Distribution of smokers by stage in three representative samples

Smoking among male psychiatric outpatients in Saudi Arabia

BACKGROUND

The prevalence rate of smoking among psychiatric patients has been shown to be higher than that among the general population, and this may have several neuropsychiatric implications. This cross-sectional study examines the prevalence, sociodemographic variables and pattern of smoking among psychiatric outpatients in Saudi Arabia.

PATIENTS AND METHODS

Over a period of 18 months (January 1996 to June 1997), 505 outpatients from five different hospitals were randomly selected to participate in the study.

RESULTS

It was observed that 292 patients (57.83%) were current smokers, 199 (39.4%) were nonsmokers and 14 patients (2.77%) were ex-smokers. Besides revealing certain attitudes towards smoking and religious antismoking notions, it was observed that unemployment, low education status, rural background, and drug abuse were significantly associated with smoking.

CONCLUSION

The prevalence rate of smoking revealed in this study is consistent with international data, and probably has implications similar to those reported in other studies. This study also found certain patterns of tobacco use in psychiatric outpatients characterized by certain sociodemographic variables and drug abuse.

Challenges and future directions for tailored communication research

As informatics technology advances, a growing number of research trials on tailored communications provide an accumulation of promising evidence to support their efficacy. These trials also reveal gaps and opportunities for future research. The scope and boundaries of tailoring must be redefined in terms of both new technology and the trade-offs between complexity, demand burden on participants, and the minimal information required for effective and efficient tailoring. Basic and methods research is needed to broaden theory, develop a common language, standardize measures, and isolate the key mediating mechanisms that facilitate tailored communications. Applied research must consider more rigorous research designs for efficacy trials and conduct more effectiveness trials to investigate the mechanisms of technology transfer to enhance large-scale diffusion of tailored communications. The role of contextual variables needs to be examined, as well as their interaction with different population groups, and also the channels, modes, and methods of tailored message delivery. Research is also needed on the feasibility of tailoring across clusters of multiple risk factors to identify the commonalities, differences, and interrelations among diverse behaviors. The potential cost-effectiveness of tailored communications must also be examined. No matter how efficacious, tailored communications delivered to large populations (i.e. mass-customization) will not make a public health impact unless proven to be practical and cost-efficient.

Characterizing and identifying "hard-core" smokers: implications for further reducing smoking prevalence

OBJECTIVES

Some smokers may never quit. Depending on how many of these "hard-core" smokers exist, tobacco control efforts could reach the limits of a minimum achievable smoking prevalence. We defined the hard core as heavy smokers with weak quitting histories who expect never to quit smoking. We compared them with other smokers and analyzed whether they represent a meaningful barrier to further reducing smoking prevalence.

METHODS

We used data from the 1996 California Tobacco Surveys (18616 adults; response rate = 72.9%).

RESULTS

In 1996, 5.2% of California smokers 26 years and older (1.3% of the California population) were hard-core smokers. Compared with other smokers, hard-core smokers were more likely to be retired non-Hispanic White males, with 12 years or less of education and incomes below $30,000 a year, who live alone. They began smoking at younger ages and attributed fewer negative health consequences to smoking than other smokers.

CONCLUSIONS

Current tobacco control efforts have a long way to go before they "hit the wall." Nonetheless, the group of hard-core smokers represents a challenge because they appear to be largely unaffected by the messages of tobacco control.

Cluster subtypes within stage of change in a representative sample of smokers

In this paper a three-level conceptualization of approaches to matching self-help behavior change strategies to individuals is presented based on the Transtheoretical Model of Change. Two of the model's intervention approaches, tailoring to Stage-of-Change and creating completely individualized interventions, have already been developed and implemented in previous research. A third intervention approach, in between stage-tailored and individualized, is targeting subtype groups within each Stage of Change. The subtype targeted intervention approach is in the initial development stage of empirically determining and validating the stage subtypes. Three studies are presented which investigate stage subtypes within a representative sample of 4,144 smokers in the Precontemplation, Contemplation, and Preparation Stages of Change. Within each Stage-of-Change study, two cluster analyses were performed using the Pros, Cons, and Situational Temptations from the Transtheoretical Model to establish cluster replicability. Cluster solutions were externally validated using the 10 Processes of Change and 2 smoking behavior variables. Four distinct subtypes were found in Precontemplation and Contemplation, and five subtypes were found in Preparation. These subtypes closely replicate subtypes previously found in a convenience sample of smokers and provide strong evidence for the existence of subtypes within the first three Stages of Change.

Methods to enhance smoking cessation after myocardial infarction

The evidence linking smoking and coronary artery disease is quite strong, and there is also a positive relationship between smoking cessation and reduction in cardiovascular disease risk. Nicotine replacement therapy and bupropion are effective treatments for smoking cessation and are most effective when combined with behavioral counseling. Intensive multicomponent interventions that include a case-management component have produced the highest smoking cessation rates for patients who suffer a myocardial infarction.

Motivating smoking cessation among dental patients: smokers' interest in biomarker testing for susceptibility to tobacco-related cancers

This study examined interest in receiving biomarker testing for tobacco-related cancer susceptibility among 148 smokers seeking routine oral health care in a public dental clinic. Patients completed a brief, self-report survey assessing their smoking history, tobacco-related illness history, readiness to quit smoking, perceived risk and worry about cancer, and their interest in being tested for genetic susceptibility for tobacco-related cancers. Participants were socioeconomically and ethnically diverse, and were primarily long-standing, nicotine-dependent smokers. Most reported (83%) interest in biomarker feedback, and most (86%) understood that a certain genetic make-up could place them at increased risk for tobacco-related cancers. Those participants who felt that quitting smoking would reduce future cancer risk, were at least in the contemplation stage of quitting readiness, felt more worried and more at risk for developing cancer, women and younger smokers were more interested in genetic testing (all ps < 0.20). Multivariate logistic regression analyses indicated that gender and risk perceptions were associated with interest in testing. The public dental clinic setting holds potential for innovative smoking cessation interventions using personalized risk feedback.

Smoking and diabetes: readiness for change and provider advice

Smoking is a serious health risk, particularly for people with diabetes. This study was designed to examine important aspects of smoking in a large group of individuals with diabetes. A survey was mailed to 2,056 individuals with diabetes. The variables examined were the stages of change for smoking, prevalence of quitting advice given by health care providers, and the patterns of readiness for change. The majority (57.8%) of current smokers were in the precontemplation stage. Comparisons on the stage of change indicated that more individuals with Type 2 diabetes have quit while there are more current smokers among those with Type 1 diabetes. Comparisons on current smokers indicated no differences on stage of change across the Type 1 and Type 2 groups, across three subgroups of individuals with Type 2 diabetes, or across duration of diabetes. Those who reported that they were given cessation advice were further along in the stages of change. These results suggest that the majority of individuals with diabetes who smoke are in the precontemplation stage of change and provider advice is important in moving smokers toward change. The current findings underscore the importance of assessing stage of change and providing stage-matched interventions when working with smokers with diabetes.

Skalen zur Selbstwirksamkeit und Entscheidungsbalance im Prozeß der Verhaltensänderung von Rauchern

Zusammenfassung. Im Kontext des transtheoretischen Modells von Prochaska werden in Anlehnung an amerikanische Originalversionen Skalen zur Erfassung der Konstrukte Selbstwirksamkeit und Entscheidungsbalance entwickelt sowie deren Testgüte überprüft. Die Stichprobe besteht aus 279 Jemals-Rauchern aus einer Gesamtheit von 592 Personen, die am “Check ab 35”, einer Gesundheitsuntersuchung nach § 25 SGB V, in 60 allgemeinärztlichen Praxen teilnahmen. Ihnen wurden u.a. folgende Skalen vorgelegt: Selbstwirksamkeits-Skala zur Raucherentwöhnung (SER), Entscheidungsbalance-Skala zur Raucherentwöhnung (EBR) und Skala zur Messung der Stufen der Verhaltensänderung nach Prochaska ( Velicer, DiClemente, Prochaska & Brandenburg, 1985 ). Die SER ist eine eindimensionale Skala und besteht aus 9 Items mit einer inneren Konsistenz von α = 0.95 und Retest-Reliabilität (6 Wochen) von r = 0.85. Die EBR ist zweidimensional, wobei mit jeweils 5 Items auf der einen Dimension die wahrgenommenen Vorteile und auf der anderen Dimension die wahrgenommenen Nachteile des Nichtrauchens abgebildet werden. Die internen Konsistenzen beider Skalen betragen α = 0.85 bzw. 0.83, die Retest-Reliabilitäten r = 0.73 bzw. 0.66. Mit fortgeschrittener Stufe der Verhaltensänderung nehmen sowohl Selbstwirksamkeitserwartung als auch die wahrgenommenen Vorteile des Nichtrauchens in ihrer Ausprägung zu und die wahrgenommenen Nachteile ab. Der Einsatz der Skalen im Prozeß der Verhaltensänderung läßt eine Verbesserung der Spezifität der Interventionen erwarten.

Testing 40 predictions from the transtheoretical model

Sensitive measurement of behavior change requires dependent measures that are sensitive to the whole spectrum of change, not just a single aspect of change. Traditional outcome variables such as point prevalence for smoking cessation focus on a single discrete event and ignore all other progress. Alternatively, the criterion measurement model (CMM) is an approach that posits a three-construct outcome model (habit strength, positive evaluation strength, and negative evaluation strength), where different constructs are sensitive to change for different aspects of the temporal domain. In this article, a series of 40 differential a priori predictions were tested using a large representative sample of smokers. The focus was on the prediction of specific effect sizes rather than statistical significance. A series of comparisons involving stage transitions was examined using five variables representing the three CMM constructs. The predictions involved movement from one of three initial stages (precontemplation, contemplation, and preparation) to stage membership 12 months later. Thirty-six of the 40 predictions were confirmed, indicating that the outcome model has strong construct validity and accurately reflects movement between the stages of change.

Population-based recruitment for quit-smoking programs: an analytic review of communication variables

BACKGROUND

Attempts to reduce the prevalence of smoking through quit-smoking programs have been unsuccessful because they have not attracted large numbers of smokers to participate in them.

METHOD

An analytic review of the literature was conducted to identify potential communication variables that might enhance recruitment for community-based quit-smoking programs. Recruitment was defined as the number of smokers who enroll in a quit-smoking program divided by the estimated number of smokers in the target population.

RESULTS

Thirty-three publications reporting the results of 40 recruitment campaigns were located. The median recruitment rate was 2.0%. Logistic regression was used to examine the effect of six variables on recruitment rate: the type of program sponsor, the type of program, program costs, use of participation incentives, whether messages were segmented by stage of change, and the type of channel used to send messages. The only significant predictor of recruitment rate was channel type (i.e., the method used to deliver a message). Studies that used interactive recruitment channels (telephone, interpersonal communication) were 66.5 times more effective than those using passive recruitment strategies (mass media, direct mail). Results examining the segmentation of messages by stage of change on recruitment were inconclusive.

CONCLUSIONS

Results suggest that researchers and practitioners interested in population-based smoking cessation programs should pay more attention to recruitment methods. The use of interpersonal channels has been underused and appears to be particularly promising for improving the population impact of quit-smoking programs.

Self-efficacy, decisional balance and the stages of change for smoking cessation in a German sample

The Transtheoretical Model (TTM) has been shown to be a powerful basis for describing and explaining behavior change and designing effective interventions. Previous research has documented its usefulness in the context of smoking cessation as well as other areas but predominantly in US samples. The goal of this study was to provide further data on the applicability of the TTM and the relationship of some of its core constructs (stage of change, self-efficacy, decisional balance) in a German sample of smokers and ex-smokers. Participants (N = 401) were ever-smokers (age M = 47 years, range 35-65, 62% male) who participated in a health check-up for cardiovascular risk factors at their general practitioner's office. For current smokers, significant differences in the number of quit attempts across the stages of change supported the criterion validity of the staging algorithm; differences in number of cigarettes per day were non-significant. Self-efficacy for non-smoking behavior showed an almost linear increase across the stages of change, with significant differences between pre-action and action stages. The pros for smoking cessation also increased significantly across the stages, mainly due to a significantly lower perception of pros by participants in the Precontemplation stage. As expected, the cons for smoking cessation decreased significantly, being lower in Action and Maintenance than in earlier stages. Although the generalizability of the results for the stage distribution is limited by the selectivity of the sample, the results underline the applicability and replicability of these TTM core constructs for smoking cessation with newly developed instruments in a German sample.

Targeting smokers with low readiness to change with tailored and nontailored self-help materials

BACKGROUND

Few smoking cessation self-help materials are available for smokers who are not planning to quit. However, computer-tailored interventions can be designed specifically for these smokers.

METHODS

In a large randomized field trial (N = 843), two different tailored smoking cessation self-help interventions (multiple tailoring and single tailoring) and one standardized smoking cessation self-help guide were compared with a no-information control group and with each other. The contents of the tailored interventions were adapted to individuals' self-reported stage of change, outcome expectations, self-efficacy levels, and smoking behavior.

RESULTS

The primary outcome measure was forward stage transition. The standardized self-help guide had no effect. Among smokers who were not planning to quit within the next 5 years the multiple-tailored intervention was more effective than the single-tailored intervention. This pattern was supported by the cognitive changes caused by the interventions. Among smokers who were planning to quit within the next 5 years but not within the next 6 months, none of the self-help materials had any effect.

CONCLUSION

The present results show that the self-help material currently available in the Netherlands, the standardized self-help guide, was not effective among smokers with low readiness to change. However, computer-generated tailored interventions seem a promising means of communicating information on smoking and smoking cessation to these smokers.

An expert system intervention for smoking cessation

The Pathways to Change system (PTC) is an expert system intervention for smoking cessation. Assessments are performed either by mail or by a telephone interview and each smoker receives a three- to four-page report that provides individualized recommendations matched to the individual's needs and readiness-to-change. The Transtheoretical Model of Change provides the theoretical basis for the expert system. Four different studies have demonstrated the efficacy of this intervention in a general population, with cessation rates of 22 to 26%. Furthermore, the difference between the groups was larger at each follow-up assessment point, indicating that the effects of the treatment increased long after the end of treatment. The studies involved two proactively recruited samples, demonstrating that a large proportion (85.3% and 82.5%) of the population of smokers could be successfully recruited into a smoking cessation program. Expert system interventions have the potential to have an extremely high impact on a total population of smokers.

Age and the role of symptomatology in readiness to quit smoking

To develop effective age-appropriate strategies for smoking cessation, it is important to understand factors associated with readiness to quit smoking. This article presents results from an analysis of the role of symptomatology in the decisions to quit smoking among three age groups (18-34, 35-54, and > or = 55 years) from a larger sample of smokers in a managed-care setting. Two measures of readiness to quit smoking were used: stages of change and intention to stop. Using ordinal logistic regression, we found that smokers in the middle and oldest age groups who had experienced at least three of five symptoms in the previous 2 weeks were more likely to be in higher stages of readiness. Regardless of age, smokers who attributed symptoms to smoking were more motivated to try to quit, whereas those who attributed symptoms to aging were less likely to intend to stop smoking. Findings from this study indicate a symptom-based approach to smoking cessation may be a useful strategy, especially in provider-based interventions.

Stage distributions for five health behaviors in the United States and Australia

BACKGROUND

A key variable for the design of individual and public health interventions is the Stage of Change. The five stages of readiness to change are Precontemplation, Contemplation, Preparation, Action, and Maintenance. The distribution of individuals across the stages of change can provide a valuable tool for designing health interventions.

METHODS

The pattern of distribution across the stages of change for five behavioral risk factors is presented from five independent surveys, two from the United States and three from Australia. The five risk factors are smoking, low fat diet, regular exercise, reducing stress, and losing weight. Identical single-item questionnaire items for staging health behaviors were used in all surveys.

RESULTS

The stage distributions for the five risk factors were similar across the five independent samples. In general, the pattern of stage distributions was stable across health risk factors, gender, country, and sample.

CONCLUSIONS

Single-item survey measures of stage of change that are readily applicable to population studies appear to provide important information about the population characteristics of readiness to change behavioral risk factors. The stability of these distributions suggests that interventions matched by stage may have broad applicability.

Reasons for quitting and smoking temptation among adolescent smokers: gender differences

Adolescent cigarette smokers from randomly selected classrooms from 24 California and Illinois high schools were assessed regarding their interest in cessation, reasons for quitting, and smoking temptation circumstances. These data were analyzed by gender. Males and females were not found to differ in quit stage or perceived likelihood of ever quitting smoking, although males reported being somewhat more likely to have ever tried to quit in the past. The associations of reasons for quitting were not found to vary by gender in most comparisons. On the other hand, the associations of smoking temptation circumstances with gender showed that a greater percentage of females than males reported more circumstances that would make them tempted to smoke. Smoking cigarettes to regulate one's affective states, and to avoid nicotine withdrawal, may be functions of smoking that impede efforts at quitting, particularly among adolescent females.

Transtheoretical measures for adolescent and adult smokers: similarities and differences

BACKGROUND

The prevalence of smoking among adolescents has remained stable and has increased in the past few years. Longitudinal results from a multitude of efforts to reduce adolescent smoking have been mostly disappointing.

METHODS

This paper discusses, in light of the theoretical knowledge obtained among adults and the empirical data collected among adults and adolescents, the applicability of the central concepts of the Trantheoretical Model of Change to the adolescent smoking problem.

RESULTS

According to the stage of change distributions, adolescent smokers appeared to be somewhat less prepared to quit than adults. Both adults and adolescents utilize identical cognitive and behavioral activities to change their smoking although teens' process use appears to differ from that of adults at each stage of change. According to the decisional balance measure, the pros of smoking among adults and teens exceeded the cons in early stages of change and then reversed once smokers took action to quit. The levels of temptations to smoke among adults and adolescents were almost identical at each stage.

CONCLUSIONS

Both age groups turned out to be remarkably similar in the Transtheoretical measures, and, except for the processes of change, both groups exhibited similar behavior at different stages of the smoking cessation process.

Gender differences among smokers and quitters in the Working Well Trial

BACKGROUND

Gender differences in smoking and smoking cessation among participants in the Working Well Trial are characterized.

METHODS

A prospective randomized matched-pair evaluation was conducted among 90 predominantly blue-collar worksites. Cross-sectional surveys of employees' tobacco use behaviors were conducted at baseline and after a 2.5-year smoking cessation intervention. Respondents included 5,523 females and 12,313 males at baseline and 4,663 females and 10,919 males at follow-up. The main outcome measures included self-reported continuous smoking abstinence rates for 7 days and for 6 months.

RESULTS

Smoking prevalence was significantly higher for women than for men at baseline, but not at follow-up. Variables believed to influence smoking cessation were compared at baseline. Significant gender differences were found for number of cigarettes smoked/day, number of previous quit attempts, job strain, stage of change, and behavioral processes of change. At follow-up, no gender differences in quit rates were observed; however, women in the intervention condition were more likely to quit than women in the control condition, whereas no differences were seen among men by treatment condition.

CONCLUSIONS

Gender is not a strong predictor of smoking cessation in this population; however, women were more likely to quit with an intervention than without one.

The Natural History of Smoking Cessation Among Medical Patients in a Smoke-Free Hospital

Our purpose was to determine the frequency and predictors of quitting smoking among patients hospitalized on the medical services of a smoke-free hospital. All smokers admitted to the medical services of a single university teaching hospital were eligible and 129 patients were enrolled. A questionnaire detailing demographic information, stages of change, smoking behavior while hospitalized, and intention to remain abstinent on discharge was administered. The primary discharge diagnosis was obtained from the medical record. Patients were followed at 3- and 6-month intervals for continuous abstinence, with expired carbon monoxide confirmation at 6 months. A total of 7% of smoking patients receiving usual medical care were continuously abstinent at 6 months. Of those who relapsed, 45% did so by the time of discharge, 18% within the first week, 20% between 1 week and 3 months, and 10% between 3 and 6 months after discharge. All patients who were abstinent at 6 months had been admitted for coronary artery disease (CAD). Nine of the 38 patients with CAD were abstinent, versus none of 93 with another diagnosis (p <.001). Smokers admitted to a smoke-free hospital had a high rate of relapse, especially early after discharge. Patients admitted for CAD had a greater likelihood of successfully quitting. Designing hospital-based smoking cessation interventions with a focus on early relapse prevention may help improve smoking cessation rates.

Stages of acquisition and cessation for adolescent smoking: an empirical integration

Adolescent cigarette smoking acquisition and cessation were integrated into a single nine-stages-of-change continuum using the transtheoretical model of change framework. Findings in a high school student sample (n > 700) showed that a few of the never smokers were planning to try smoking, and half of the current smokers were contemplating quitting. More than half of former smokers were long-term quitters. The high pros of smoking scores assessing coping benefits of cigarettes were related to smoking acquisition and the high con (disadvantages) scores to long-term abstinence. Never smokers were most tempted to try smoking when they anticipated that smoking would help reduce negative and increase positive mood. Current and former smokers were tempted due to peer cigarette offers and negative mood. These temptations were significantly reduced among ex-smokers.

Smokers in four stages of readiness to change

Smoking cessation is increasingly considered to be a process rather then a discrete event. Several stage models that stress the process nature of behavior change have been developed in the last decade. In the present study, a stage model is investigated that categorizes smokers into four groups with increasing readiness to change: immotives, precontemplators, contemplators, and preparers. Smokers from the general population were recruited to participate in an investigation on smoking cessation interventions. At pretest, the anticipated positive and negative outcomes of quitting, perceived self-efficacy, and smoking behavior were assessed. Three and 14 months after the pretest, the follow-up measurements were conducted. The cross-sectional results showed that smokers in the four stages differed from each other on the factors pertaining to the positive outcomes and perceived self-efficacy. No differences between the four stages were detected concerning the number of cigarettes smoked a day, the nicotine dependence score, and the number of years smoked. The longitudinal results showed that the stage of readiness to change at pretest was highly predictive of quitting at both follow-ups. It is concluded that this stage model is worthy of support.

Computer-based smoking cessation interventions in adolescents: description, feasibility, and six-month follow-up findings

The impact of adolescent smoking cessation clinics has been disappointing due to low participation rates, high attrition, and low quit rates. This paper describes two computerized self-help adolescent smoking cessation intervention programs: 1) a program utilizing the expert system which is based on the transtheoretical model of change and 2) a popular action-oriented smoking cessation clinic program for teens which was modified for computer presentation. High participation rates in the program among 132 smokers demonstrate the high feasibility and acceptability of the programs. Quit rates of up to 20% were observed during the intervention, and an additional 30% made unsuccessful quit attempt(s). The 6-month follow-up findings indicated that adolescents were poorly prepared to maintain abstinence.

Predicting smoking stage of change among a sample of low socioeconomic status, primary care outpatients: replication and extension using decisional balance and self-efficacy theories

An expanding body of research using the transtheoretical model with both self-change and treatment programs suggests that differences in readiness for smoking cessation are important predictors of successful abstinence. Understanding the cognitive processes underlying these differences may hold tremendous potential for improving the efficacy and efficiency of intervention strategies. Decisional balance theory and self-efficacy theory have been used to help explore how and why people move through the stages of change, but they have been validated almost exclusively with middle-class, educated White samples This study sought to investigate whether these theories relate in each other in the same manner among low socioeconomic status (SES) primary care outpatients. Results indicated that variables from decisional balance theory (pros, cons) and self-efficacy theory successfully differentiated stage membership and yielded results consistent with the extant literature. Self-efficacy demonstrated the most powerful association with stage membership, whereas pros, cons, and temptations exhibited varying degrees of association. Clinical implications and special considerations when conducting research and implementing interventions with low-SES smokers are discussed.

Physicians and smoking cessation. Development of survey measures

Data from a mailed survey to primary care physicians (N = 122) were used to construct and evaluate psychosocial scales related to performance of smoking cessation counseling. Scales measuring counseling barriers, self-efficacy, and motivation demonstrated considerable promise with excellent or reasonable internal consistency. The correlation for each scale with performance of cessation counseling and with stage of change was statistically significant. Physicians who report they are currently assisting patients had higher performance and self-efficacy rating. Physicians who had participated in formal smoking cessation training had higher self-efficacy; however, their scores on the Barriers, Motivation, and Performance Scales did not differ. Further study with a representative group is encouraged.

What makes a good staging algorithm: examples from regular exercise

PURPOSE

This study retrospectively compared subjects from three unrelated studies using eight algorithms to stage exercise behavior.

SUBJECTS AND SETTINGS

Study One included 936 employees involved in a smoking cessation study at four worksites--a medical center, retail store, manufacturing firm, and a government agency. Study Two included 19,212 members of a New England HMO; and Study Three included a convenience sample of 327 adult New Englanders.

MEASURES

The eight algorithms used different descriptions of stages based on the transtheoretical model, as well as different definitions of exercise and response formats.

RESULTS

Algorithms using longer, more precise definitions of exercise resulted in larger numbers of subjects being staged in precontemplation and contemplation in comparison to algorithms using shorter definitions, which tended to stage subjects in preparation and action. Maintenance was the most and preparation the least consistently described stage across algorithms.

CONCLUSIONS

Alteration of the descriptions of stage and the definition of exercise has consequences for the staging of subjects. Definitions need to be explicit, stating all parameters needed to meet criterion, and subjects must be able to assess themselves. Either a 5-Choice or a true/false response format is effective in assessing stage.

The transtheoretical model of health behavior change

The transtheoretical model posits that health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations. Basic research has generated a rule of thumb for at-risk populations: 40% in precontemplation, 40% in contemplation, and 20% in preparation. Across 12 health behaviors, consistent patterns have been found between the pros and cons of changing and the stages of change. Applied research has demonstrated dramatic improvements in recruitment, retention, and progress using stage-matched interventions and proactive recruitment procedures. The most promising outcomes to data have been found with computer-based individualized and interactive interventions. The most promising enhancement to the computer-based programs are personalized counselors. One of the most striking results to date for stage-matched programs is the similarity between participants reactively recruited who reached us for help and those proactively recruited who we reached out to help. If results with stage-matched interventions continue to be replicated, health promotion programs will be able to produce unprecedented impacts on entire at-risk populations.

Distributions of smokers by stage: international comparison and association with smoking prevalence

OBJECTIVES

The goals of this study were to describe the distribution of smokers by stage of change in Geneva, Switzerland; to compare this result with distributions observed in other countries; and to assess whether, across samples from different countries, the stage distribution of current smokers was associated with the prevalence of smoking.

METHODS

Two mailed surveys were conducted in Geneva in 1995-1996, in a representative sample of residents (n = 742) and in a representative sample of university members (n = 2,270). A literature review produced seven studies describing the stage distribution in representative samples.

RESULTS

In the Geneva population, 74% of smokers were in the precontemplation stage, 22% in contemplation, and 4% in preparation. In the university sample, the corresponding figures were 72, 20, and 8%. Our results were similar to other European samples, but less favorable than in American samples, where these distributions were typically 40, 40, and 20%, respectively. Across all samples, a low prevalence of smoking was associated with a more favorable stage distribution (r = 0.88, P = 0.002).

CONCLUSIONS

Interventions in Europe need to take into account the large proportion of precontemplators repeatedly observed among smokers. A shift to the right of the distribution of current smokers across stages may help increase quit rates and thereby reduce smoking prevalence. This hypothesis should be tested in prospective intervention studies.

Readiness for change: implications for patient care

The strategic position of pharmacists within the community allows frequent interactions with many patients, thus making pharmacists potentially valuable resources for assisting patients in making behavioral changes regarding adherence to treatment. The Transtheoretical Model is a behavior-change model that provides a functional approach through which pharmacists can help patients to reach specific behavioral goals. The model is described and stage-specific examples of patient-pharmacist dialogue are provided to show how the model may be used to promote progression through the stages.

Patients' perceptions of their physician's role in smoking cessation by age and readiness to stop smoking

BACKGROUND

Patients' perceptions of their physician's role in smoking cessation, using the 4As protocol (asking, advising, assisting, and arranging), were assessed with a focus on associations with age (18-29, 30-49, and > or = 50) and stage of readiness to stop smoking (precontemplation, contemplation, and preparation).

METHODS

Self-administered questionnaires were completed by 524 smokers presenting for regularly scheduled appointments at six clinics of an HMO in the Chicago metropolitan area.

RESULTS

Almost all patients said their physician should ask about their smoking status and advise them to quit. About half said their physician should assist them with quitting, and about two-thirds said their physician should follow up (arrange) on their smoking behavior. Bivariate associations were found for endorsement of the 4As with both age and stage. Multiple logistic regressions found age was the most consistent and strongest correlate of 4As endorsement, with younger smokers more likely than those age 50 or older to endorse the 4As protocol.

CONCLUSIONS

A proactive health promotion orientation should be encouraged among physicians. Patients should be screened for stage of readiness to stop smoking so that health-care providers can emphasize aspects of the 4As protocol that are most appropriate for each patient. Age-tailored smoking cessation strategies should be employed within stages of readiness to stop smoking.

A self-help smoking cessation program for inner-city African Americans: results from the Harlem Health Connection Project

The authors develop and test a culturally sensitive, low-intensity smoking cessation intervention for low-socioeconomic African Americans. African American adult smokers were randomly assigned to receive either a multicomponent smoking cessation intervention comprising a printed guide, a video, and a telephone booster call or health education materials not directly addressing tobacco use. The results of the study were mixed. Although no significant effects were observed for the entire treatment cohort, the results of post hoc analyses suggest that culturally sensitive self-help smoking cessation materials plus a single phone contact can produce short-term cessation rates similar to those reported for majority populations. This conclusion should be tempered by the low completion rate for the booster call and several design limitations of the study.

Readiness to change smoking behavior in a community health center population

This study examines predictors of readiness to change smoking behavior in a sample of smokers who receive care at a community health center that serves a predominantly low income African American population. Prior to initiating interventions we conducted a telephone survey with a random sample of 1318 adult users who had visited the center in the last 18 months; 379 (28.8%) were current smokers (40.3% of males, 23.9% of females, 42.7% of Whites, and 25.3%, of African Americans). Multiple logistic regression analysis showed nine factors significantly associated with readiness to change smoking behavior: male gender; a previous quit attempt; a perception of risk of lung cancer from smoking; greater desire to quit smoking; a perception that smoking bothers others; doctor advice to stop smoking at last health visit; records kept for scheduling doctor appointments; thinking that losing a pleasure would not be a problem if quit smoking; and poorer self-reported health status. These findings provide direction for developing interventions for similar low income, high risk populations. The results indicate that it may be useful to heighten awareness of the risks of smoking and to assure that smokers receive clear quit smoking messages from their providers. Women need special attention since they are less ready to quit than men.

A trial of church-based smoking cessation interventions for rural African Americans

BACKGROUND

The Alliance of Black Churches Health Project was begun in an effort to address the health problems of the African-American residents of two rural Virginia counties. Smoking cessation was chosen as the principal target behavior in one county. Church coalitions were chosen as the principal organizations through which to implement the interventions.

METHOD

A smoking cessation program was designed that combined one-on-one counseling with self-help materials and community-wide activities. To provide these services, up to two smoking cessation counselors were trained from participating churches. To evaluate the impact, population-based cohorts of smokers were assembled in each county using a door-to-door survey. Respondents were recontacted after 18 months. Smoking cessation (1-month continuous abstinence), stages of change, and exposure to the interventions were assessed.

RESULTS

The overall smoking prevalence at baseline was 25.8%. At follow-up, the smoking cessation rate in the intervention county was 9.6% and in the control county 5.4% (P = 0.18). Among those attending church once a month or more, the respective quit rates were 10.5% and 5.9% (P = 0.20). There was significantly more progress along the stages of change in the intervention than in the control county. There was also higher awareness of and contact with smoking cessation programs in the former compared with the latter.

CONCLUSION

Smoking cessation interventions for African Americans can be successfully implemented through a church coalition. The interventions were associated with significant progress along the stages of cessation. Although the quit rate was higher in the intervention community, the difference was not significant.

A stage paradigm for integrating clinical and public health approaches to smoking cessation

Clinical interventions for the addictions typically generate the highest abstinence rates but the lowest participation rates. Public health interventions reach the largest percentage of populations but have the lowest efficacy. Applying a stage paradigm to smoking cessation can integrate the clinical and public health approach and generate unprecedented impacts. Theoretical, empirical, and practical examples are provided for enhancing five issues in intervention: recruitment, retention, progress, process and outcomes.

Retracing the steps of Marco Polo: from clinical trials to diffusion of interventions for smokers

We report the results from a series of four controlled trials which evaluate efficacy, effectiveness, and implementation of interventions for smokers, and then discuss diffusion of our program in feasibility studies both nationally in Australia and internationally. In our first study we reported that when general practitioners delivered moderately brief advice to smokers, they have a 36% abstinence rate at three years. In the second study we found that doctors achieve a 12% abstinence at one year after giving minimal advice to patients, and when using a more involved intervention, quit rates of just less than 20% at one year. In the third and fourth studies of utilization of the smoking cessation program we report that reinforcement contact following a 2-hour training workshop increased doctors' use of a smoking cessation program at 6 months compared to no contact. The challenge of translating research findings into practice for the benefit of doctors in Australia as well as in a low-income country such as China, is described in two feasibility studies. Over the past 11 years we have disseminated the program nationally in Australia, and over 4500 doctors have been trained. Diffusion theory provides a useful model which has guided us in our implementation efforts in Australia and is being used to allow us to introduce the smoking cessation intervention for Chinese doctors to use.

A criterion measurement model for health behavior change

Researchers in the field of health behavior change have traditionally relied on a univariate criterion measure to evaluate the efficacy of an intervention. Such measures have superficial face validity but suffer from a number of problems: (a) lack of precise definitions; (b) poor statistical power; and (c) a lack of meaningfulness for some aspects of the problem. As an alternative, a theoretical model is developed that attempts to define more appropriate multivariate sets of dependent variables for the study of health behavior change. The model involves three separate constructs: Positive Evaluation Strength, Negative Evaluation Strength, and Habit Strength. The pattern of change for each construct is described across four stages of change: Precontemplation, Contemplation, Action, and Maintenance. For each construct, two thresholds are proposed representing the ability of the environment to modify the construct. Four tests of the model are provided from existing data sets. First, a structural model analysis was used to test if the proposed measurement model adequately fits the data. Second, a dynamic typology approach produced profiles of change that are consistent with the model. Third, a time series analysis provided support for the assumed model. Fourth, longitudinal, five-wave panel design was employed to test if the relation between the two cognitive variables (Pros and Cons) and the behavioral measure (Habit Strength) was consistent with the model. Implications for alternative intervention strategies are discussed.