Carlo C. DiClemente

The Process of Smoking Cessation: An Analysis of Precontemplation, Contemplation, and Preparation Stages of Change.

Traditionally smoking cessation studies use smoker and nonsmoker categories almost exclusively to represent individuals quitting smoking. This study tested the transtheoretical model of change that posits a series of stages through which smokers move as they successfully change the smoking habit. Subjects in precontemplation (n = 166), contemplation (n = 794), and preparation (n = 506) stages of change were compared on smoking history, 10 processes of change, pretest self-efficacy, and decisional balance, as well as 1-month and 6-month cessation activity. Results strongly support the stages of change model. All groups were similar on smoking history but differed dramatically on current cessation activity. Stage differences predicted attempts to quit smoking and cessation success at 1- and 6-month follow-up. Implications for recruitment, intervention, and research are discussed.

Toward a Comprehensive Model of Change

In 1984, a group of researchers, theorists, and therapists gathered at an international conference in Scotland to contribute to the development of a more comprehensive model of change for the treatment of addictive behaviors. The conference and this book that grew out of the conference are signs of the Zeitgeist; they are part of a new attempt to integrate diverse systems of psychotherapy (Prochaska, 1984). In his classic call for a rapproachment across competing systems of therapy, Goldfried (1980) signaled that it is time to move beyond parochial approaches to treatment. It is time to move toward more comprehensive models of change.

Decisional balance measure for assessing and predicting smoking status.

The Decisional Balance Sheet of Incentives has been proposed by Janis and Mann (1977) as a general schema for representing both the cognitive and motivational aspects of human decision making. In this study, a brief 24-item paper and pencil measure was constructed to study the decision-making process in smoking cessation. Two scales were identified and labeled the Pros of Smoking and the Cons of Smoking. These scales were successful in differentiating between five groups representing stages of change in the quitting process. The two scales were also successful when employed as predictors of smoking status at a 6-month follow-up. The Decisional Balance Scale appears to be a powerful construct of potentially wide application in behavior change.

Standardized, individualized, interactive, and personalized self-help programs for smoking cessation.

Smokers (N = 756) were randomly assigned by stage of change to (a) standardized self-help manuals (ALA+ condition), (b) individualized manuals matched to stage (TTT condition), (c) interactive expert-system computer reports plus individualized manuals (ITT condition), or (d) a personalized condition with 4 counselor calls, stage manuals, and computer reports (PITT condition). Over 18 months, the ITT groups results more than doubled those of the ALA+ group on abstinence measures. The ALA+ and TTT conditions were equivalent over 12 months, but at 18 months the TTT condition was more effective. The ITT condition was the best or comparable with the best treatment at all follow-ups for smokers at all stages of change. Results suggest that an effective expert system has been developed, and discussion focuses on delivering this system to entire populations of smokers.

Relapse situations and self-efficacy: An integrative model☆☆☆

Researchers studying relapse for an addictive behavior have employed two different conceptual models. Researchers concerned with typologies of relapse situations have developed a variety of discrete classes of high risk situations. Researchers who have employed a Self-efficacy approach have typically assessed different situations but scored the measure as a single general construct. Using structural modeling, this paper evaluates five alternative measurement models, representing alternative conceptualizations. A hierarchical model which integrates the previously competing models provided the best fit to the data and serves to explain a large body of previous findings. The model includes three first order constructs (Positive/Social; Negative/Affective; and Habit/Addictive) and one general second-order factor. The results were replicated across two different response formats and two different subject samples.

Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance☆

Cigarette smokers who quit on their own (n = 29) were compared with subjects from two commercial therapy programs: Aversion Group (n = 18) and Behavior Management Group (n = 16). Subjects were administered a Change-Process Questionnaire and a demographic and smoking-history questionnaire within seven weeks of successful cessation, then interviewed again in five months. Using a transtheoretical model of change developed by Prochaska (1979) six verbal and four behavioral processes of change and three stages of change (Decision to Change; Active Change; Maintenance) were analyzed. Subjects in each treatment group were middle class, heavy-smoking adults. The change-process analysis of cessation discriminated between the self-quitters and therapy quitters and between the two groups of therapy subjects on five variables. Stages of change interacted with the processes of change in the cessation of smoking behavior. Verbal processes were seen as important in making the decision to change while action processes were critical for breaking the actual smoking habit. Maintenance of cessation was related to, but not dependent on, how subjects actively changed smoking behavior.

Oral topiramate for treatment of alcohol dependence: a randomised controlled trial

BACKGROUND Topiramate, a sulphamate fructopyranose derivative, might antagonise alcohols rewarding effects associated with abuse liability by inhibiting mesocorticolimbic dopamine release via the contemporaneous facilitation of gamma-amino-butyric acid activity and inhibition of glutamate function. We aimed to see whether topiramate was more effective than placebo as a treatment for alcohol dependence. METHODS We did a double-blind randomised controlled 12-week clinical trial comparing oral topiramate and placebo for treatment of 150 individuals with alcohol dependence. Of these 150 individuals, 75 were assigned to receive topiramate (escalating dose of 25-300 mg per day) and 75 had placebo as an adjunct to weekly standardised medication compliance management. Primary efficacy variables were: self-reported drinking (drinks per day, drinks per drinking day, percentage of heavy drinking days, percentage of days abstinent) and plasma gamma-glutamyl transferase, an objective index of alcohol consumption. The secondary efficacy variable was self-reported craving. FINDINGS At study end, participants on topiramate, compared with those on placebo, had 2.88 (95% CI -4.50 to -1.27) fewer drinks per day (p=0.0006), 3.10 (-4.88 to -1.31) fewer drinks per drinking day (p=0.0009), 27.6% fewer heavy drinking days (p=0.0003), 26.2% more days abstinent (p=0.0003), and a log plasma gamma-glutamyl transferase ratio of 0.07 (-0.11 to -0.02) less (p=0.0046). Topiramate-induced differences in craving were also significantly greater than those of placebo, of similar magnitude to the self-reported drinking changes, and highly correlated with them. INTERPRETATION Topiramate (up to 300 mg per day) is more efficacious than placebo as an adjunct to standardised medication compliance management in treatment of alcohol dependence.

Self-efficacy and the stages of self-change of smoking

Efficacy expectations are postulated to mediate all behavior change. This study examined the construct of self-efficacy in the self-change of smoking behavior. A 31-item measure of self-efficacy was used that included ratings of both temptation (cue strength) and confidence (efficacy). The subjects were 957 volunteers representing five stages of self change: (1) immotives, (2) contemplators, (3) recent quitters, (4) long-term quitters, and (5) relapsers. Subjects were assessed initially and at a 3- to 5-month follow-up. The self-efficacy scale proved to be an extremely reliable and coherent instrument with identifiable but not clearly interpretable subcomponents. Groups of subjects demonstrated significant differences in total self-efficacy scores. Efficacy expectations demonstrated small but significant relationships with smoking history variables and the pros and cons of smoking, but not with demographic, life stress, or persistence measures. Subjects efficacy evaluations at the initial assessment were related to changes in status for recent quitters and contemplators at the follow-up. The relationship between temptation and efficacy ratings is complex and varies for subjects in the various stages of change. Correlations between total self-efficacy and temptation scores were largest for contemplators (r = −.65) and relapsers (r = −.67) and smallest for the recent quitters (r = −.18). Finally, the magnitude of the difference between temptation and efficacy increased with length of abstinence for subjects in maintenance.

Predicting change in smoking status for self-changers

Fourteen different measures were investigated as predictors of change in smoking status for self-change efforts at smoking cessation. Adult subjects (N = 866) were classified into five stages of change: precontemplation, contemplation, action, maintenance, and relapse. Subjects were assessed on 10 change processes, self-efficacy, temptations to smoke, and their decisions weighing the advantages and disadvantages of smoking; and these 14 variables were used as predictors of change in smoking status 6 months later. Six significant functions were found which predicted movement for each of the stages. These predictors are of both theoretical interest and practical significance because they may be modified in self-change efforts to overcome addictive behaviors. Overall, the change processes of self-reevaluation and the helping relationship and the self-efficacy and decisional balance variables were the most efficacious predictor variables. A general pattern emerged in which processes oriented more toward environmental events, such as dramatic relief and social liberation, tended to predict failure or no progress whereas more experientially oriented processes predicted progress.

Readiness and Stages of Change in Addiction Treatment

Understanding the role of personal motivation in addiction treatment changed with the advent of the Transtheoretical Model of intentional behavior change, a better understanding of relapse, and a shift in focus from denial to readiness. Motivation is a complex concept that covers many diverse aspects of the process of intentional behavior change. This review examines current perspectives on readiness and the stages of change, criticisms and measurement issues, and clinical applications and future research in this area. Although significant challenges remain, properly incorporating the concepts of readiness and the stages of change into addiction treatment enables providers to address the diverse needs of substance abusers and treatment seekers, supports more proactive interventions, creates a concentration on motivational enhancement, and helps researchers understand the larger process of change where addict and treatment provider meet. Better measurement, more frequent assessments, and a better understanding of the stage subtasks and how they relate to readiness and successful change are needed to deepen our understanding of motivation and its role in the treatment of addiction.