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Journal
of
Consulting
and
Clinical
Psychology
1983,
Vol.
51,
No. 3,
390-395
Copyright 1983
by the
American Psychological Association, Inc.
Stages
and
Processes
of
Self-Change
of
Smoking:
Toward
An
Integrative
Model
of
Change
James
Q
Prochaska
University
of
Rhode Island
Carlo
C.
DiClemente
Texas
Research
Institute
of
Mental
Sciences
An
integrative m od el
of
change
was
ap pl ied
to the
study
of 872
subjects changing
their
smoking habits
on
their own.
The
subjects represented
the
following
five
stages
of
change: precontemplation, contemplation, action, maintenance,
and
relapse.
Ten
processes
of
change were expected
to
receive
differential
emphases
during
particular stages
of
change. Results indicate
that
self-changers:
(a) use the
fewest
processes
of
ch ange during pr ec onte mp la tion ;
(b)
emphasize consciousness
raising
during
the
contemplation stage;
(c)
emphasize
self-reevaluation
in
both
contemplation
and
action stages;
(d)
emphasize self-liberation,
a
helping rela-
tionship,
and
reinforcement management during
the
action stage;
and (e) use
counterconditioning
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
model
of
self-change
of
smoking
and
enhancing
a
more integrative general model
of
change.
Formalized
treatment programs
for
smok-
ing
fail
with
a
majority
of
smokers (Hunt,
Barnett,
&
Branch, 1971). Nevertheless,
30
million
Americans quit smoking
in the
past
decade, with
70% to 80%
quitting
on
their
own
(Adult
Use of
Tobacco,
1975).
Further-
more,
70% of
smokers surveyed indicated
that
if
they were
to
quit, they would
not at-
tend
a
formal
treatment program (McAlister,
1975).
In
spite
of the
preponderance
of and
preference
for
self-change approaches,
re-
search
on
smoking ces sa ti on
has
focused pri-
marily
on
formalized treatments.
The
pres-
ent
study re po rt s
on the
change processes
that
were
emphasized
by 872
self-changers rep-
resenting
five
different
stages
of
quitting
smoking.
In
one of the few
studies
on
self-change,
self-changers
did not
differ
from
individuals
in
formalized treat me nt s
on
smoking habits,
locus
of
con tr ol ,
and
measures
of th e
Jackson
Personality Inventory (Pederson
&
Lefcoe,
1976).
DiClemente
and
Prochaska
(1982)
also
found
that
self-changers
did not
differ
from
subjects
in two
types
of
therapy pro-
grams
in
terms
of
smoking history variables,
This work
was
supported
by
Grant
CA
27821
from
the
National Cancer
Institute.
Requests
for
reprints should
be
sent
to
James
O.
Pro-
chaska,
Department
of
Psychology, University
of
Rhode
Island,
Kingston,
Rhode Island 02881.
including
history
of
prev io us attempts
to
quit
smoking.
DiClemente
and
Prochaska
(1982)
found
that
self-changers
did
differ
from
ther-
apy
changers
in
terms
of the
processes
of
change
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 during
early
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 students
who
had
made attempts
to
quit smoking
on
their own.
The
successful self-changers
re-
ported using self-reinforcement procedures
significantly
more than
the
relapsers.
Al-
though
encouraging, this study
was
limited
by
focusing
on
just
two
stages
and
four
pro-
cesses
of
change. Baer,
Foreyt,
and
Wright
(1977)
ana ly ze d letters describing
the
quitting
experiences
of
51
self-changers
who had
maintained nonsmoking
for at
least
2
years.
While
most
of the
self chan gers used multiple
techniques,
the
investigators were
not
able
to
discover
any
systematic clustering
of
their
quitting
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
model
that
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
the
model
in a
cross-sectional design
to
study
self-changers
who
we re
i n one
of
t h e
following
five
s ta ge s
of
change:
precontemplation,
con-
templation,
action,
maintenance,
and re-
lapse.
The
transtheoretical model involves
10
processes
of
change receiving
differential
ap-
plication
during
the five
stages
of
change
(Prochaska
&
DiClemente,
1982).
The 10
processes
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
previous
research (DiClemente
&
Prochaska, 1982),
the
following p r e d i c t i o n s were
ma de.
Because
precontemplators
tend
to
be
defensive
and
avoid changing their thinking
and
behavior,
they would
use the
change processes
signifi-
cantly less than subjects
in
other stages.
Be-
cause contemplators
are
seriously thinking
about changing
their
smoking behavior, they
would
use
consciousness raising
the
most
to
gather further information about their smok-
ing.
Because self-reevaluation
appears
to be
a
process
tha t
bridges contemplation
and ac-
tion,
self-reevaluation would
be
used most
in
the
contemplation
and
action
stages. Because
subjects
in the
action
stage
are
most com-
mitted
to
making behavioral changes, they
would
use
self-liberation,
counter-condition-
ing,
stimulus
control,
and
reinforcement
management
the
most.
No
clear
predictions
had
emerged
from previous research
on
which processes would
be
emphasized during
the
maintenance
and
relapse stages.
Method
Subjects
There were
87 2
subjects
from
Rhode Island
and
Hous-
ton, Texas
who
volunteered
to
participate
in the
study
in
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
a t
least
6
months.
The
mean
duration
of
maintenance
was 5.9
years.
The
mean
age
was
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
sub jects
represented
the
action stage, since they
had
quit smoking
on
their
own
within
6
months
of
entering
the
study.
The
mean
duration
of
time since they
had
quit
was 2.2
months.
The
mean
age of
these subjects
was 35
years,
and
there
were
80
females
a nd 54
males. They
had
begun smoking
at a
mean
age of
16.6 years.
Contemplators
(Cs).
These
187
subjects represented
the
contemplation stage, since they were smoking reg-
ularly
for the
past year
but
reported
that they were
se-
riously
thinking a b o u t quitting smoking
in the
next yea r.
The
mean
age of
these subjects
was 40
years,
and
there
were
113
females
and 74
male s, They
had
begun smok ing
at a
mean
age of
17.4 ye ars.
Immotives
(I's).
These
108
smokers represented
the
precontemplation
stage, since they reported that they
had no
intention
of
quitting smoking
in the
next year.
The
mean
age of
th is group
was 38
yea rs,
and
there were
74
females
an d 34
males. Their mean
age of
beginning
smoking
was
16.3
years.
Relapsers
(RLs).
An
exploratory group
of 196
re lap-
sers
was
in clu ded
to
investigate
how
individuals
u s e
par-
ticular change processes
after
having
failed
within
the
past year
in
their attempt
to
quit smoking.
The
mean
age
of
this
group
was 36
years,
and
there
were
129 fe-
males
and 67
males. Their mean
age of
beginning sm ok -
ing
was
17.3 yea rs.
Basic de mogr aph ic
data
on the
subjects in d ic at e d that
they
were middle-ag e
an d
middle-class adults
who
began
smoking
as
teenagers
(M
=
17
years).
The
mean
age was
40 and the
median
37
years.
Of the
total
sample
62%
were
married,
27%
s i n g l e , 16.5% divorced,
and
5.8% sep-
arated
or
wi dowe d.
O f t he
total
samp le,
19.3% co mp le t ed
high
school
or
less, 41.7%
had
attended some college
classes,
17.8%
had
bachelor degrees,
and
19.3%
had
some
postgraduate education
or a
graduate degree. Approxi-
mately
one
half
of the
subjects
had
incomes
of
less than
$15,000,
and 8% ha d
incomes
of
more than
$30,000.
Measures
The
processes
of
change
test. This test
is a
40-item
questionnaire
that
measures
10
processes
of
change
in
a
statistically
well-defined
and
highly reliable manner
(Prochaska
et
al.,
Note
1).'
Table
1
presents
a
sample
item
and the
alpha
coefficient
for
each process. There
are
four
items representing each
of the
10
processes.
Subjects were ask e d
to
rate
on a
5-point
Likert
scale
ho w
frequently
they employed each item
in the
past month
(1
= not at
all;
5 =
repeatedly).
Smoking-status
measures.
Saliva
samples
wer e taken
from
each subject
to
increase validity
of
self-reports
via
the
bogus pipeline phenomenon (Jones
&
Sigall,
1971).
'
Copies
of the
test
are
available
from
the
authors.
392
JAMES
O.
PROCHASKA
AND
CARLO
C.
DiCLEMENTE
Table
1
Sample
Items
and
Alpha
Coefficients
for the 10
Processes
of
Change
Processes
Alpha
Sample item
Consciousness raising
.88
Self-liberation
.89
Social
liberation
.81
Self-reevaluation
.87
Environmental
reevaluation
.88
Counterconditioning
.88
Stimulus
control
.81
Reinforcement
management
.78
Dramatic
relief
.91
Helping
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
tha t
smoking status
will
be
val-
idated
by
physiological measures,
the
accuracy
of
self-
reports increases. Because
the
laboratory
in
charge
of
analyzing
thiocyanate levels
was
unaware
of the
latest
techniques
for
extracting saliva
from
cotton
swabs, they
did not
have a d e q u a t e saliva
fo r
te st in g
all
su bj e ct s. There
were
adequate samples
for 64% of the
sample. Thus,
thiocyanate
levels were used
to
simply provide some
group
validation
of
self-reports. Thiocyanate
data
were
available
for 304
smokers
(M
=
296.9;
SD =
127.2)
and
250
nonsmokers
(M =
148.6;
SD =
93.2).
A
one-way
analysis
of
variance
(ANOVA)
between these groups
was
highly
significant,
F(l,
552)
=
235.1,
p <
.0001.
Self-report
measures
of
smoking status were used
in
the
present study
for
three reasons. First,
the
present
study
involved
more than discriminating smokers
from
nonsmokers,
since
it
also compared types
of
smokers
(immotives,
contemplators,
and
relapsers)
and
types
of
nonsmokers
(recent
and
long-term quitters). Secondly,
self-report
measures were available
for all
subjects.
Fi-
nally,
recent evidence suggests
that
self-reports
may be
more valid indicators
of
smoking status than
are
thio-
cyanate
levels (P e ti tt i , Friedman,
&
Kahn,
1981).
Procedure
When
subjects c a l l e d
the
Self Ch an ge
Lab t o
v ol u nt e er ,
they
were given
the
following
information:
The
study
would
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
completing
the
questionnaire
and $4 for the
interview
a nd
would
be
eligible
for one of 10
bonus prizes ranging
from
$50 to
$500
to be
giv en e v e r y
6
months.
Th e
subjects w e r e as k e d
a
series
of five
questions
to
determine which stage
of
change
they were
in. The
present study
reports
cross-
sectional
data
from
the
initial assessment. Longitudinal
data
will
be
reported
in
future
publications.
Results
Table
2
presents
T
scores
for
each
of the
five
g ro u ps representing
the
stages
of
change
on
each
of the 10
processes
of
change.
A
multivariate
analysis
of
variance
(MANOVA)
Table
2
T
Scores
of
the
10
Processes
of
Change
for the
Five
Stages
of
Change
Groups
Process
Consciousness raising
Self-liberation
Social
liberation
Self-reevaluation
Environmental
reevaluation
Counterconditioning
Stimulus
control
Reinforcement
management
Dramatic relief
Helping
relationship
I
45.3
41.3
51.0
41.5
44.3
42.6
45.6
45.2
46.6
48.5
C
53.1
48.2
51.4
52.4
50.8
49.3
48.3
49.4
51.3
49.6
'
Group
RQ
48.5
55.9
46.6
51.9
48.9
52.6
52.5
53.8
49.0
51.4
LTQ
48.6
51.3
50.3
47.8
51.4
52.0
51.3
49.6
50.6
49.2
RL
52.2
50.8
'
50.1
53.7
51.4
50.4
50.7
51.0
51.1
51.2
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 dimensions
of the
MANOVA
were
significant.
The
signif-
icant
MANOVA
was
followed
up by
separate
ANOVAS
be ca use
the
10
ch ange p roc esses h a ve
been
found
to be
relatively in de pend en t
(Pro-
chaska'et
al.,
Note
1) a n d
because
the
results
from
the
separate
ANOVAS
can be
more
clearly
communicated than results
from
dis-
criminant
function
analysis. Table
2
presents
the Fs and
probability levels
for
these one-
way
ANOVAS.
The
ANOVAS
in dic ate
that
there
were
significant
d i f f e r e n ce s
in how
frequently
the
groups used each
of the 10
processes
of
change.
To
determine exactly
which
groups dif-
fered
on how
frequently
they used each
of
the
change processes,
Newman-Keuls
com-
parisons
were
run. Each
of the five
groups
was
compared
on