Health Education Research, Vol. 15, No. 4, 423-434,
August 2000
© 2000 Oxford University Press
Subtypes of precontemplating smokers defined by different long-term plans to change their smoking behavior
Department of Clinical and Health Psychology, Leiden University, PO Box 9555, 2300 RB Leiden and
1 Department of Health Education, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
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Abstract |
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Many smokers are not motivated to quit smoking. In the Stages of Change model these smokers are called precontemplators. When developing interventions designed to motivate these smokers to quit, it is of importance to know whether this group is homogeneous or not. In the present study, different groups of precontemplators were distinguished according to their long-term quitting smoking plan: 861 precontemplators were asked to indicate the one plan that best fitted their own plans with regard to their smoking behavior: (1) planning to never quit and not planning to cut down (n = 194), (2) planning to never quit but planning to cut down (n = 186), (3) planning to quit somewhere in the future but not within the next 5 years (n = 290), (4) planning to quit within the next 5 years (n = 136) and (5) planning to quit within the next year but not within the next 6 months (n = 54). These groups of smokers were compared on several variables cross-sectionally and longitudinally. The results indicate that the psychological factors that will have to be targeted in smoking cessation interventions in efforts to motivate smokers to quit could be assessed reliably in precontemplators. Furthermore, precontemplators with different quitting plans differed on several cognitive variables and the quitting plans at pre-test were predictive of quitting activity after 7 months. Precontemplators who received self-help smoking cessation materials made forward changes in quitting plans and these changes seemed to follow a certain order. Forward changes in plans were differentially related to positive outcome expectations, to self-efficacy expectations depending on the quitting plan and not to changes in negative outcomes. The present study is one step in mapping the psychology of low motivation to change behavior.
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Introduction |
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Although smoking tobacco is widely known to be potentially lethal, a large percentage of smokers still are not motivated to quit. For example, in the US the percentage of smokers with low motivation to quit smoking is about 40%, while in two European countries, the Netherlands and Spain, the percentages are even higher, 70 and 68%, respectively (Etter et al., 1997
). According to the criterion, these smokers are not planning to quit within the next 6 months and are called precontemplators in the Stages of Change model (Prochaska et al., 1992). In attempts to lower the percentage of smokers in the population, interventions might be aimed at stimulating these precontemplators in the process of quitting. In the framework of the Stages of Change model, a stage-matched intervention will have to be developed to target this group of smokers and to stimulate them to transit to the next stage, the contemplation stage. However, recent studies suggest that the large precontemplating smoker populations may be heterogeneous (Crittenden et al., 1994; Dijkstra et al., 1997). That is, there may be subtypes within the group of precontemplating smokers and subtypes might benefit from different interventions.
Crittenden et al. (Crittenden et al., 1994) distinguished between three sorts of precontemplators. The first and second types were not seriously thinking of quitting smoking and not planning to quit, although the second type was planning to cut down, whereas the first type was not. The third type was seriously thinking of quitting smoking or planning to quit, but not within the next 6 months. In a similar vein, Dijkstra et al. (Dijkstra et al., 1997) developed a short questionnaire assessing precontemplators' long-term quitting plans. Within a sample of smokers who were not planning to quit at least within the next 6 months, they distinguished between: (1) smokers who were planning to quit within 1 year, (2) smokers who were planning to quit within 5 years, (3) smokers who were planning to quit somewhere in the future but not within 5 years, (4) smokers who were planning to never quit and (5) smokers who felt none of these plans was representative of their own long-term quitting plan. A proportion of the latter group of smokers is probably planning to cut down on cigarettes.
The fact that precontemplators with different quitting plans exist gives little insight in the psychological factors that will have to be changed by smoking cessation interventions. Therefore, the psychological characteristics of smokers with different plans are of importance. The three types of Crittenden et al. (Crittenden et al., 1994) differed significantly on the motivation to quit and the confidence to be able to quit. However, in a second study they showed that these types differed significantly only on motivation to quit (Crittenden et al., 1998). The subtypes of Dijkstra et al. (Dijkstra et al., 1997) differed significantly on the perceived pros of quitting but not on the perceived cons and self-efficacy. Thus, these data indicate that the subtypes differed on psychological factors that might be targeted by smoking cessation interventions.
The present study aims to replicate the findings from the Dijkstra et al. (Dijkstra et al., 1997) study with larger statistical power, adapted categories of long-term quitting plans and adding longitudinal analyses. Furthermore, because few data are available on the cognitive characteristics of precontemplators, the set of cognitive constructs which will be assessed will be expanded. That is, basic constructs of Bandura's (Bandura, 1986) Social Cognitive Theory (SCT) will be assessed: outcome expectations, self-efficacy expectations and self-evaluation inhibiting mechanisms. These psychological factors are thought to determine precontemplators' quitting plans and, thus, interventions will have to aim at changing these factors. Outcome expectations refer to the anticipated gain or loss that will follow quitting smoking. On theoretical (Bandura, 1986, 1997) and empirical grounds (Dijkstra, 1998a,b), several sorts of outcome expectations can be distinguished. Self- efficacy expectations refer to a judgement of the personal ability to quit smoking. Also, several sorts of self-efficacy expectations can be distinguished (Dijkstra and De Vries, 2000). Two self-evaluation inhibiting mechanism can be distinguished: the frequency of worrying thoughts and the adherence to excuses to smoke. Both constructs refer to the functional regulation of information input (Dijkstra et al., 1999a). That is, when the information input is decreased and distorted (low frequency and many excuses, respectively), the salience of expected outcomes, such as health damage through smoking, is lowered.
The first goal of the present study is to map different sorts of positive and negative outcome expectations, self-efficacy expectations and self-evaluation inhibiting processes in precontemplators. The second goal is to explore the cognitive characteristics of precontemplators with different plans with regard to their smoking behavior. The third goal of this study is to assess the predictive validity of these plans. The final goal of this study is to investigate the cognitive changes smokers undergo when they change quitting plans.
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Method |
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Procedure and design
Smokers with low readiness to change were recruited by advertisements in local newspapers throughout the Netherlands. The recruitment procedure was the same as used in an earlier study on smokers with low readiness to change (Dijkstra et al., 1998c
). After smokers had phoned the university in order to register (n = 1000), they were sent the pre-test questionnaire which could be returned in a pre-paid envelope. After 2 weeks, 915 (91.5%) pre-test questionnaires had been returned. Forty-five of these questionnaires were excluded, because the respondents only smoked a pipe or cigars, or because they did have plans to quit within the next 6 months. This resulted in 861 respondents at T1 (86.1%). These smokers were randomly assigned to one of three experimental conditions offering different smoking cessation self-help materials by mail or one no-information control condition. The results on the efficacy of the self-help materials are published elsewhere (Dijkstra et al., 1999b). Six months after the intervention, these 861 participants were sent the post-test questionnaire (T2) of which 751 (89%) were returned.
Questionnaire
Quitting plans
Precontemplation quitting plans were assessed by confronting smokers with different long-term plans with regard to smoking cessation (Dijkstra et al., 1997, 1998a). They were asked to score the one plan that was the most similar to their own quitting plan: `Are you: (1) planning to quit within the next month; (2) planning to quit within the next 6 months; (3) planning to quit within the next 12 months; (4) planning to quit within the next 5 years; (5) planning to quit somewhere in the future; (6) planning to never quit, but planning to cut down on cigarettes; (7) planning to never quit and not planning to cut down on cigarettes'. The participants, then, were categorized in one of three stages of readiness to change: precontemplation (plans 3, 4, 5, 6 and 7), contemplation (plan 2) or preparation (plan 1). Smokers who had quit for the last 24 h were considered to be in the action stage.
Intention to quit
Intention was measured with a composite of three 10-point scales: `To what extent do you intend to quit smoking: (1) within the next 6 months; (2) within the next 5 years; (3) ever?' The items could be scored from `not at all' (1) to `very much' (10). The composite intention score was the average item score (Cronbach's 
= 0.79).
Quitting behavior
Quitting behavior was measured with a one point prevalence measure: `Have you been smoking during the last 7 days? (even one puff)' (yes/no) and a retrospective report of a quit attempt: `Have you engaged in a quit attempt since the last measurement?' (yes/no).
Smoking behavior and quitting history
Smoking behavior was measured by asking smoker s how many years they had been smoking and how many cigarettes they smoked on the average. Nicotine dependence was assessed using the Fagerström Test for Nicotine Dependence (FTND) (Heatherton et al., 1991) which assesses smoking habits: How much do you smoke? How soon after awaking? Is it hard not to smoke in public places? Do you smoke when you are ill? Do you smoke more in the morning and which cigarette is most difficult to give up? The minimum possible score was 0, the maximum 10 ( = 0.71). Quitting history was measured by asking whether they had ever engaged in a 24 h quit attempt and in the last 12 months.
Demographics
Demographics measured were sex, age and level of education. Level of education was categorized as low, medium or high. In the diverse schooling system in the Netherlands, low level of education refers to vocational training, medium level to advanced vocational training and high level to college/university training.
The following four psychological constructs were assessed: positive outcome expectations, negative outcome expectations, self-efficacy expectations and self-evaluation inhibiting thoughts.
Positive and negative outcome expectations
The items of these scales were validated in earlier studies (Dijkstra et al., 1996, 1997) and referred to possible gain (positive outcome expectations) or loss (negative outcome expectations) smokers anticipated as a consequence of quitting and were in the following format: `If I quit smoking, then...'. The items could be scored from `not sure' or `not expecting a certain outcome' (0) to a `strong expectation of the outcome' (3). Earlier studies showed that different factors could be distinguished within the positive outcome expectations (Dijkstra et al., 1998b). Thus, the following scales assessing positive outcome expectations were formed: Long-term physical outcomes (three items; = 0.91); Short-term physical outcomes (three items; = 0.74); Social outcomes (three items; = 0.77); and Self-evaluative outcomes (three items; = 0.76). Two sets of items were used to assess the negative outcome expectations (Dijkstra et al., 1998b). The first set referred to the anticipation of loss of functions of smoking, such as the loss of a means to relax or a means to cope with anger (nine items; = 0.84). The second set assessed the expected withdrawal symptoms. Within this set, two factors could be distinguished: expected withdrawal symptoms (four items; = 0.81) and expectations of physical complaints (four items; = 0..72).
Self-efficacy expectations
Self-efficacy was assessed using the 20 self- efficacy items developed by Dijkstra and De Vries (Dijkstra and De Vries, 2000). From these items four self-efficacy scales were formed: Emotional self-efficacy (four items; = 0.88), which assesses the confidence to be able to refrain from smoking in emotional situations; Social self-efficacy (four items, = 0.90), which assesses confidence in social situations; Skill self- efficacy (seven items; = 0.85), which assesses confidence to use specified non-smoking skills, such as, `thinking of all the benefits of quitting'; and Relapse self-efficacy (five items; = 0.90), which assesses the confidence to recover from a (re)lapse. All items were measured on a seven-point scale and could be scored from `not sure at all I am able to' (–3) to `very sure I am able to' (+3). Emotional, Social, Skill and Relapse self-efficacy items were introduced as follows: `Imagine you are engaging in a serious quit attempt. Are you able to...'. In the case of Relapse self-efficacy it was asked: `Are you able to maintain your quit attempt after an initial lapse when you have been refraining from smoking for...(a specified period)...'.
Self-evaluation inhibiting processes
Two measures of self-evaluation inhibiting processes or the `the functional regulation of information input`, were used. The first measure assessed the frequency of worrying thoughts (eight items; = 0.88). The eight items of this scale were derived from interviews with smokers and the `frequency' answer format was adopted from Prochaska's Processes of Change questionnaire (Prochaska et al., 1988). The items referred to the frequency of thoughts and intrusions on the health damaging effects of smoking. For example, the frequency of: `thinking about the effects of smoking in your body' or the frequency of `thinking about how my lungs will look'. The items could be scored from `never' (0) to `very often' (4). The second measure assessed excuses to smoke (seven items; = 0.76). This scale was tested and validated in an earlier study (Dijkstra et al., 1999a). The items could be scored from `I do not agree' (–2) to `I do agree' (+2) and were formulated to finish the sentence: `Smoking can make me ill, but...'. The items gave reasons (or excuses) why it was alright to smoke, despite the well-known detrimental effects. A typical excuse may be true in itself but may only address half the truth (e.g. `I know heavy smokers who live a long and healthy life' or `I am exposed to so many risks in my life`) or it may actually not be based on reality (e.g. `If smoking were really that bad, it would be prohibited`).
Statistical analyses
Firstly, the scale characteristics of the 14 cognitive measures were assessed. Secondly, Pearson correlations among the scales were computed. The nicotine dependence scale and the intention to quit composite were added to the correlation matrix to further assess whether the relations were in the expected directions. Thirdly, smokers with different plans were compared on cognitive variables, using analyses of variance. Since the relationships between quitting plans and cognitive variables may differ for smokers with different demographic, smoking behavioral and smoking history characteristics, several interactions were tested. In the case of a significant interaction, the analyses were stratified by the demographic, smoking behavioral or smoking history variable. Fourthly, the predictive validity of the long-term quitting plans was tested using point prevalence quitting, a retrospective report of quitting and forward plan change as outcome variables. The former analyses were conducted using logistic regression, while the latter analysis was tested using 
2 analysis. Fifthly, the changes in the cognitive variables smokers undergo when they move forward to a shorter-term quitting plan were assessed. In five sets of analyses, one for each pre-test long-term quitting plan, post-test scores on the cognitive variables between smokers who moved forward and smokers who did not move forward were compared. The pre-test scores on the cognitive variables were entered as covariates. All tests in the present study were two-tailed and was set at 0.05. In the longitudinal tests, intervention condition was entered as a covariate to control for possible differential effects of the interventions.
Sample characteristics
Of the 861 respondents, 23% were planning to never quit and not planning to cut down, 22% were planning to never quit, only planning to cut down, 34% were planning to quit in the future but not within the next 5 years, 16% were planning to quit within the next 5 years and 6% were planning to quit within the next year. Furthermore, 63% were female, 29% had a low level of education, 45% had a medium level and 26% a high level of education, and the mean age was 41.7 years (SD = 12.9; range 16–81 years). On average, they smoked 21.5 cigarettes a day (SD = 10.1; range 1–80 cigarettes) and they had smoked for 24.5 years (SD = 12.9; range 1–70 years). Thirty-one percent had never engaged in a quit attempt, while 85% had not engaged in a quit attempt in the last 12 months.
Scale characteristics and Pearson correlation's among the scales.
Most scales had good internal consistency; only the Cronbach's of the Excuses scale was below 0.70. To explore and validate the relations among the scales, Pearson correlations were computed (Table I). Correlations among the four Positive outcomes scales ranged from 0.39 to 0.58, indicating that the scales measure distinct but related constructs. Correlations among the three Negative outcomes scales ranged from 0.45 to 68, indicating that the scales measure distinct but related constructs, although the latter high correlation indicate that the scales have a clear overlap. The correlations among Positive outcomes scales and the Negative outcomes scales were all significant but low (<0.21), thereby supporting the distinction between both concepts. The correlations of Positive outcomes scales with Self-efficacy scales were all non-significant, while Negative outcomes scales had negative correlations with the Self-efficacy scales. Thus, the more negative outcomes of quitting a smoker perceives, the lower the smoker's confidence to be able to quit. The Worrying thoughts scale correlated positively with the Positive outcomes scales and positively but low with the Negative outcomes scales. The former finding might indicate that the more positive outcomes smokers perceive (meaning the stronger they anticipate the relief from the present negative effects of smoking through quitting) the more frequently they think of the damaging physical effects of smoking. The Excuses scale had a negative correlation with the Positive outcomes scale. Excuses might moderate the perceived benefits from quitting, that is, lower the salience of the perceived negative effects of smoking. The FTND correlated positively with the Negative outcomes scales and negatively with the Self-efficacy scales. Thus, the more dependent a smoker is, the more negative outcomes of quitting he or she anticipates and the lower the self-efficacy. Only the Negative outcomes scales had no correlation with intention to quit. All these relationships are in expected and interpretable directions.
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Results |
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Cognitive characteristics of precontemplators with different quitting plans
Smokers with different long-term quitting plans were compared on the cognitive characteristics (Table II
). All analyses are corrected for differences in demographics, smoking behavior and quitting history by entering these variables as covariates.
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The overall analyses showed that smokers with different plans differed significantly on all positive outcomes (P < 0.001), on expected withdrawal symptoms only in smokers who had made a quit attempt (P < 0.05), on Emotional and Skill self-efficacy (P < 0.01), and on Social self-efficacy only in medium (P < 0.001) and highly (P < 0.05) addicted smokers, and on both self-evaluation inhibiting processes (P < 0.001) and intention to quit (P < 0.001). Thus, the quitting plans had no significant relationships with expected loss of function, expected withdrawal symptoms only in smokers who had made no quit attempt, expected physical symptoms, Social self-efficacy in light smokers and Relapse self-efficacy.
Looking more closely at the data, the following contrasts and interactions were detected. With regard to the positive outcome expectations, the data show that the more proximal and the more concrete the quitting plans, the more positive outcomes smokers expected. In particular, smokers who were planning to never quit and not planning to cut down perceived fewer of all sorts of positive outcomes than other smokers with other plans. Furthermore, the relation between the quitting plans and self-evaluative outcomes differed significantly for males and females: females with concrete plans (quitting within 1 and 5 years) anticipated more self-evaluative outcomes than males with such plans. Moreover, self-evaluative outcomes were the only positive outcomes that discriminated between smokers who planned to quit within 1 year and those who planned to quit within 5 years.
The data on the perceived negative outcomes of quitting showed that only the relation between quitting plans and Withdrawal symptoms was significant and that this was only the case for those who had engaged in a quit attempt: smokers in both groups who were not planning to quit anticipated many withdrawal symptoms, only when they had engaged in a quit attempt. The relation between quitting plans and Physical complaints depended significantly on age although no main effects of quitting plan occurred in the separate age groups: older smokers (47–84 years of age) who were not planning to quit and not planning to cut down anticipated fewer physical symptoms, whereas in the intermediate age group (36–46 years of age), it was smokers who planned to quit within 1 year who anticipated fewer physical symptoms. In the youngest age group (16–35 years of age), only very small differences between smokers with different plans occurred.
With regard to Emotional self-efficacy, only smokers who were planning to never quit and not planning to cut down scored significantly lower. The relation of Social self-efficacy with the different quitting plans was a function of the extent to which someone was nicotine dependent. Medium dependent smokers who were planning to never quit and not planning to cut down scored lower than smokers with other plans. In smokers who scored high on nicotine dependence, all but the smokers who planned to quit within 5 years scored low, i.e. below the mean of 50. Skill self- efficacy gradually increased as smokers had a more proximal plan to quit.
The relation between worrying thoughts and quitting plans depended on the number of years smoked. Smokers who had smoked for the highest number of years (29–70 years) and were planning to quit within the next year scored very high, compared to smokers with other plans. Smokers who smoked for 19–28 years and were planning to quit within 1 year, in contrast, scored lower than smokers who were planning to quit within the next 5 years. With regard to excuses to smoke, the data show a steady decrease as smokers adhere to a more proximal plan to quit. Intention to quit was a strong discriminator between the different quitting plans, especially in smokers who had quit in the past.
Predictive validity of the different quitting plans
The analyses on predictive validity are corrected for differences in demographics, smoking behavior and quitting history (Table III). Quitting plan was a significant predictor of point prevalence quitting (P < 0.001). Specifically, smokers who were planning to quit within the next 1 year scored high: 19.6% after seven months versus 1.8–5.9% in smokers with other plans. Furthermore, quitting plan was a significant predictor of engaging in a quit attempt since pre-test (P < 0.001). Smokers who were planning to never quit and not planning to cut down scored especially low (6.6%), whereas this percentage in smokers who were planning to quit within the next 1 year was 43.5%. Quitting plan was a significant predictor of forward plan change (P < 0.001). The data can be summarized as follows. With regard to four of the five quitting plans, about half of the smokers had the same plan after 7 months; only among smokers who were planning to quit within 1 year there was a lower percentage (28%) who had made no change in plans. Furthermore, in four of the five quitting plans a backward change was possible. The percentages of backward change were around 15% in three plans and 8% in one plan. Thus, larger percentages changed forward. In four of the five plans the highest percentage forward change was to the subsequent plan. About 55% of smokers who were planning to quit within 1 year made a forward change in plans, of whom almost half had quit smoking.
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Cognitive changes during forward changes in quitting plans
Smokers with a certain quitting plan at pre-test who made a forward change in plans were compared to smokers who made no forward change in plans on cognitive changes from pre-test to post-test (Table IV
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Significant increases in positive outcome expectations were related to a forward change in plans in three subtypes: in smokers in both groups with plans to never quit and in smokers who were planning to quit somewhere in the future. In smokers with concrete plans (to quit within 1 and 5 years), only significant increases in the self-evaluative positive outcomes were associated with a forward change in plans. Changes in negative outcome expectations were hardly related to forward changes in quitting plans.
Significant increases in self-efficacy were related to a forward change in plans in three groups of smokers: in smokers who were only planning to cut down, in smokers who were planning to quit somewhere in the future and those who were planning to quit within 1 year.
Significant changes in self-evaluation inhibiting processes occurred especially in smokers who were planning to quit somewhere in the future, who made a forward change in the quitting plan. They had significantly more worrying thoughts and they used significantly fewer excuses. For all groups of smokers, a forward plan change was related to a significantly larger increase in intention to quit.
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Discussion |
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The goal of the present study was to investigate whether subtypes of precontemplators could be distinguished based on their long-term quitting plans. Before comparing the smokers with different plans we studied some central cognitive constructs from Bandura's (Bandura, 1986
) SCT. The internal consistencies of the scales were good and all relations among the scales were in the expected directions. Thus, it seems that precontemplators can be validly described in terms of positive and negative outcome expectations, self-efficacy expectations and self-evaluation inhibiting processes.
The first finding concerned the differences between and similarities of precontemplating smokers with different quitting plans. The data with regard to the cognitive measures showed that smokers with different plans differed on the positive outcome expectations, self-efficacy expectations, self-evaluation inhibiting processes and intention to quit. Thus, generally speaking, the more rewards precontemplators expect from quitting, the more confidence they have that they are able to quit, and the less bias in how they process information (high worry frequency and few excuses), the more concrete and proximal their plans to quit smoking. There was no relation between quitting plans and negative outcome expectations. This is in line with the expectations of the negative outcomes having little to do with the early phases of the process of behavior change (Prochaska, 1994; Dijkstra et al., 1996).
The question to what extent precontemplators are a homogenous group was central in the present study. The above results indicate that on the cognitive variables—which are considered to be related causally to behavior change—large differences among precontemplators exist. However, it is important to show that these cognitive differences are related to actual behavior. Therefore, the predictive validity of quitting plans is a more stringent test of the homogeneity of this group. With regard to the point prevalence quitting measure, specifically smokers who were planning to quit within the next year were more active than the others. It could be questioned to what extent these smokers can be classified as precontemplators. That is, early models of the stages of change defined precontemplators as smokers who were not planning to quit within the next year in contrast with contemplators, who were planning to quit within this term (DiClemente et al., 1985; Prochaska et al., 1985; Wilcox et al., 1985). When we accept the high scores on the frequency of worrying thoughts of precontemplators with the 1 year quitting plan as being an indication of their `openness' to information on the effects of smoking, this further supports the notion that they are more like contemplators (Prochaska et al., 1992). Future studies including contemplators might further study the best classification algorithm in Dutch smokers. The data with regard to the retrospectively reported quit attempts showed a more linear relation between quitting plans and quitting activity: The more concrete and the more proximal the quitting is planned, the higher the probability that precontemplators will engage in a quit attempt. These data on the predictive validity seem to support the notion that relevant subgroups of precontemplators might be distinguished based on their quitting plans.
The data on the changes in quitting plans showed that, after 7 months, in four of the five quitting plan groups, around 50% made no detectable change. Again, smokers who were planning to quit within the next year deviated: only 28% made no change. Furthermore, in all five groups, smokers who made a forward change in plans had the highest probability of adhering to the subsequent (more concrete and more proximal) quitting plan. This might mean that in becoming more motivated to quit, precontemplators follow a certain order in plans. Furthermore, the fact that precontemplators who were planning to quit within 1 year were about 4 times as probable to have moved forward to the action stage—a finding overlapping and parallel with the point prevalence quitting figures—further supports this notion. Although we certainly do not advocate that the five quitting plans refer to stages within the precontemplation stage, smoking cessation interventions targeted at precontemplators might take into account the fact that most precontemplators do not jump to the contemplation stage but rather make small changes to more concrete and proximal plans to quit.
The present data on the cognitive changes which accompany forward changes in plans might further increase our insight in the change process and the changes to be brought about by interventions in precontemplators. In interpreting the data on the cognitive changes, the theoretical assumption is that positive, negative and self-efficacy expectations and self-evaluation inhibiting processes are causes, not effects, of the formation of quitting plans. A forward change in plans, first, seemed to be accompanied by increases in several sorts of positive outcomes. In precontemplators with concrete plans—to quit within the next 5 years or the next year—only the self-evaluative outcomes changed. The perception of self-evaluative outcomes is influenced by the active and unbiased processing of information on physical and social outcomes (Dijkstra et al., 1999a). Therefore, it might be concluded that offering information on physical and social outcomes is important in precontemplators with one of the first three (non-quitting or vague) quitting plans, whereas in precontemplators with the concrete quitting plans the active and unbiased cognitive processing of this information—which might already be in memory—is more important. The cross-sectional data, indeed, show that precontemplators with concrete quitting plans score significantly lower on our measure of (un)biased information processing; the excuses. With regard to negative outcome expectations, no differences occurred between precontemplators who made a forward change in plans and those who made no forward change. This further underlines the notion that the perception of the negative outcomes of behavior change is not related to the motivational change process in precontemplators (Prochaska et al., 1994). Increases in self-efficacy were, firstly, relevant in smokers who were only planning to cut down. Thus, an increase in self-efficacy might make these smokers more confident that they are able to quit completely. As a result they might adhere to a new complete-quitting plan. Interventions targeted at smokers who are only planning to cut down might communicate self-efficacy enhancing information. Secondly, the clearest changes in self-efficacy occurred in smokers with a vague quitting plan, to quit somewhere in the future. Again, increases in self-efficacy might make quitting a realistic and feasible option for these smokers. Together with the motivating power of the perceived positive outcomes of quitting, this might make them adhere to a new and more concrete quitting plan. The same principle could account for precontemplators who were planning to quit within 1 year.
The following limitations of this study must be taken into account. First of all, the sample of precontemplators was recruited re-actively. It is plausible that this led to a certain selection of respondents. However, the recruitment advertisements included the statement that respondents did not have to quit in order to join the study. Reactions of smokers in the telephone interviews further supported our idea that many respondents were still resistant to change and had very low motivation to change. Secondly, although only 11% of the pre-test respondents dropped out, this may have further led to a selective sample of precontemplators. Thirdly, the precontemplators in this study had received smoking cessation materials just after the pre-test. Although the longitudinal statistical analyses were controlled for effects which might be caused by the intervention conditions, it remains obscure to what extent this has influenced the results.
In conclusion, in smoking, precontemplators are a heterogeneous group and relevant subgroups can be distinguished by their plans to quit smoking. Precontemplators who receive self-help smoking cessation materials can make forward changes in quitting plans and these changes seem to follow a certain order. Forward changes are mainly related to positive outcome expectations, to self-efficacy expectations depending on the quitting plan and not to changes in negative outcomes. The present study, thus, is one step in mapping the psychology of low motivation to change behavior.
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Acknowledgments |
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This research was supported by a grant from the Dutch Cancer Society.
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References |
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Received on July 16, 1999; accepted on December 18, 1999
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