Stages of change for smoking cessation among former problem drinkers: a cross-sectional analysis

Patient navigation to promote lung cancer screening in a community health center for people experiencing homelessness: Protocol for a pragmatic randomized controlled trial

BACKGROUND

Lung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers.

METHODS

The Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results.

DISCUSSION

This trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US.

Applying the Transtheoretical Model to Tobacco Cessation and Prevention: A Review of Literature

Objective.

To comprehensively review all published, peer-reviewed research on the Transtheoretical Model (TTM) and tobacco cessation and prevention by exploring the validity of its constructs, the evidence for use of interventions based on the TTM, the description of populations using TTM constructs, and the identification of areas for further research. The three research questions answered were: “How is the validity of the TTM as applied to tobacco supported by research?” “How does the TTM describe special populations regarding tobacco use?” “What is the nature of evidence supporting the use of stage-matched tobacco interventions?”

Data Source.

Computer Database search (PsychInfo, Medline, Current Contents, ERIC, CINAHL-Allied Health, and Pro-Quest Nursing) and manual journal search.

Inclusion/Exclusion Criteria.

All English, original, research articles on the TTM as it relates to tobacco use published in peer-reviewed journals prior to March 1, 2001, were included. Commentaries, editorials, and books were not included.

Data Extraction and Synthesis.

Articles were categorized as TTM construct validation, population descriptions using TTM constructs, or intervention evaluation using TTM constructs. Summary tables including study design, research rating, purpose, methods, findings, and implications were created. Articles were further divided into groups according to their purpose. Considering both the findings and research quality of each, the three research questions were addressed.

Results.

The 148 articles reviewed included 54 validation studies, 73 population studies, and 37 interventions (some articles fit two categories). Overall, the evidence in support of the TTM as applied to tobacco use was strong, with supportive studies being more numerous and of a better design than nonsupportive studies. Using established criteria, we rated the construct validity of the entire body of literature as good; however, notable concerns exist about the staging construct. A majority of stage-matched intervention studies provided positive results and were of a better quality than those not supportive of stage-matched interventions; thus, we rated the body of literature using stage-matched tobacco interventions as acceptable and the body of literature using non–stage-matched interventions as suggestive. Population studies indicated that TTM constructs are applicable to a wide variety of general and special populations both in and outside of the United States, although a few exceptions exist.

Conclusions.

Evidence for the validity of the TTM as it applies to tobacco use is strong and growing; however, it is not conclusive. Eight different staging mechanisms were identified, raising the question of which are most valid and reliable. Interventions tailored to a smoker's stage were successful more often than nontailored interventions in promoting forward stage movement. Stage distribution is well-documented for U.S. populations; however, more research is needed for non-U.S. populations, for special populations, and on other TTM constructs.

Self-Initiated Cessation from Substance Use: A Longitudinal Study of the Relationship between Postulated Mediators and Quitting

This study examines psychosocial predictors of self-initiated substance use cessation among youths who have had recent substance use experience. Variables included those that are the focus of many primary prevention programs. Middle school and high school students who used either alcohol, cigarettes, smokeless tobacco, marijuana, or inhalants were surveyed on two occasions, one year separating the pretest and posttest. Pretest differences distinguished those who would quit versus those who would continue using alcohol, tobacco, and marijuana, but not inhalants. The largest pretest differences were youths' normative beliefs, manifest commitments to not use substances, and perceived incongruence between drug use and their desired lifestyles. Those who continued to use had scale values for most mediators that continued to worsen in programmatic terms, whereas measures among those who quit significantly improved. School-aged users may benefit from programs that target some of the same mediators currently promoted as effective in primary prevention programs.

Stages of change of the readiness to quit smoking among a random sample of minority Arab male smokers in Israel

BACKGROUND

Despite advanced smoking prevention and cessation policies in many countries, the prevalence of cigarette smoking among indigenous and some ethnic minorities continues to be high. This study examined the stages of change (SOC) of the readiness to quit smoking among Arab men in Israel shortly after new regulations of free-of-charge smoking cessation workshops and subsidized medications were introduced through primary health care clinics.

METHODS

We conducted a countrywide study in Israel between 2012-2013. Participants, 735 current smokers; 18-64 years old; were recruited from a stratified random sample and interviewed face-to-face using a structured questionnaire in Arabic. We used ordered regression to examine the contribution of socio-economic position (SEP), health status, psychosocial attributes, smoking-related factors, and physician advice to the SOC of the readiness to quit smoking (pre-contemplation, contemplation and preparation).

RESULTS

Of the current smokers, 61.8% were at the pre-contemplation stage, 23.8% were at the contemplation stage, and only 14.4% were at the preparation stage. In the multinomial analysis, factors significantly (P < 0.05) contributing to contemplation stage compared to pre-contemplation stage included [odds ratio (OR), 95% confidence interval (CI)]: chronic morbidity [0.52, (0.31-0.88)], social support [1.35, (1.07-1.70)], duration of smoking for 11-21 years [1.94, (1.07-3.50)], three or more previous attempts to quit [2.27, (1.26-4.01)], knowledge about smoking hazards [1.75, (1.29-2.35)], positive attitudes toward smoking prevention [1.44, (1.14-1.82)], and physician advice to quit smoking [1.88, (1.19-2.97)]. The factors significantly (P < 0.05) contributing to preparation stage compared to pre-contemplation stage were [OR, (95 % CI)]: chronic morbidity [0.36, (0.20-0.67)], anxiety [1.07, (1.01-1.13)], social support [1.34, (1.01-1.78)], duration of smoking 5 years or less [2.93, (1.14-7.52)], three or more previous attempts to quit [3.16, (1.60-6.26)], knowledge about smoking hazards [1.57, (1.10-2.21)], and positive attitudes toward smoking prevention [1.34, (1.00-1.82)].

CONCLUSIONS

Most Arab men who currently smoke are in the pre-contemplation stage, indicating low readiness to quit smoking. New policies of free-of-charge smoking-cessation group sessions and subsidized medications introduced through primary health care clinics in Israel may be less effective among Arab men. For these policies to promote cessation more successfully, tailored interventions and campaigns may be needed to increase the readiness to quit smoking in this population, especially for those at the pre-contemplation stage.

Motivational Interviewing: III. On the Ethics of Motivational Intervention

This article is intended to promote consideration and discussion of ethical issues in motivational interventions. The popular concept of client “denial” encompasses a broad range of motivational behaviors including lying, perceptual bias, unawareness, ambivalence, resistance and reactance. The “problem of motivation” typically arises when a therapist perceives a problem and sufficient need for change in someone who does not share this perception. In considering how to respond to such situations, one can conceive of a continuum of levels of readiness to change, and of therapeutic strategies ranging from passivity to coercion. Ethical concerns arise when there is a perceived mismatch between readiness level and intervention strategy. Motivational interviewing is a middle way between passivity and coercion, seeking to evoke intrinsic motivation for change by making salient the inconsistency of problem behavior and that which is more deeply valued. The concern that this approach is “manipulative” combines a descriptive element and an evaluative component. Three possible descriptive meanings are discussed: that it effectively alters behavior, that it does so in persons not seeking or requesting change, and that it may operate through processes not immediately apparent. Ethical concerns regarding motivational intervention are considered within this broader context.

Application of the Transtheoretical Model to substance abuse: historical development and future directions

As a growing literature has documented applications of the Transtheoretical Model (TTM) to substance abuse, the utility or futility of such an application has been debated widely. The purpose of this paper is to critically examine the TTM, and its conceptual and empirical applications to the field of substance abuse. This review focuses not only on the stage of change dimension of the TTM, but also the processes, decisional balance, and self-efficacy dimensions, which have received less attention in earlier reviews. Particular emphasis is placed on the measurement and conceptualization of the stage of change construct. Unanswered questions and directions for future research are identified. It is concluded that, to effectively determine the TTM's applicability to substance abuse, all dimensions must be more fully developed, validated and evaluated across a range of substance abuse problems. Further, prospective studies are needed to determine the predictive utility of the TTM, and evaluation of TTM-matched interventions will help to address the model's specificity.

Decision making in the transtheoretical model of behavior change

Decision making is an integral part of the transtheoretical model of behavior change. Stage of change represents a temporal dimension for behavior change and has been the key dimension for integrating principles and processes of change from across leading theories of psychotherapy and behavior change. The decision-making variables representing the pros and cons of changing have been found to have systematic relationships across the stages of change for 50 health-related behaviors. Implications of these patterns of relationships are discussed in the context of helping patients make more effective decisions to decrease health risk behaviors and increase health-enhancing behaviors.

Attitudes, social influences and self-efficacy expectations across different motivational stages among immigrant smokers: replication of the Ø pattern

BACKGROUND

Information about the factors that determine motivation to quit in immigrant populations is needed to enable the development of tailored smoking cessation programs for them. Dutch studies in the general population suggest that attitudes are important for motivating persons to change and self-efficacy for helping motivated persons to change. We analyzed whether this pattern also exists among Surinamese immigrants.

METHODS

Structured face-to-face interviews were held among 1,100 Surinamese people in Amsterdam (The Netherlands), including measures of attitudes towards smoking (cessation), social influences and self-efficacy expectations (between 2001 and 2003).

RESULTS

The majority of the smokers were not motivated to quit and in the pre-contemplation phase (73%). Pre-contemplators perceived significantly weaker advantages of quitting than contemplators and preparators. Self-efficacy expectations of Surinamese pre-contemplators were lower than those of smokers preparing to quit within a month.

CONCLUSION

Similar attitudinal and self-efficacy patterns as those in the general population were found in an immigrant population. However, the items constituting the factors are culturally sensitive. Furthermore, many Surinamese smokers were unmotivated to quit smoking.

Correlates of stages of change of smoking among inhabitants of deprived neighbourhoods

BACKGROUND

This study examines the prevalence and correlates of stages of change of smoking, in terms of psychosocial, structural and sociodemographic factors, among inhabitants of deprived neighbourhoods.

METHODS

Cross-sectional data were obtained from a survey on health related behaviour. Subjects were 2009 current and former smokers, aged 20-46, living in deprived neighbourhoods in Rotterdam, the second largest city in the Netherlands. Three groups of smokers were formed according to the stages of change-definitions of the Transtheoretical Model: smokers not planning to quit (precontemplators), smokers planning to quit (contemplators/preparators) and former smokers (actors/maintainers). Smokers planning to quit and smokers not planning to quit were compared regarding psychosocial factors (attitude, social norm, self-efficacy), structural factors (neighbourhood problems, material deprivation, financial problems, employment status) and sociodemographic factors (age, gender, marital status, cultural background, educational level). Former smokers were compared with smokers planning to quit regarding structural and sociodemographic factors. Logistic regression was used to assess correlates of stages of change.

RESULTS

Smokers planning to quit (prevalence = 19%) reported a more positive attitude, stronger social norms and higher self-efficacy expectations in quitting smoking than smokers not planning to quit (prevalence = 57%). Smokers planning to quit less often were Dutch-born, more often had attended higher vocational schooling or university and more often reported experiencing two or more neighbourhood problems compared to smokers not planning to quit. Former smokers (prevalence = 24%) were older, more often Dutch-born, married, employed and higher educated, compared to smokers planning to quit. Furthermore, former smokers less often reported material deprivation and financial problems than smokers planning to quit.

CONCLUSION

Among people living in deprived neighbourhoods, different factors correlate with different stages of change of smoking. Implications for health promotion are discussed.

Nicotine and other substance interaction expectancies questionnaire: relationship of expectancies to substance use

Smoking and substance abuse co-occur at high rates and substance abusers are less likely to quit smoking than are smokers in general. Therefore, more information about the beliefs substance abusers have about the role of smoking in substance use and in recovery would be useful when designing interventions to impact smoking among substance abusing patients. The present study developed a Nicotine and Other Substance Interaction Expectancies Questionnaire (NOSIE) to investigate the expectancies held by substance abusers in treatment about the effects of smoking on substance use, the effects of substance use on smoking, smoking to cope with recovery, and receptivity to smoking cessation during substance abuse treatment. The 29 items were Likert-rated by 160 substance dependent patients in an inner-city residential substance abuse treatment program and participating in a larger study of smoking at this site. Four components were derived and reduced to a 20-item measure with good reliability. No differences by gender or age were found. On average, the patients reported that substance use almost always increases their smoking or urges to smoke but that smoking only increased substance use or urges about half of the time, that they use smoking to cope with urges to use substances about half of the time, and that they generally agreed that smoking cessation or treatment should be tried during substance abuse treatment and would not harm recovery efforts. Three of the scales correlated with smoking dependence while one scale correlated with drug use severity and heavy drinking days. The scale of receptivity to smoking cessation correlated significantly with measures of motivation and barriers and predicted 1-month smoking cessation outcomes. However, scale scores on smoking to cope with recovery did not significantly predict 3-month relapse to substance use. Implications for theory and clinical interventions with substance abusers who smoke were discussed.

Stages of change. A critique

The stages of change proposed by Prochaska and DiClemente have been applied to change efforts within and outside of formal treatment and in relation to virtually any problem behavior. This model has gained widespread popularity in health psychology and addictions and is being used to guide interventions and allocate treatment resources in several fields. In this article, the authors review 87 studies on the stages of change across problem behaviors. Research findings suggest that the proposed stages are not mutually exclusive and that there is scant evidence of sequential movement through discrete stages in studies of specific problem behaviors, such as smoking and substance abuse. Although the stage model may have considerable heuristic value, its practical utility is limited by concerns about the validity of stage assessments. The model's underlying concepts and alternative views of readiness for change are considered, along with directions for future research.

Variables Associated with Therapy Attendance in Runaway Substance Abusing Youth: Preliminary Findings

Service providers and researchers note that youth with substance abuse problems are difficult to engage in treatment and, when engaged, often drop out early. Estimates of the alcohol and drug abuse rate of runaway youth range from 70% to 95%. This study evaluated predictors of therapy attendance in a sample of substance abusing youth recruited through two southwestern runaway shelters. Runaway youth and their families (N = 36) were engaged into a 15-session ecologically-based family therapy (EBFT) intervention. Fewer days between the pretreatment assessment and the first therapy session, as well as less perceived parental care, predicted more therapy sessions attended. No relationship was found between level of substance use and treatment attendance. The findings highlight the importance of engaging families in therapy soon after the youth's arrival to the shelter, as treatment motivation may decrease as the crisis lessens.

Community reinforcement and family training (CRAFT): engaging unmotivated drug users in treatment

Although motivation for drug abuse treatment is a substantial problem, unilateral intervention through concerned significant others (CSOs) represents a promising method for engaging unmotivated individuals. The Community Reinforcement and Family Training (CRAFT) program, based on principles of reinforcement was developed for this specific purpose. In Phase I, CSOs received the CRAFT intervention, whereby they were taught skills for modifying a loved one's drug-using behavior and for enhancing treatment engagement. CSOs were evaluated at 3 and 6 months. In Phase II, engaged drug users received treatment using the Community Reinforcement Approach (CRA). A total of 62 CSOs participated in this evaluation of the effectiveness of CRAFT. CSOs completed, on average, 87% of offered treatment sessions. During the 6-month study period, 74% succeeded in engaging their resistant loved one in treatment. Reported abstinence both from illicit drugs and alcohol increased significantly for drug users engaged in treatment, but not for unengaged cases. All CSOs showed significant reduction in depression, anxiety, anger, and physical symptoms, with average scores dropping into the normal range on all measures. CRAFT provides a promising alternative to confrontational and detachment approaches in counseling CSOs to help their loved ones.

Motivational profiles of polysubstance-dependent patients: do they differ from alcohol-dependent patients?

Changing addictive behaviors may be conceptualized as a stage phenomenon consisting of precontemplation, contemplation, preparation, action, and maintenance stages. Prior research has provided empirical support for the existence of two discrete motivational subtypes of alcohol-dependent patients (i.e., precontemplation and contemplation/action stage patients). The present study attempted to identify similar motivational profiles for polysubstance-dependent patients and to provide empirical support for the validity of these profiles. Results from a sample of polysubstance-dependent VA patients revealed two clusters consistent with precontemplation (n = 62) and contemplation/action stage (n = 71) profiles, similar to findings from alcohol-dependent samples. Although, as expected, contemplation/action stage patients were more likely to complete treatment than were precontemplators, relatively few differences were noted between these two groups on several other theoretically relevant variables. These results suggest that these subtypes may not identify clinically similar types of patients across alcohol- and polysubstance-dependent samples.

Smoking cessation following treatment in a smoke-free Navy Alcohol Rehabilitation program

The purpose of this study was to examine changes in smoking behavior and attitudes following treatment in the smoke-free Navy Alcohol Rehabilitation program (NARC) and to evaluate changes in staff attitudes toward the smoke-free policy. Consecutive patients (N = 404; 93.8% male) admitted to the NARC between February 1, 1993 and September 30, 1993 were studied, of whom 54.7% were current smokers. Measures included patient surveys administered repeatedly at admission and discharge and at 12 months following the 4-week treatment program. The staff were also administered a survey 2 months before (N = 86) and 6 months after (N = 104) policy implementation. Results indicate that alcohol treatment in a smoke-free environment did not markedly affect the smoking status of patients; the proportion of current smokers at discharge was 54.7%. Significant reductions in cigarettes smoked per day (p < .001) were observed among patients from admission to discharge. However, no statistically significant change in readiness to consider smoking cessation scores was detected. Results indicated no significant change in patient smoking status at 12-month follow-up, although the survey response rate was low (35.1%; N = 142). Six months following implementation of the smoke-free policy, 84.6% of staff indicated that the NARC should remain smoke-free and 84.6% recommended that other alcohol and drug treatment facilities be smoke-free.

Differential beliefs, perceived social influences, and self-efficacy expectations among smokers in various motivational phases

BACKGROUND

The ASE model, an integration of social psychological models, states that motivational phases and the transition from one phase to another can be predicted by behavioral determinants. The goal of the present study was to replicate the so-called O pattern that was found in earlier Dutch studies.

METHODS

In four cross-sectional studies (N = 918, N = 354, N = 225, N = 317), smokers filled in a questionnaire based on the ASE model, while the motivational phase question was based on the stage definitions from the Transtheoretical model.

RESULTS

Precontemplating smokers perceived fewer advantages of quitting than contemplators. Precontemplators encountered less support for quitting than contemplators. Contemplators reported lower self-efficacy expectations than those in preparation, while this group had lower self-efficacy expectations than respondents in action. Ex-smokers in maintenance reported fewer disadvantages of quitting than those in action.

CONCLUSIONS

Since changes in cognitive determinants are thought to mediate transitions in motivational phases, the results can be used to tailor health education messages to the needs of smokers in the various motivational phases. The results suggest that smokers in precontemplation would benefit most from information about the pros of quitting and from obtaining support for quitting. Smokers in contemplation and preparation may benefit most from self-efficacy-enhancing information.

Psycho-social determinants and motivational phases in smoking behavior of cardiac inpatients

BACKGROUND

To explore possibilities for health education, this study analyzed the differences in motives regarding smoking cessation of cardiac inpatients in various motivational phases. The Attitude-Social influence-Efficacy Model (ASE model) was used to assess motives, while motivational phases were measured with concepts from the Transtheoretical Model.

METHODS

Data on smoking behavior, attitudes, social influences, self-efficacy expectations, and motivational phases were collected from a sample of 532 cardiac inpatients. A revised typology of the Transtheoretical Model was used for measuring motivational phases and resulted in four groups: smokers in precontemplation, smokers in contemplation, externally motivated actors, and internally motivated actors. Analysis of variance with Tukey's multiple comparison test was used to study differences in psycho-social determinants between these four groups.

RESULTS

As hypothesized, externally motivated actors differed from internally motivated actors in having less positive attitudes, less social support, and lower self-efficacy expectations. Attitudes and social support were most positive among smokers in contemplation and internally motivated actors. Self-efficacy expectations were lowest among subjects in precontemplation and contemplation.

CONCLUSIONS

Subjects in different motivational phases differed in their psycho-social determinants. Therefore, it is recommended that stage-tailored education be developed. Finally, externally motivated actors have to be approached in a different way than internally motivated actors.

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.

Subtypes within a sample of precontemplating smokers: a preliminary extension of the stages of change

Precontemplating smokers are not planning to quit within the next 6 months. There are indications that this group is not homogeneous. The present investigation aimed at identifying relevant subgroups within this large group of smokers in order to refine stage-matched interventions. Precontemplators were asked whether they were planning to quit (1) within the next year. (2) within the next 5 years, (3) not within the next 5 years but sometime, (4) never, or (5) none of the above. Smokers who were planning to quit within 5 years (redefined precontemplators) differed from smokers who were not planning to quit within the next 5 years (immotives) on the pros of quitting but not on self-efficacy scores. Compared to smokers in the other groups, immotives scored significantly lower on specific factors within the pros of quitting.

Feasibility of smoking cessation counseling by phone with alcohol treatment center graduates

Several studies have tested the effectiveness of telephone counseling as a smoking cessation intervention, but few have addressed its application with the special population of smokers who are also problem drinkers or recovering alcoholics. Two hundred and eighty-eight male and female subjects were recruited from six residential alcohol treatment programs in Nebraska, Iowa, and Kansas to receive three postreatment telephone calls based on the stages of change model. Most subjects (71%) participated in at least one telephone counseling session, but only 38% participated in all three. Those who completed of session were significantly (p < .01) more likely to have advanced one stage of change in their readiness to quit smoking and to report having quit smoking for at least 24 hours since leaving treatment (p < .01). Stage-based telephone counseling appears to be a feasible approach to addressing smoking cessation among recovering alcoholics, with a modest positive effect on subsequent tobacco use.

Construct validity and predictive utility of the stages of change scale for alcoholics

Recent theory and research suggest that the process of changing addictive behaviors may be conceptualized as a stage phenomenon consisting of precontemplation, contemplation, preparation, action, and maintenance stages. Accurately assessing motivation or commitment to change seems to be a crucial step in matching patients to appropriate interventions. Using the University of Rhode Island Change Assessment Scale (URICA; McConnaughy, Prochaska, & Velicer, 1983), previous research has identified subtypes of outpatient alcoholics based on their attitude toward each of the stages of change. Profiles derived for each subtype roughly corresponded to one of the specific stages of change. The goals of this study were to determine if similar groups could be identified for patients receiving substance abuse treatment in a residential setting and to examine whether these groups would differ on other theoretically relevant variables. Stage of change scale scores for 141 patients entering an alcohol treatment program at a VA domiciliary were submitted to a hierarchical cluster analysis. A two-cluster solution appeared to fit the data best, with group means suggesting the existence of precontemplation and contemplation/action stage groups in this population. The two clusters did not differ on demographic variables, biochemical markers of alcohol consumption, or self-reported awareness of alcohol-related problems. However, participants in the precontemplation cluster reported being less worried about their use, less receptive to help, and having sought out help fewer times in the past. Participants in the contemplation/action cluster also reported greater symptoms of depression and anxiety. Preliminary treatment outcome data for each group are presented, as well as suggestions for treatment matching. Results suggest that the URICA can be used to identify clinically meaningful subtypes of treatment-seeking alcoholics.

Nicotine dependence and intentions to quit smoking in three samples of male and female recovering alcoholics and problem drinkers

We report gender-specific data on tobacco use and quitting smoking from three studies of nicotine-related issues during alcoholism treatment. Study 1 data are from 309 alcoholism treatment professionals who were current or former smokers with a personal history of alcoholism or problem drinking. Study 2 data are from 496 smokers receiving counseling for their problems with alcohol in outpatient alcoholism treatment centers. Study 3 data are from 90 smokers receiving intensive alcoholism treatment in residential or inpatient programs. Interest in smoking cessation was high in all groups. Significant gender differences were apparent among the recovering alcoholics but not among the problem drinkers. Severity of alcohol use problems also showed some association with smoking cessation behaviors.

Predictors of tobacco quit attempts among recovering alcoholics

Reported here are findings from a randomized community intervention trial that followed 90 recovering alcoholic smokers for 6 months. Because the brief (10-min) study intervention had no effect on tobacco use, intervention and control participants were pooled to identify predictors of attempts to quit smoking that may inform clinical practice. During the first 6 months after discharge from residential alcohol treatment, 31% of all participants reported having quit smoking for 48 hrs or longer. Demographic and drug use history variables did not predict quit attempts, but two baseline tobacco use variables did, specifically the Fagerstrom Test for Nicotine Dependence and stage of readiness to quit smoking, p < .01. Participants with high or very high nicotine dependence scores were significantly less likely than those with moderate or low scores to attempt smoking cessation. Compared to those in precontemplation at baseline, those in the preparation stage of readiness to change were about 12 times more likely to make a serious quit attempt.

Effect of cigarette smoking on alcohol treatment outcome

Although smoking cigarettes and drinking alcohol are highly correlated, little research has examined the effects of smoking on alcohol abusers' posttreatment functioning. Alcohol abusers (N = 155) were classified on the basis of their pretreatment smoking status as: nonsmoker, ex-smoker, low dependent smoker (first cigarette of the day > 10 minutes after waking), and high dependent smoker (first cigarette of the day < or = 10 minutes after waking). All subjects had received brief cognitive-behavioral outpatient treatment for their alcohol problem. Subjects who were less dependent on nicotine had fewer drinking days and fewer heavy drinking days prior to entering treatment than those who were more dependent on nicotine; the two nonsmoking groups had fewer abstinent days than the low nicotine-dependent subjects and fewer heavy drinking days than the high nicotine-dependent subjects. At the 1-year follow-up, the two smoking groups did not differ from each other on the alcohol variables but reported significantly more abstinent days than the two nonsmoking groups. Treatment implications are discussed.

A processes of change model for weight control for participants in community-based weight loss programs

The processes of change model has been successful in predicting behavior change across a wide range of both addictive and nonaddictive problem behaviors. This study was designed to examine the application of the processes of change model to weight control. Study participants included 285 women and men enrolled in three community-based weight loss programs. Results based on structural equation analyses showed that the processes of change model fit the data better than several plausible alternative models. In addition, structural analyses revealed the existence of two general (higher order) processes of change for weight control, the experiential and behavioral processes. These results are similar to those previously reported for eight other problem behaviors. Limitations of the current work and future directions for this line of research are discussed.

"Stage of change" by drug problem in concurrent opioid, cocaine, and cigarette users

Within the field of addiction, the majority of work regarding "stages and processes of change" has focused on single drug problems, such as cigarette smoking or alcohol use. However, the majority of the substance abuse treatment population present with more than one substance use disorder. This article reports the results of the internal consistency and test-retest reliability of the University of Rhode Island Change Assessment (URICA) in a sample of 41 methadone-maintained, opioid-dependent male veterans who had concurrent problems of cigarette and cocaine dependence. These volunteers were given a URICA for each of their three drug problems, followed by a repeated administration three to five days later. All the stage-of-change scale scores showed excellent internal consistency and stability across the three- to five-day interval for all three drug problems, thus confirming the reliability of the measure in this population. URICA scores were lowest on the precontemplation stage, with higher and approximately equivalent scores on the other three stage measures. Most surprising was that these profile scores were almost identical across the three drugs tested, suggesting limits to the validity of this measure with this population.