledge, attitudes, perceived benefits and barriers, SE, SOC and contraceptive behaviours. Data were collected on three separate occasions at 2-month intervals over a 4-month period in 2004-2005.

RESULTS

Initially, a striking lack of knowledge was evident among study participants. The experimental groups' knowledge increased statistically significantly with repeated interventions, while the control group's knowledge did not change over the same period. Both groups started with no pregnancies, and at the end of the study, the pregnancy rate between the two groups was statistically significant: experimental group 0%, and control group 14%.

CONCLUSIONS

The intervention led to increased knowledge, which in turn led to avoidance of pregnancy. The proposed model was appropriate for the evaluation and consequently can be considered as an effective tool to use for development or refinement of existing programmes.

What does it mean to want to quit?

INTRODUCTION AND AIMS

To report on the prevalence of attitudes and beliefs about the importance of wanting to quit and need for use of cessation assistance, that may act as barriers to quitting smoking and adopting cessation assistance.

DESIGN AND METHODS

National telephone survey of 802 randomly selected adults (685 smokers, 117 recent quitters).

RESULTS

Seventy per cent of smokers believed that 'wanting to quit' was both a necessary and sufficient condition for being able to quit. While only one-third of smokers believed that they were too addicted to be able to quit, only a quarter believed they could quit any time they want to. Belief that use of cessation assistance is a sign of weakness was endorsed by 35% of participants, and related to stage of change.

DISCUSSION AND CONCLUSIONS

Beliefs about the importance of wanting to quit are commonly held. Many smokers appear to believe that a rational, unambivalent desire to quit is needed before it is worthwhile trying. Short-term impulses to act are not perceived as sufficient. The role of cessation assistance in helping smokers form a rational desire to quit appears to be poorly understood by the majority of smokers. There is a need to engender greater understanding of the potential value of cessation aids to smokers experiencing ambivalence about wanting to quit.

Associations between the transtheoretical processes of change, nicotine dependence and adolescent smokers' transition through the stages of change

AIMS

To examine the significance of the transtheoretical processes of change in predicting transition through the stages of change in adolescent smokers, as well as the relative role of nicotine dependence in predicting stage transitions.

DESIGN

In grades 9 and 10, adolescents' stage of change, the use of processes of change and nicotine dependence were assessed (T1). Stage transitions were assessed 1 year later (T2). Response rate was 73.2%.

SETTING

Twenty-five secondary schools throughout the Netherlands participated in the present study.

PARTICIPANTS

Respondents were 721 adolescents who were classified as smokers at T1 and consequently completed the paper-and-pencil questionnaire at T2.

MEASUREMENTS

Stages of change and processes of change were assessed according to the original transtheoretical measures. Nicotine dependence was measured using a newly developed multi-dimensional scale consisting of 11 items.

FINDINGS

Few associations were found between the processes of change and stage transitions. Nicotine dependence contributed significantly to the explanation of adolescents' transition from preparation to action, after adjustment for processes of change. No evidence for a moderating effect of nicotine dependence in the relation between the processes of change and stage transitions was found.

CONCLUSIONS

Processes of change do not seem significant in explaining adolescents' stage transitions. As an alternative for promoting the use of the processes of change for intervention purposes in adolescents, it might be more useful to focus on treating nicotine dependence.

Is attributing smoking to genetic causes associated with a reduced probability of quit attempt success? A cohort study

AIMS

Pharmacogenetic smoking cessation interventions would involve smokers being given information about the influence of genes on their behaviour. However, attributing smoking to genetic causes may reduce perceived control over smoking, reducing quit attempt success. This study examines whether attributing smoking to genetic influences is associated with reduced quitting and whether this effect is mediated by perceived control over smoking.

DESIGN

Cohort study.

PARTICIPANTS

A total of 792 smokers, participating in a trial of nicotine replacement therapy (NRT)-assisted smoking cessation. Participants were informed that the trial investigated relationships between genetic markers and smoking behaviour, but personalized genetic feedback was not provided.

SETTING

Primary care in Oxfordshire and Buckinghamshire, UK.

MEASUREMENTS

Perceived control over smoking and perceived importance of genetic factors in causing smoking assessed pre-quit; abstinence 4, 12, 26 and 52 weeks after the start of treatment.

FINDINGS

A total of 515 smokers (65.0%) viewed genetic factors as playing some role in causing their smoking. They had lower perceived control over smoking than smokers who viewed genetic factors as having no role in causing their smoking. Attributing smoking to genetic causes was not associated significantly with a lower probability of quit attempt success.

CONCLUSIONS

Attributing smoking to genetic factors was associated with lower levels of perceived control over smoking but not lower quit rates. This suggests that learning of one's genetic predisposition to smoking during a pharmacogenetically tailored smoking cessation intervention may not deter quitting. Further research should examine whether the lack of impact of genetic attributions on quit attempt success is also found in smokers provided with personalized genetic feedback.

Excuses to continue smoking: the role of disengagement beliefs in smoking cessation

BACKGROUND

The aim of the present study was to investigate the role of disengagement beliefs in smoking cessation. The association of disengagement beliefs with forward transition through the transtheoretical stages of change and self-reported quitting were examined, with and without adjusting for processes of change.

METHODS

A longitudinal survey was conducted among Dutch smokers, resulting in 367 respondents who completed two questionnaires, one at baseline and one at 8 months follow-up. Disengagement beliefs, intention to quit, actual quitting, and the processes of change were assessed.

RESULTS

The findings showed that disengagement beliefs were negatively associated with forward stage transition and actual quitting. Processes of change only partly mediated these associations.

CONCLUSIONS

Adhering to disengagement beliefs seems to be an inhibitor of progression towards smoking cessation and actual quitting, also after adjustment for processes of change.

The relation between processes-of-change and stage-transition in smoking behavior: a two-year longitudinal test of the Transtheoretical Model

AIMS

To test the theoretical predictions of the Transtheoretical Model regarding process-use and progressive stage-transition in relation to smoking behavior.

DESIGN AND SETTING

Secondary data analyses of a 2-year longitudinal worksite-based smoking-cessation study [Working Well Trial (Abrams, D., Boutwell, W., Grizzle, J., Heimendinger, J., Sorensen, G., & Varnes, J. (1994). Cancer control at the workplace: The Working Well trial. Preventative Medicine, 23, 15-27)].

FINDINGS

The results demonstrated some support for the predictions generated from the Model: those making the transition from the Precontemplation stage to the Contemplation stage showed a heightened use of experiential processes-of-change from the baseline measurement to the 2-year follow-up, while those remaining in the Precontemplation stage reported no differences across time in their ratings of experiential and behavioral processes-of-change. Contrary to Transtheoretical Model's claims, however, smokers moving from the Contemplation stage to the Preparation stage over the 2-year period did not manifest an increasing use of experiential or behavioral processes over time in comparison to their counterparts remaining in the Contemplation stage.

CONCLUSIONS

Given the lack of longitudinal relation between process-use and the Contemplation-to-Preparation transition, the findings in this paper undermine the Transtheoretical Model's central tenet that stage-matched processes-of-change serve as the primary mechanisms of stage progression from the Contemplation stage to the Preparation stage.

Can transtheoretical model measures predict relapse from the action stage of change among ex-smokers who quit after calling a quitline?

This study explored whether transtheoretical model (TTM) measures could predict relapse from the action stage, i.e., during the first 6 months of smoking cessation. Predictors of relapse were examined between time 2 (3-month) and time 3 (6-month) assessments (n = 247), and also between time 3 (6-month) and time 4 (12-month) assessments (n = 204). Consistent predictors of relapse included lower self-efficacy and determination to quit and higher temptations to smoke. Some predictors of relapse changed according to how long a person had already been quit for. Contrary to the TTM, greater behavioral change process use predicted relapse among people who had already quit for less than a month, and did not prevent relapse among those who had already quit for a month or more between time 2 and time 3. Cross-sectional analyses showed significant decreases in temptations to smoke and in the use of some of the change processes, which stabilised at about 1 month post-cessation. The findings suggest that there may be a stage boundary at around 1 month post-cessation, and question the homogeneity, and hence validity, of the TTM-defined action stage of change.

Adolescents' smoking behavior and its relationships with psychological constructs based on transtheoretical model: a cross-sectional survey

BACKGROUND

Korean adolescents' smoking is currently being considered as a crucial factor determining the health status of adolescents and an important public health and social issue.

OBJECTIVES

The purpose of the study was to test the applicability of the Transtheoretical model to gain an understanding of smoking behavior change.

METHODS

A total of 706 adolescents who participated in the smoking cessation programs administered by the Korea Quit Smoking Association or Korean Association of Smoking & Health in 2003 were recruited. Four Korean-version questionnaires were used to identify the stages of smoking behavior and psychological attributes: Stage of Smoking Behavior Change Scale, Processes of Change Scale for Smoking, Decision Balance Scale for Smoking, and Self-efficacy Scale to avoid smoking.

RESULTS

Korean adolescents' smoking behavior was differed according to gender. In addition, the findings revealed that behavioral and cognitive processes of change, self-efficacy, and positives differed across the stages of smoking behavior, and that psychological constructs of the transtheoretical model had a statistically significant impact on smoking behavior change.

CONCLUSIONS

This research could spawn the development of theory-based and empirically supported smoking cessation intervention strategies and programs directed toward adolescents in the health care and nursing areas.

What Is the Right Thing at the Right Time? Interactions Between Stages and Processes of Change Among Smokers Who Make a Quit Attempt

C. A. Perz, C. C. DiClemente, and J. P. Carbonari (1996) claim support for the transtheoretical model notion that success in smoking cessation involves doing the right thing at the right time: emphasising experiential change processes during the contemplation and preparation stages and shifting to behavioral process activities during action. A key methodological limitation of Perz et al. was their failure to control for stage of change, a measure that has been shown to be predictive of cessation. This study replicates the prospective findings of Perz et al. in a different data set, then controls for stage of change when it is predictive of cessation, and finds that the measures of "appropriate" change process use developed by Perz et al. no longer predict cessation. The authors conclude that stage of change, in particular the distinction between smoking and not smoking, is more important than change process use in predicting cessation outcomes.