David B. Abrams

The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation.

Presents evidence for the validity of the Contemplation Ladder, a measure of readiness to consider smoking cessation. Analyses of data collected from more than 400 smokers at two worksites before and during a 10-month intervention indicate that Ladder scores were significantly associated with reported intention to quit, number of previous quit attempts, perceived co-worker encouragement to quit, and socioeconomic status. Ladder scores predicted subsequent participation in programs designed to educate workers about their smoking habit and its contingent risks. The Ladder did not predict biochemically validated abstinence of 24 hr or more. To assess its ability to distinguish between groups known a priori to differ in readiness, we administered the Ladder to 36 participants in a clinic-based smoking cessation program. As predicted, clinic patients scored significantly higher than the workers on the Ladder. The importance of distinguishing between smokers at the lowest stages of readiness to quit is discussed.

The stages and processes of exercise adoption and maintenance in a worksite sample.

We applied the model of the stages and processes of change to exercise adoption and maintenance. This model has shown promise in advancing theory and treatment of the addictions and other negative health behaviors, but there have been few systematic attempts to apply the model to positive health behaviors, such as exercise adoption. Questionnaires dealing with the stages and processes of exercise change were developed and administered to a sample of 1,172 participants in a worksite health promotion project. The sample was split randomly into halves for (a) initial model development and testing and (b) confirmatory measurement model testing. Additional model confirmation was obtained by examining the hierarchical structure of the processes of change and by conducting Stage x Process analyses. Results suggest that the underlying constructs derived from smoking cessation and other addictive behaviors can be generalized to exercise behavior. Understanding the stages and processes of exercise behavior change may yield important information for enhancing exercise adoption, adherence, and relapse prevention at both individual and public health levels.

Self-Efficacy in Weight Management.

Self-efficacy is an important mediating mechanism in advancing understanding of the treatment of obesity. This study developed and validated the Weight Efficacy Life-Style Questionnaire (WEL), improving on previous studies by the use of clinical populations, cross-validation of the initial factor analysis, exploration of the best fitting theoretical model of self-efficacy, and examination of change in treatment. The resulting 20-item WEL consists of five situational factors: Negative Emotions, Availability, Social Pressure, Physical Discomfort, and Positive Activities. A hierarchical model was found to provide the best fit to the data. Results from two separate clinical treatment studies (total N = 382) show that the WEL is sensitive to changes in global scores as well as to a subset of the five situational factor scores. Treatment programs may be incomplete if they change only a subset of the situational dimensions of self-efficacy. Theoretical and clinical implications are discussed.

Using the Stages of Change Model to Increase the Adoption of Physical Activity among Community Participants

Purpose. This study examined the use of the stages of change model to design an exercise intervention for community volunteers. Design. The “Imagine Action” campaign was a community-wide event incorporating the involvement of local worksites and community agencies. Community members registering for the campaign were enrolled in a six-week intervention program designed to encourage participation in physical activity. Subjects. Six hundred and ten adults aged 18 to 82 years old enrolled in the program. Seventy-seven percent of the participants were female and the average age was 41.8 years (SD = 13.8). Setting. The campaign was conducted in a city with a population of approximately 72,000 and was promoted throughout community worksites, area schools, organizations, and local media channels. Measures. One question designed to assess current stage of exercise adoption was included on the campaign registration form as were questions about subject name, address, telephone number, birthdate, and gender. Intervention. The intervention included written materials designed to encourage participants to initiate or increase physical activity, a resource manual describing activity options in the community, and weekly “fun walks” and “activity nights.” Results. A Stuart-Maxwell test for correlated proportions revealed that subjects were significantly more active after the six-week intervention. Sixty-two percent of participants in Contemplation became more active while 61 % in Preparation became more active. Conclusions. Most participants increased their stage of exercise adoption during the six-week intervention. This study provides preliminary support for use of the stages of change model in designing exercise interventions.

e-Cigarette Awareness, Use, and Harm Perceptions in US Adults

OBJECTIVES We estimated e-cigarette (electronic nicotine delivery system) awareness, use, and harm perceptions among US adults. METHODS We drew data from 2 surveys conducted in 2010: a national online study (n = 2649) and the Legacy Longitudinal Smoker Cohort (n = 3658). We used multivariable models to examine e-cigarette awareness, use, and harm perceptions. RESULTS In the online survey, 40.2% (95% confidence interval [CI] = 37.3, 43.1) had heard of e-cigarettes, with awareness highest among current smokers. Utilization was higher among current smokers (11.4%; 95% CI = 9.3, 14.0) than in the total population (3.4%; 95% CI = 2.6, 4.2), with 2.0% (95% CI = 1.0, 3.8) of former smokers and 0.8% (95% CI = 0.35, 1.7) of never-smokers ever using e-cigarettes. In both surveys, non-Hispanic Whites, current smokers, young adults, and those with at least a high-school diploma were most likely to perceive e-cigarettes as less harmful than regular cigarettes. CONCLUSIONS Awareness of e-cigarettes is high, and use among current and former smokers is evident. We recommend product regulation and careful surveillance to monitor public health impact and emerging utilization patterns, and to ascertain why, how, and under what conditions e-cigarettes are being used.

Attendance and outcome in a work site weight control program: Processes and stages of change as process and predictor variables☆

This naturalistic study assessed client changes during treatment and identified salient predictors of therapy attendance and outcome. Subjects were assessed on processes and stages of change, self-efficacy, social support, weight history (including expectations, goals, and reasons for losing weight), and demographics at the beginning, middle, and end of a 10-week, behaviorally oriented work site program for weight control. Significant shifts from contemplation to action occurred for clients remaining in treatment. There were also significant modifications in the use of change processes as a result of treatment: counterconditioning, contingency management, stimulus control, interpersonal control, and social liberation increased while medication use, wishful thinking, and minimizing threats decreased. Change processes employed during the early portion of the group treatment were the best predictors of treatment attendance and outcome, superior to self-efficacy, social support, weight history, and demographic variables. The results supported a transtheoretical model that emphasizes dynamic processes and stages as core dimensions for understanding how people change.

Evaluation of motivationally tailored vs. Standard self-help physical activity interventions at the workplace

Purpose. This study compares the efficacy of a self-help intervention tailored to the individuals stage of motivational readiness for exercise adoption with a standard self-help exercise promotion intervention. Design. Interventions were delivered at baseline and 1 month; assessments were collected at baseline and 3 months. Setting. Eleven worksites participating in the Working Healthy Research Trial. Subjects. Participants (n = 1559) were a subsample of employees at participating worksites, individually randomized to one of two treatment conditions. Intervention. Printed self-help exercise promotion materials either (1) matched to the individuals stage of motivational readiness for exercise adoption (motivationally tailored), or (2) standard materials (standard). Measures. Measures of stage of motivational readiness for exercise and items from the 7-Day Physical Activity Recall. Results. Among intervention completers (n = 903), chi-square analyses showed that, compared to the standard intervention, those receiving the motivationally tailored intervention were significantly more likely to show increases (37% vs. 27%) and less likely to show either no change (52% vs. 58%) or regression (11% vs. 15%) in stage of motivational readiness. Multivariate analyses of variance showed that changes in stage of motivational readiness were significantly associated with changes in self-reported time spent in exercise. Conclusions. This is the first prospective, randomized, controlled trial demonstrating the efficacy of a brief motivationally tailored intervention compared to a standard self-help intervention for exercise adoption. These findings appear to support treatment approaches that tailor interventions to the individuals stage of motivational readiness for exercise adoption.

Socioeconomic status over the life course and stages of cigarette use: initiation, regular use, and cessation

Study objective: To investigate the association between multiple indicators of socioeconomic status (SES) over the life course and three stages of cigarette use: initiation, regular use, and cessation. Design: Prospective birth cohort study. Setting: Providence, Rhode Island. Participants: Subjects (n=657) aged 30 to 39 were offspring of participants in the Brown University cohort of the United States National Collaborative Perinatal Project started in 1959. Main results: A significantly increased risk of smoking initiation was observed among people from lower socioeconomic backgrounds. Low SES in childhood also increased the risk for progression to regular smoking, and was associated with a reduced likelihood of smoking cessation. Progression to regular smoking and smoking persistence were also associated with lower adult SES. Conclusions: Socioeconomic conditions over the life course accumulate to produce increased rates of smoking uptake and reduced rates of cessation among lower SES people. Addressing SES gradients in smoking will require persistent and extended intervention over multiple life stages.

Integrating individual and public health perspectives for treatment of tobacco dependence under managed health care: a combined stepped-care and matching model.

There is an increasing momentum to integrate prevention into mainstream health care. Three decades of research on tobacco dependence can provide insights into the conceptual, clinical, economic, and service delivery challenges to such an integration. Biological sciences, cognitive-behavioral, clinical treatment outcome, and public health arenas are selectively reviewed. The key conceptual issues are explored relevant to the optimal delivery of quality smoking cessation treatments for the general population of adult smokers at reasonable cost. A comprehensive model for adult smoking cessation treatment is developed. The model consists of an overarching public health approach, focusing on enhancing motivational level from low motivation to quit to high motivation. A common outcome metric of overall impact is proposed to facilitate comparisons between clinical and public health interventions. Smokers are then assessed and triaged into one of three treatment steps of minimal, moderate, and maximal intensity and cost. Smoker individual differences at both the population and individual level are also taken into account as part of a tailoring or matching strategy within and across the stepped interventions. Smoker profiles include sociocultural, nicotine dependence, and comorbidity factors. The result is a hybrid stepped-care matching model. The model serves to illustrate some of the needs and challenges facing future tobacco dependence research and practice. Comparisons are made between tobacco control and other preventive medicine practices in terms of cost per quality adjusted life-year saved. The barriers and opportunities under managed care are explored. The conceptual principles identified here could be used as a guidepost for integrating other preventive medicine programs into the evolving managed health care system.

Cue reactivity in addictive behaviors: Theoretical and treatment implications

Several learning theory based models propose that substance users may have conditioned reactions to stimuli (cues) associated with substance use and that these reactions may increase the probability of relapse. The conditioned withdrawal, conditioned compensatory response, and appetitive motivational models were evaluated in light of empirical evidence from cue reactivity studies with alcoholics, smokers, opiate users, and cocaine users. The nature of the stimuli that elicit reactivity and the nature of the responses elicited are most consistent with an appetitive motivational model and do not appear to support the other two models. A few studies have been conducted or are underway that investigate the use of cue exposure with response prevention as a treatment to decrease cue reactivity. Preliminary work with alcoholics, opiate users and cocaine users is promising but insufficient evidence exists to evaluate this approach. The implications for theory and treatment are discussed.