Seediscussions,stats,andauthorprofilesforthispublicationat:https://www.researchgate.net/publication/16334721

StagesandProcessesofSelf-ChangeofSmoking-TowardAnIntegrativeModelofChange

ArticleinJournalofConsultingandClinicalPsychology·July1983

ImpactFactor:4.85·DOI:10.1037//0022-006X.51.3.390·Source:PubMed

CITATIONS

4,676

READS

12,520

2authors,including:

CarloDiclemente

UniversityofMaryland,Baltim…

212PUBLICATIONS27,919CITATIONS

SEEPROFILE

Availablefrom:CarloDiclemente

Retrievedon:30May2016

Journal of Consulting and Clinical Psychology1983, Vol. 51, No. 3, 390-395

Copyright 1983 by theAmerican Psychological Association, Inc.

Stages and Processes of Self-Change of Smoking:Toward An Integrative Model of Change

James Q ProchaskaUniversity of Rhode Island

Carlo C. DiClementeTexas Research Institute of Mental Sciences

An integrative model of change was applied to the study of 872 subjects changingtheir smoking habits on their own. The subjects represented the following fivestages of change: precontemplation, contemplation, action, maintenance, andrelapse. Ten processes of change were expected to receive differential emphasesduring particular stages of change. Results indicate that self-changers: (a) use thefewest processes of change during precontemplation; (b) emphasize consciousnessraising during the contemplation stage; (c) emphasize self-reevaluation in bothcontemplation and action stages; (d) emphasize self-liberation, a helping rela-tionship, and reinforcement management during the action stage; and (e) usecounterconditioning and stimulus control the most in both action and mainte-nance stages. Relapsers were found to respond like a combination of contempla-ters and people in action. Results are discussed in terms of developing a modelof self-change of smoking and enhancing a more integrative general model ofchange.

Formalized treatment programs for smok-ing fail with a majority of smokers (Hunt,Barnett, & Branch, 1971). Nevertheless, 30million Americans quit smoking in the pastdecade, with 70% to 80% quitting on theirown (Adult Use of Tobacco, 1975). Further-more, 70% of smokers surveyed indicatedthat if they were to quit, they would not at-tend a formal treatment program (McAlister,1975). In spite of the preponderance of andpreference for self-change approaches, re-search on smoking cessation has focused pri-marily on formalized treatments. The pres-ent study reports on the change processes thatwere emphasized by 872 self-changers rep-resenting five different stages of quittingsmoking.

In one of the few studies on self-change,self-changers did not differ from individualsin formalized treatments on smoking habits,locus of control, and measures of the JacksonPersonality Inventory (Pederson & Lefcoe,1976). DiClemente and Prochaska (1982)also found that self-changers did not differfrom subjects in two types of therapy pro-grams in terms of smoking history variables,

This work was supported by Grant CA 27821 fromthe National Cancer Institute.

Requests for reprints should be sent to James O. Pro-chaska, Department of Psychology, University of RhodeIsland, Kingston, Rhode Island 02881.

including history of previous attempts to quitsmoking. DiClemente and Prochaska (1982)found that self-changers did differ from ther-apy changers in terms of the processes ofchange that were emphasized in recent at-tempts to quit smoking. More importantly,both self-changers and therapy changers re-ported retrospectively that they had used af-fective and cognitive processes more duringearly stages of change and emphasized be-havioral processes during later stages.

Perri, Richards, and Schulteis (1977) com-pleted retrospective interviews with 24 suc-cessful and 24 unsuccessful college studentswho had made attempts to quit smoking ontheir own. The successful self-changers re-ported using self-reinforcement proceduressignificantly more than the relapsers. Al-though encouraging, this study was limitedby focusing on just two stages and four pro-cesses of change. Baer, Foreyt, and Wright(1977) analyzed letters describing the quittingexperiences of 51 self-changers who hadmaintained nonsmoking for at least 2 years.While most of the self changers used multipletechniques, the investigators were not able todiscover any systematic clustering of theirquitting methods.

Research to date on self-change ap-proaches to smoking cessation has been lim-ited by inadequate models of change and ret-rospective methodologies. The present re-

390

SELF-CHANGE OF SMOKING 391

search applied the transtheoretical modelthat has been developed both from the ther-apy literature (Prochaska, 1979; Prochaska& DiClemente, 1982) and from data on self-changers (DiClemente and Prochaska, 1982;Prochaska, DiClemente, Velicer, & Zwick,Note 1). The present research applied themodel in a cross-sectional design to studyself-changers who were in one of the followingfive stages of change: precontemplation, con-templation, action, maintenance, and re-lapse.

The transtheoretical model involves 10processes of change receiving differential ap-plication during the five stages of change(Prochaska & DiClemente, 1982). The 10processes of change are as follows: conscious-ness raising, self-liberation, social liberation,self-reevaluation, environmental reevalua-tion, counterconditioning, stimulus control,reinforcement management, dramatic relief,and helping relationships.

Based on the transtheoretical model (Pro-chaska & DiClemente, 1982) and previousresearch (DiClemente & Prochaska, 1982),the following predictions were made. Becauseprecontemplators tend to be defensive andavoid changing their thinking and behavior,they would use the change processes signifi-cantly less than subjects in other stages. Be-cause contemplators are seriously thinkingabout changing their smoking behavior, theywould use consciousness raising the most togather further information about their smok-ing. Because self-reevaluation appears to bea process that bridges contemplation and ac-tion, self-reevaluation would be used most inthe contemplation and action stages. Becausesubjects in the action stage are most com-mitted to making behavioral changes, theywould use self-liberation, counter-condition-ing, stimulus control, and reinforcementmanagement the most. No clear predictionshad emerged from previous research onwhich processes would be emphasized duringthe maintenance and relapse stages.

Method

SubjectsThere were 872 subjects from Rhode Island and Hous-

ton, Texas who volunteered to participate in the studyin response to newspaper articles and ads. All subjects

were assigned to one of the following five groups, de-pending on the stage of change they currently were in:

Long-term quitters (LTQs). These 247 subjects rep-resented the maintenance stage, since they had main-tained their nonsmoking for at least 6 months. The meanduration of maintenance was 5.9 years. The mean agewas 44 years, and there were 133 females and 114 males.They had begun smoking^at a mean age of 17.2 years.

Recent quitters (RQs). These 134 subjects representedthe action stage, since they had quit smoking on theirown within 6 months of entering the study. The meanduration of time since they had quit was 2.2 months.The mean age of these subjects was 35 years, and therewere 80 females and 54 males. They had begun smokingat a mean age of 16.6 years.

Contemplators (Cs). These 187 subjects representedthe contemplation stage, since they were smoking reg-ularly for the past year but reported that they were se-riously thinking about quitting smoking in the next year.The mean age of these subjects was 40 years, and therewere 113 females and 74 males, They had begun smokingat a mean age of 17.4 years.

Immotives (I's). These 108 smokers represented theprecontemplation stage, since they reported that theyhad no intention of quitting smoking in the next year.The mean age of this group was 38 years, and there were74 females and 34 males. Their mean age of beginningsmoking was 16.3 years.

Relapsers (RLs). An exploratory group of 196 relap-sers was included to investigate how individuals use par-ticular change processes after having failed within thepast year in their attempt to quit smoking. The meanage of this group was 36 years, and there were 129 fe-males and 67 males. Their mean age of beginning smok-ing was 17.3 years.

Basic demographic data on the subjects indicated thatthey were middle-age and middle-class adults who begansmoking as teenagers (M = 17 years). The mean age was40 and the median 37 years. Of the total sample 62%were married, 27% single, 16.5% divorced, and 5.8% sep-arated or widowed. Of the total sample, 19.3% completedhigh school or less, 41.7% had attended some collegeclasses, 17.8% had bachelor degrees, and 19.3% had somepostgraduate education or a graduate degree. Approxi-mately one half of the subjects had incomes of less than$15,000, and 8% had incomes of more than $30,000.

Measures

The processes of change test. This test is a 40-itemquestionnaire that measures 10 processes of change ina statistically well-defined and highly reliable manner(Prochaska et al., Note 1).' Table 1 presents a sampleitem and the alpha coefficient for each process. Thereare four items representing each of the 10 processes.Subjects were asked to rate on a 5-point Likert scale howfrequently they employed each item in the past month(1 = not at all; 5 = repeatedly).

Smoking-status measures. Saliva samples were takenfrom each subject to increase validity of self-reports viathe bogus pipeline phenomenon (Jones & Sigall, 1971).

' Copies of the test are available from the authors.

392 JAMES O. PROCHASKA AND CARLO C. DiCLEMENTE

Table 1Sample Items and Alpha Coefficients for the 10 Processes of Change

Processes Alpha Sample item

Consciousness raising .88Self-liberation .89Social liberation .81Self-reevaluation .87Environmental reevaluation .88Counterconditioning .88Stimulus control .81

Reinforcement management .78Dramatic relief .91Helping relationships .84

I look for information related to smoking.I tell myself I am able to quit smoking if I want to.I notice that public places have sections set aside for nonsmokers.My depending on cigarettes makes me feel disappointed in myself.I stop to think that smoking is polluting the environment.I do something else instead of smoking when I need to relax.I remove things from my place of work that remind me of

smoking.I am rewarded by others if I don't smoke.Warnings about health hazards of smoking move me emotionally.I have someone who listens when I need to talk about my smoking.

When subjects are aware that smoking status will be val-idated by physiological measures, the accuracy of self-reports increases. Because the laboratory in charge ofanalyzing thiocyanate levels was unaware of the latesttechniques for extracting saliva from cotton swabs, theydid not have adequate saliva for testing all subjects. Therewere adequate samples for 64% of the sample. Thus,thiocyanate levels were used to simply provide somegroup validation of self-reports. Thiocyanate data wereavailable for 304 smokers (M = 296.9; SD = 127.2) and250 nonsmokers (M = 148.6; SD = 93.2). A one-wayanalysis of variance (ANOVA) between these groups washighly significant, F(l, 552) = 235.1, p < .0001.

Self-report measures of smoking status were used inthe present study for three reasons. First, the presentstudy involved more than discriminating smokers fromnonsmokers, since it also compared types of smokers(immotives, contemplators, and relapsers) and types ofnonsmokers (recent and long-term quitters). Secondly,self-report measures were available for all subjects. Fi-nally, recent evidence suggests that self-reports may bemore valid indicators of smoking status than are thio-cyanate levels (Petitti, Friedman, & Kahn, 1981).

ProcedureWhen subjects called the Self Change Lab to volunteer,

they were given the following information: The studywould last for 2 years and they would be asked to com-plete a questionnaire and an interview every 6 months.In return the subjects would be paid $4 for completingthe questionnaire and $4 for the interview and would beeligible for one of 10 bonus prizes ranging from $50 to$500 to be given every 6 months. The subjects were askeda series of five questions to determine which stage ofchange they were in. The present study reports cross-sectional data from the initial assessment. Longitudinaldata will be reported in future publications.

Results

Table 2 presents T scores for each of thefive groups representing the stages of changeon each of the 10 processes of change. Amultivariate analysis of variance (MANOVA)

Table 2T Scores of the 10 Processes of Change for the Five Stages of Change Groups

Process

Consciousness raisingSelf-liberationSocial liberationSelf-reevaluationEnvironmental reevaluationCounterconditioningStimulus controlReinforcement managementDramatic reliefHelping relationship

I

45.341.351.041.544.342.645.645.246.648.5

C

53.148.251.452.450.849.348.349.451.349.6

' Group

RQ48.555.946.651.948.952.652.553.849.051.4

LTQ

48.651.350.347.851.452.051.349.650.649.2

RL

52.250.8 '50.153.751.450.450.751.051.151.2

F

15.64***40.82***

5.19**38.13***12.22**21.48***10.28***12.41***7.21***2.50*

Note. I = immotives; C = contemplators; RQ = recent quitters; LTQ = long-term quitters; RL* p < .05. ** p < .001. *** p < .0001.

= relapsers.

SELF-CHANGE OF SMOKING 393

for these data was significant, F(l, 40) =11.199, p < .001. The first three dimensionsof the MANOVA were significant. The signif-icant MANOVA was followed up by separateANOVAS because the 10 change processes havebeen found to be relatively independent (Pro-chaska'et al., Note 1) and because the resultsfrom the separate ANOVAS can be moreclearly communicated than results from dis-criminant function analysis. Table 2 presentsthe Fs and probability levels for these one-way ANOVAS. The ANOVAS indicate that therewere significant differences in how frequentlythe groups used each of the 10 processes ofchange.

To determine exactly which groups dif-fered on how frequently they used each ofthe change processes, Newman-Keuls com-parisons were run. Each of the five groupswas compared on each of the 10 processesof change. Table 3 presents the results of theNewman-Keuls comparisons, indicatingwhich groups differed from each other at ap < .05 level or greater.

Relationships between the processes ofchange and the stages of change can be seenmost clearly if the relapse group is tempo-rarily bracketed. The relapse group was in-cluded as an exploratory group, with no pre-dictions from the transtheoretical modelabout which processes of change would beemphasized by this group. More importantly,the results in Table 3 suggest that the relapsegroup behaves like a mixture of the contem-plation and action groups.

Table 4 presents a diagram showing thestages in which particular processes of changeare emphasized the most and the least. Table4 indicates that, as predicted by the tran-stheoretical model, subjects in the precon-templation stage use 8 of the 10 processessignificantly less than any other group. Aspredicted, consciousness raising is empha-sized the most by individuals in the contem-plation stage. Self-reevaluation appears tobridge contemplation and action^ since it isemphasized in both stages. Self liberation isemphasized when subjects take action, as arehelping relationships and reinforcementmanagement. Counterconditioning and stim-ulus control appear to bridge action andmaintenance since these two processes areemphasized in both stages. The only rela-

Table 3Group Comparisons on Each of the Processesof Change

Comparisons of stage-of-Process change groups

Consciousness raisingSelf-liberationSocial liberationSelf reevaluationEnvironmental

reevaluationCounterconditioningStimulus controlReinforcement

managementHelping relationship

I < RQ, LTQ < RL, CI < C < RL, LTQ < RQRQ < I, C, LTQ, RLI < LTQ < C, RQ, RL

I < C, RQ, LTQ, RLI< C, RL < RQ, LTQI < C < RQ, LTQ, RL

I < C, LTQ, RL < RQI, C, LTQ, < RL, RQ

Note, 1 = immotives; C = contemplators; RQ = recentquitters; LTQ = long-term quitters; RL = relapsers; <= p < .05, using Newman-Keuls tests.

tionship of social liberation to a stage is theunexpected finding that subjects in the actiongroup emphasize this process the least.

Discussion

The results of this study provide importantdata for enhancing our understanding of self-change of smoking and for.developing a moreintegrative model of change. Assuming thatthe stages-of-change groups represent a cross-sectional analysis of quitting smoking, thefollowing pattern emerges. As predicted fromthe transtheoretical model, subjects in theprecontemplation stage used the processes ofchange the least. Specifically, the precontem-plators used 8 of 10 processes of change sig-nificantly less than subjects in any otherstage. This suggests that precontemplatorsprocess less information about smoking,spend less time reevaluating themselves assmokers, experience fewer emotional reac-tions to the negative aspects of smoking, anddp little to shift their attention or their en-vironment away from smoking.

What moves individuals into seriouslycontemplating change is not clear from thedata. However, as predicted, once in the con-templation stage, subjects are the most likelyto respond to feedback and education assources of information about smoking. Alongwith this increased openness to informationabout smoking, contemplators report feeling

394 JAMES Q PROCHASKA AND CARLO C. DlCLEMENTE

Table 4Processes of Change Listed Under the Stages in Which They Are Emphasized Most

Precontemplation (I's)a Contemplation (Cs) Action (RQs) Maintenance (LTQs)

Consciousness raisingSelf-reevaluation"

Self-liberationHelping relationshipReinforcement management

Counterconditioningb

Stimulus controlb

a Eight processes were used the least in the precontemplation stage.b Processes emphasized in two stages are shown overlapping both stages.

and thinking more about themselves in re-lationship to their problem behavior. As pre-dicted, the increased reevaluation of them-selves appears to carry over into action assubjects perhaps become upset enough withthemselves and their smoking to make com-mitments to quit. As predicted, during theaction stage subjects use both countercon-ditioning and stimulus-control proceduresfor actively changing their smoking behaviorand environment. They report more self- andsocial reinforcement for their changes andrely more on helping relationships for sup-port and understanding. It is interesting thatthe subjects experience less reinforcementduring the maintenance stage, although theycontinue to emphasize counterconditioningand stimulus-control processes for copingwith temptations to smoke.

The results also provide a view of how in-dividuals respond after having recently re-lapsed following a period of quitting smok-ing. The subjects report emphasizing changeprocesses that are used most often by indi-viduals in the contemplation and actionstages. Specifically, the relapsers used con-sciousness raising as often as contemplaters,self-reevaluation as often as contemplatersand recent-quitters, helping relationships asoften as recent quitters, and stimulus controlas often as subjects in the action and mainte-nance stages. The relapsers may be preparingthemselves to quit smoking again as they en-gage in processes associated with contempla-tion. They may also be attempting to preventcomplete relapse as they use action andmaintenance processes to control their cur-rent levels of smoking.

These results provide support for recentmodifications in the transtheoretical modelof change. First of all, cathartic processeswere originally thought to provide the bridgebetween contemplation and action (Pro-chaska & DiClemente, 1982). Rather thanemotional experiences moving people to act,the results suggest that it is a combined cog-nitive/affective reevaluation process that car-ries over from contemplation into action.Second, the results suggest that the self-lib-erating process is emphasized most duringthe action stage. This result is consistent withearlier findings that commitments are real-ized once action is taken (DiClemente & Pro-chaska, 1982). Finally, counterconditioningand stimulus control processes appear tobridge action and maintenance rather thanbeing emphasized just in action. This resultis consistent with the view that maintenanceis indeed an active stage of change rather thanan absence of change (Prochaska & Di-Clemente, 1982).

The model and data of self-change couldbe used to increase the effectiveness of smok-ing cessation programs and to maximize self-help approaches. Rather than assume that allsmokers coming for treatment are ready foraction, as is the case in most behaviorallybased programs (Prochaska & DiClemente,1982), clients would be grouped accordingto which stage of change they are in. Researchwith clients applying for therapy indicatesthat there are clusters of clients in each of thestages of change (McConnaughy, Prochaska,& Velicer, in press). Thus, smokers in thecontemplation stage would begin with con-sciousness raising and self-reevaluation pro-

SELF-CHANGE OF SMOKING 395

cesses, whereas smokers ready for actioncould begin to apply the more behaviorally-based processes.

Smokers preferring to quit on their ownreport that they would take advantage of self-help manuals. The problem is that currentself-help manuals for smokers are not partic-ularly effective (Glasgow & Rosen, 1978;Glasgow, Schafer, & O'Neill, 1981). The au-thors are currently developing and testingself-help manuals based on self-change dataand models, with the anticipation of im-proving the effectiveness of such materials.

The present results provide both substan-tial support for the transtheoretical model ofchange as well as suggesting important mod-ifications in the model. What is needed arelongitudinal data to determine the predictivevalidity of the model as individuals movefrom one stage of change to another. Alsoneeded are comparative studies with otherproblem behaviors to determine the extentto which change processes vary in emphasisas different problem behaviors are beingchanged.

Reference Note1. Prochaska, J. O., DiClemente, C. D., Velicer, W. F,

& Zwick, W. Measuring processes of change. Paperpresented at the annual meeting of the InternationalCouncil of Psychologists, Los Angeles, August, 1981.

ReferencesAdul( Use of Tobacco, 1975 (U.S. Department of Health,

Education and Welfare Publication). Washington,D.C.: U.S. Government Printing Office, 1976.

Baer, P. E., Foreyt, J. P., & Wright, S. Self directed ter-mination of excessive cigarette use among untreated

smokers. Journal of Behavior Therapy and Experi-mental Psychiatry, 1977,5, 71-74.

DiClemente, C. C., & Prochaska, J. O. Self change andtherapy change of smoking behavior: A comparisonof processes of change in cessation and maintenance.Addictive Behavior, 1982, 7, 133-142.

Glasgow, R. E., & Rosen, G. M. Behavioral bilblioth-erapy: A review of self-help,behavior therapy manuals.Psychological Bulletin, 1978, 85, 1-23.

Glasgow, R. E., Schafer, L,, & O'Neill, N. K. Self-helpbooks and amount of therapist contact in smokingcessation programs. Journal of Consulting and Clini-cal Psychology, 1981, 49, 659-667.

Hunt, W. A., Barnett, G. W., & Branch, L. G. Relapserates in addiction programs. Journal of Clinical Psy-chology, 1971, 27, 455-456.

Jones, E. E., & Sigall, H. The bogus pipeline: A newparadigm for measuring affect and attitude, Psycho-logical Bulletin, 1971, 76, 349-364.

McAlister, A. Helping people quit smoking: Currentprogress. In A. M. Enelow & J. B. Henderson (Eds.),Applying behavioral science to cardiovascular risk.New York: American Heart Association, fl 975.

McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F.Stages of change in psychotherapy: Measurement andsample profiles. Psychotherapy: Theory, Research .andPractice, in press.

Pederson, L. L., & Lefcoe, N. M. A psychological andbehavioral comparison of ex-smokers and smokers.Journal of Chronic Diseases, 1976, 29, 431-434.

Perri, M. G., Richards, S. C., & Schultheis, K. R. Be-havioral self control and smoking reduction: A studyof self initiated attempts to reduce smoking. BehaviorTherapy, 1977, 8, 360-365.

Petitti, D. B., Friedman, G. D., & Kahn, W. Accuracyof information on smoking habits provided on self-administered research questionnaires. American Jour-nal of Public Health, 1981, 71, 308-311.

Prochaska, J. O. Systems of psychotherapy: A transtheo-retical analysis. Homewood, 111.: Dorsey Press, 1979.

Prochaska, J. O., & DiClemente, C. C. Transtheoreticaltherapy: Toward a more integrative model of change.Psychotherapy: theory, research and practice, 1982,19,276-288.

Received July 29, 1982Revision received October 15, 1982 •