Stages of change analysis of smokers attending clinics for the medically underserved

,

Original Research

Stages of change analysis of smokers attending clinics for the medically underserved

J Fam Pract. 2002 December;51(12):1-1

By

Karen M. Gil, PhD

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References

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13. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12:38-48.

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Address reprint requests to: Karen M. Gil, PhD, F-236, PO Box 95, Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272-0095. E-mail: kmg1@neoucom.edu.

To submit a letter to the editor on this topic, click here: jfp@fammed.uc.edu.

ABSTRACT

OBJECTIVE: To determine whether smokers at clinics providing care for the medically underserved can be characterized according to the transtheoretical stages of change model.
STUDY DESIGN: Prospective, descriptive study.
POPULATION: Smokers in the waiting rooms of clinics providing care for the medically underserved.
OUTCOMES MEASURED: Standardized questionnaires that assessed stages of change, processes of change, decisional balance, and self-efficacy and temptation.
RESULTS: The smoking rate of subjects interviewed at 4 clinics was 44%. Two hundred current smokers completed the questionnaires. Smokers claiming that they planned to quit within 6 months scored higher on experiential process statements that are consistent with quitting smoking than did smokers who claimed they were not planning to quit within 6 months. They also scored higher on behavioral statements related to quitting. Concerns about the negative aspects of smoking were more important to smokers planning to quit than to smokers not planning to quit, whereas the statements assessing positive aspects of smoking were rated the same. Fifty-five percent of the smokers were smoking a pack or more each day and reported smoking more during negative situations and from habit than did smokers who smoked less than a pack a day.
CONCLUSIONS: Smokers planning to quit who still smoke at least a pack a day may benefit from counseling to decrease smoking for specific reasons or from pharmacologic aids. Smokers at the clinics who planned to quit smoking reported experiences and behaviors that were consistent with their stated desire to quit and should be counseled in the same fashion as smokers from more traditional practices.

KEY POINTS FOR CLINICIANS

Smokers planning to quit smoking within 6 months scored higher on statements that are consistent with quitting smoking than did smokers who claimed they were not planning to quit within 6 months. Concerns about the negative aspects of smoking were more important to smokers planning to quit than to smokers not planning to quit, whereas statements assessing positive aspects of smoking were rated the same.
Smokers attending clinics for the underserved should be counseled to quit smoking in the same manner as smokers from the general population.

Cigarette smoking is a modifiable behavior and the chief preventable cause of illness and death in the United States.^1,2 The rate of smoking dropped from 40% to 25% between the mid-1960s and 1997, but this decrease was not uniform across all segments of the population.^3,4 In 1997, college graduates had a smoking rate of about 12%, whereas high school graduates had a smoking rate of 28%, and those with less than a high school education had a smoking rate of 35%.⁴ If these differences continue, a significant social divide will develop in this country with smoking, and the diseases resulting from smoking, found predominantly among the more poorly educated and socioeconomically disadvantaged members of society.⁵

Epidemiologic data indicate that approximately 70% of smokers want to quit and about 40% try to quit each year.^6-8 Federal guidelines stress the importance of providing counseling to every smoker at every office visit.^8,9 A growing area of research concerns the kind of information that should be provided to these patients, and whether information should be tailored to individual or group characteristics.^10,11 An area that could be targeted is willingness to modify behavior according to the stages of change construct from the transtheoretical model.^12,13 According to this model, smokers in the precontemplation stage do not intend to quit smoking within 6 months, contemplators are thinking about quitting within the next 6 months, and smokers in the preparation stage intend to quit within 30 days and have made a quit attempt at some time in the past. This model also proposes processes, derived from a comparative analysis of leading theories of psychotherapy and behavior change, that people use when they think about smoking.^13,14 These constructs (processes of change, assessment of the pros and cons of smoking, and efficacy and temptation) are characteristically associated with smokers at different stages of change. For example, a crossover in assessment of the pros and cons of smoking across the stages of change is observed in cross-sectional studies so that the pros of smoking outweigh the cons for smokers in the precontemplation stage, but the cons outweigh the pros for smokers in the preparation stage.¹²

Proponents of this model argue that information should be tailored to match an individual’s stage of change and that the processes of change characteristic of the different stages should be used to move people to a more forward stage and, ultimately, to behavioral change.^13,14 The model proposes that people may make progress to a more forward stage of change but also may relapse (eg, quit smoking and then start again), and that information should be provided to the patient’s current stage. These proponents argue that using this model, rather than applying an action approach to all smokers, regardless of their willingness to consider changing their behavior, leads to increased behavioral change.^13,14 In response to this model, concern has been raised about the theoretical validity of the model,¹⁵ whether stage of change is the best predictor of future behavioral change,^16,17 and whether the identified processes can be used to predict forward stage progression.¹⁸ From a practical point of view, the model is clinically appealing, and suggestions for incorporating the model into counseling approaches are beginning to appear in the literature.¹⁹ Research continues to focus on the issue of whether information that is matched to individual or group characteristics, including stages of change, is more effective than information that is not, and, although preliminary, the research to date supports the idea that tailored information is more effective.^10,20