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The Stages of Change in Tobacco Intervention and Cessation

Intervening With Teen Tobacco Users (TEG) and Helping Teens Stop Using Tobacco (TAP) are firmly grounded on research. One of the empirical pillars is the Transtheoretical Model of Change (TMC), the model that includes the "Stages of Change." The TMC defines five stages of change related to tobacco cessation. The following is a brief description of each phase along with its operational, research-oriented definition:

Precontemplation. The person has not yet identified the behavior as a problem, e.g., "Smoking is fun and it's not doing me any harm." (Operational definition: no intention to quit in the next six months.) Note: Many precontemplators may wish to change, but this is very different from intending to change or seriously considering changing within the next six months.

Contemplation. The person is aware that a problem exists, is thinking about addressing it, but has not made a commitment to take action. The person is ambivalent, e.g., "My tobacco use is bothering me, and I really ought to quit. But not YET." (Operational definition: seriously considering quitting smoking within the next six months). People can remain in the contemplation stage for a long time.
Preparation. This is the point at which the person decides to change or quit the behavior. Typical of statements at this point is, "Smoking is not cool any more. I'm thinking about quitting. What do I do now?" (Operational definition: person is intending to quit within the next 30 days and has made a failed attempt within the previous six months.) Preparation means not only intention but also some behavioral manifestations of that intention. Behaviors such as smoking fewer cigarettes, delaying first use, and restricting use in certain situations all indicate a positive attempt toward quitting tobacco.
Action. The person starts to take specific steps to quit tobacco use. "I have recently quit tobacco and have to work very hard at staying tobacco free." (Operational definition: person has quit smoking within the last six months.) People remain in the "action" rather than "maintenance" stage until they have been tobacco-free for six months or more.
Maintenance. A person is in this stage if he or she has not used for an extended period of time. This stage involves on-going efforts to keep off cigarettes or chew: "I've quit tobacco use and continue to take steps to keep myself relaxed, healthy, and away from situations that lead to tobacco use." (Operational definition: person has not used tobacco for six months or more.)

Different Programs for Different Stages of Change

One of the most important findings of the research on stages of change is that programs designed for people who are in the preparation or action stage are seldom effective for those in the "pre-contemplation" and "contemplation" stage. According to one author (Pallonen, 1998): "The fact that half of the smokers who are in the pre-contemplation stage have no initial interest in quitting and will make only minimal progress over time clearly illustrates an urgent need to design and implement specific cessation programs for precontemplators. These programs should emphasize stage progression rather than immediate cessation as their immediate goal. Stage changes over time serve as an alternative outcome indicator to quit rates."

This research points to the role of Community Intervention’s Intervening with Teen Tobacco Users (TEG) in the tobacco cessation process. Although evaluation shows that young people can quit as a result of TEG (e.g.,Wallace, 1995), the main goal is to move precontemplators and contemplators into the preparation stage. Moving participants from one stage of change to another is more than a theoretical exercise. Researchers have demonstrated that clients who progress from one stage to the next during the first month of treatment double their chances of taking action. (i.e., quitting) within six months.

Participants in TEG, tend to be in the "pre-contemplation" stage. A very few, perhaps, will be in the "contemplation" stage. In Intervening with Teen Tobacco Users (TEG), all of the exercises, demonstrations, self-assessments, and discussions focus on raising participants’ awareness of the problem and increasing their desire to take action. The program is designed to grab participants’ attention; make the tobacco issue very personal to each of them; help them feel and comprehend the destruction that tobacco use brings on themselves and those around them; and to offer them a clear, immediate choice to begin a cessation program.

For TEG to be effective, a tobacco cessation program -- Helping Teens to Stop Using Tobacco (TAP) -- should be in place and readily available to participants. Its exercises dovetail with those of TEG but do not overlap or repeat the same material.

Community Intervention's voluntary tobacco cessation program, Helping Teens Stop Using Tobacco (TAP) has more participants in the "preparation" stage. The goal of that program is to move participants from "preparation" to "action" and into "maintenance."

Facilitators who are familiar with the stages of change can use them to gauge the progress participants make as TEG and TAP unfolds. There are several reminders in the Facilitator's Guide to ask participants which stage they believe they are in at the time.

Change: A Cyclical Process

The stages of change model takes into account the likelihood that people often fail at efforts to change. Studies on the stages of change indicate that 85 percent of smokers who relapse do not slip all the way back to the pre-contemplation stage. Rather, they return to the contemplation stage, in which they are seriously considering another attempt to stay drug-free, or to the preparation stage, in which they make actual steps to reduce or quit their use of tobacco. Each time smokers relapse, they recycle through earlier stages but tend to learn from their mistakes and try something different the next time. People who change on their own average three to four attempts before they reach the maintenance stage.