1 | Childress

Eiren Childress
Thursday, November 19, 2015
HLTH 634 D01: Health Communication and Advocacy; Fall, 2015
Dr. Z

Literature Review:
A Need for the Transtheoretical Model of Change in Smoking Cessation Efforts

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Introduction
Smoking Cessation Success has been founded out of a desire to help individuals achieve
and maintain lifelong cessation of smoking cigarettes. Too often smokers are forced into a
paradigm of knowing that smoking cigarettes is harmful not only to themselves but also those
around them, often times being shamed and questioned for why they would willingly do such a
harmful thing to themselves. Nicotine, a primary substance that is found in tobacco products, is
considered to be highly addictive.1 While not all tobacco users will become addicted to nicotine,
it is important that we as a general populous remember that the use of tobacco products, in most
cases, is a situation of a dependency, or an addiction, and we must treat it as such. We should not
be singling out smokers as being bad individuals, instead we should be helping them treat their
addiction, just as we have treatment plans for anyone else with an addiction.
A fundamental core belief of SCS lies within the Transtheoretical Model of Change
(TTM or TMC).2 When a course of change is initiated, all individuals will begin the course at
different points of preparedness. This means that we are not all at the same starting line. In the
mindset of SCS, this also means that we cannot apply the same basic intervention structures to
all people. We must be able to adapt the historically developed intervention structures to meet
the needs of individual people wherever they are on this trajectory. By initiating intervention
methods that are personalized and adapted specifically to the individual, we bring ownership and
accountability directly back to the person themselves. We are there to educate them in best
practices to maneuver and support their own cessation efforts for a lifetime, while continuing to
support their efforts through proven and tested techniques that are utilized in the industry on a
regular basis.
We realize that by targeting Richmond, Virginia as our initial target location, we face
several difficulties, including tobacco availability and cost, smoking as a social norm within the
area, lack of high policy support for smoking cessation, and a mostly adult population. However,
we also recognize that Virginia has seen continuous downward trends in adult smoking
prevalence over the last several years, and we strongly believe that we can help not only
Richmond or Virginia, but the United States as a whole achieve the Healthy People 2020
Initiative of a 12% prevalence of adult smoking.
In this literature review, we will discuss several risk factors of smoking and why smoking
cessation efforts are critical to not only individual health but also the health of the greater
community and populous as a whole. We will also discuss why TTM is an ideal ideologic
framework for the type of work and research that SCS aims to complete. We will disclose why
Richmond, Virginia is an ideal location to launch the type of progam(s) that the SCS will
sponsor. These three core components make the base of Smoking Cessation Success and all of
its core beliefs and principles. To retrieve the reviewed literature, searches were done in the
Liberty Universitys library database using key terms such as: adult smoking cessation,
smoking cessation in Virginia, smoking cessation efforts in America, TTM, and
transtheoretical model and smoking cessation. Government websites, including the CDC and
CHSI, were also searched for statistical information about Virginia.

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Body of Evidence
The Effects of Smoking and the Need for Cessation
Due to extensive public awareness campaigns, the majority of people are aware of the
dangers of smoking.3 Sadly, too many individuals still make the decision to begin smoking,
continue smoking, and are then sucked into the paradigm of addiction. According to the CDC,
smoking is a major contributor to every leading cause of death in America: heart disease, cancer,
chronic obstructive pulmonary disease, and stroke.3 Therefore, tobacco is the number one cause
of preventable disease and death in America.3 Young adults, aged 18-29, have Americas highest
smoking prevalence rates.4
As is very well known throughout society, tobacco, due to its nicotine content, is highly
addictive.5 If it were not addictive, there would be no significance to the process of initiation,
deciding to continue, and quitting smoking. All of this terminology is very specific to cases of
addiction.5 However, it is common that cigarette smoking is not viewed as an addiction and
therefore does not receive the same type of treatment and sensitivity as other addictions. This is
despite the fact that cigarette smoking follows the same thought process constructs as any other
addiction.5 A non-smoker decides to start smoking based on a their view of a utility gain from
starting, whether that be social, personal, or other gains.5 Likewise, smoking participation and
continuation comes from the viewpoint of a utility gain from smoking. When an established
smoker makes the decision to quit smoking, there is a shift in views from there being a utility
gain from smoking to there being a utility gain from quitting.5 In order for these changes to
continue, that shift in viewpoint of smoking having benefits to smoking having negatives must
also continue.5 Sadly, our society is still too centered around supporting smoking rather than
supporting cessation efforts. Therefore when an individual makes the decision to quit smoking,
there are very little resources and support for them to begin, maintain, and achieve their
cessation.
A 2010 study found that 68.8% of all identified adult smokers in America want to quit
smoking. Of that percentage, 52.4% made attempts to quit, but only 6.2% were successful in
achieving their long term cessation goals.3 Another study found high correlations of predictors to
quit attempts and abstinence. It found that the prevalence of quit attempts in persons aged 45-64
has drastically increased in the last decade.4 Predictors of these quit attempts include: access to
resources, number of prior attempts, and the presence of true intent.4 Predictors of abstinence
included: high self-efficacy, the use of resources, having a strong support system, and low
addiction levels.4 Similarly, levels of education, levels of addiction, high use of available
resources, having a strong support system, number of prior attempts, presence of quit intention,
and perceived addiction are all associated with successful long term cessation behaviors.4
Research suggests that utilization of group behavioral interventions may be one of the
most effective cessation methods, both short term, intermediate, and long term, by utilizing these
different constructs.3 The research showed that at 12 months, 20-40% of persons maintained
their cessation efforts, and at more than 12 months, 30% or less of persons maintained their
cessation efforts. Total, it was estimated that only 15-25% of persons that undertake smoking
cessation for the long term are successful in maintaining their efforts.3
The lack of cessation effort support is also evident in the American political system, at
both federal and state levels. The Healthy People 2010 Initiatives called for increases in
cigarette taxes.5 In 2007, substantial federal tax increases on cigarettes was vetoed.5
Surprisingly, higher costs of cigarettes does not have an impact on smoking initiation, but it does

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have a very clear impact on cessation.5 By simply increasing the costs of cigarettes, we can help
individuals decide that now is the time for them to begin their cessation efforts.
All of the bodies of research reviewed demonstrated a common theme: there is a serious
lack of support for cessation efforts. The American society as a whole does not have enough
resources in place to encourage smoking cessation to the levels needed to be able to achieve the
Healthy People 2020 goal of a 12% total adult smoking prevalence rate. More so, we do not
have the programs needed to support the smoking population in being successful in their
cessation efforts. This lack of support has led to us attempting to apply one set of fixed
principles to all persons, despite the fact that all persons are not in the same place in their
cessation journey. We need to adjust our efforts to better suit individual needs in order to best
support their efforts and to encourage the continuation of these efforts.
Transtheoretical Model of Change
In regards to smoking cessation, a central theory of TTM is that using interventions that
would encourage processes of change applicable to a persons paired stage would be more
effective than using interventions that are found in other stages than the one identified as the
persons current one.6 This hypothesis has not been rigorously tested.6 The different stages of
TTM (precontemplation, contemplation, prepatory, action, and maintenance) are psychologically
different from one another.6,7 Also, the components of the TTM framework as a whole together
to improve the stage matching of individuals and the effectiveness of behavior change
interventions.6,7
80% of smokers are considered to be in the precontemplation or contemplation stages.6
However, most standard smoking interventions are aimed at persons in the prepatory stage.6
Therefore it is common for there to be a mismatching of utilized interventions to the stage that a
person is in. A recent study had findings that while people in the prepatory stage are more likely
to stop smoking using TTM based interventions than standard interventions, TTM interventions
can also be used for persons in precontemplation and contemplation stages, when they are
matched appropriately. In fact, they are 20% more likely to make positive stage changes, and the
likelihood of them moving towards quitting smoking is much higher by using TTM based
interventions.6 This study showed that stage movement, whether positive or negative, is much
more common than sustained abstinence and in turn cessation.6
By developing interventions that are aimed at each stage and process of change of TTM,
one can help smokers be successful in their cessation efforts. It is important to identify whether
the person is in an experiental (consciousness raising, dramatic relief, environmental
reevaluation, social liberation, or self-reevaluation) process of change or in a behavioral process
of change (helping relationships, stimulus control, counter-conditioning, reinforcement
management, or self-liberation).8 By identifying this and what TTM stage the person is in, we
can then develop interventions using tools such as: demographics, stage of change and smoking
behavior identifiers, decisional balance identifiers, situational temptations, tolerance
questionnaires, development of coping skills, motivational enhancement, motivational
interviewing, self-efficacy development, and decisional balance development.7,8 The core of
TTM is simply to develop self-based resources for individuals to utilize in every day to day
situations. The self-efficacy approach of TTM is only one way to help develop the need of
resources to support cessation efforts in America.

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Richmond, Virginia: The Hot Spot

In 2013, The American Lung Associations State of Tobacco Control Report had startling
findings regarding Virginias national standings. The state received failing grades in all
measured categories: Tobacco Prevention Control and Spending, Smoke Free Air, Cigarette
Excise Tax, and Cessation.3 For Tobacco Prevention Control and Spending, the state received
failing scores, because it did not allocate at least 50% of the CDCs recommended $103,200,000
towards tobacco control programs.3 In fact, Virginia allotted only $11,279,257 to this type of
programming in fiscal year 2013.3 Under Smoke Free Air, Virginia received failing marks due to
a lack of policies that restrict smoking. Currently the state enforces regulations only for the
smoking at healthcare facilities, restaurants, retail stores, and grocery stores; smoking within
these locations must be limited to within designated spaces. Smoking is not allowed on the
premises of public K-12 schools and licensed childcare facilities.3 Virginia failed in the Cigarette
Excise Tax category for having a tax of less than $0.73. The state was ranked 49th in the country
by having a tax of only $0.30.3 Finally, Virginia failed the Cessation category for having
inadequate coverage of cessation efforts under Medicaid, state employee health plans, and the
states Quit Line.3 While the CDC requires $10.53 to be invested into a states Quit Line per
identified smoker, Virginia invested a mere $0.42 per identified smoker.3
In 2013, the United States Census Bureau found Richmond City to have 214,704
residents. In the same year, Virginia was found to have 8,270,345 residents.9 this means that
2.6% of Virginias total population resides within the city limits of Richmond. Between April 1,
2010 and July 1, 2013, Richmond saw a 5.1% increase in residency. 75.1% of Richmonds total
population classifies as an adult, above the age of 18.9 This is equal to 161,243 persons of
Richmonds total population being evaluated.
44.5% of Richmonds total population was found to be racially classified as White Only.
Another 50.1% of the population was found to be Black Alone. 2.4% was Asian, 6.4% was
Hispanic, and 2.2% was Two or More Races.1 52.4% of Richmonds total population was found
to be female.9 The median per capita income was measured at $27, 184, while the median
household income was $40,496, with an average of 2.33 persons living in a household.9 25.6%
of Richmonders were living below the poverty line.9 Of the adults that were at least twenty-five
years of age, 81.5% were found to be high school graduates or higher; 34.8% were found to hold
at least a Bachelors degree, if not higher.9
Richmonds overall Health Behaviors ranking was #80 out of 133.11 According to CHSI
and the County Health Rankings, between 18.8-19% of Richmonds adults smoke.10,11 This is the
equivalent of 30,314 30,636 persons, and gives the city a moderate ranking.10 According to
CHSI, the US median of adult smokers in the total population is 21.7%10; Virginias median is
18%.11 The best ranking in the United States for adult smokers is at 14%.11 According to this
data, Richmonds percentage of adult smokers in the total population is well below the national
average and in line with Virginias average. However, there is much work to be done in order to
meet the Healthy People 2020 goal of 12%.10
Several of Richmonds surrounding areas, including: Henrico, Hanover, Goochland,
Powhatan, Chesterfield, Hopewell, and Petersburg were also evaluated. Both Henrico and

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Hanover counties had an adult smoking population of 17%, while Goochland saw 14%,
Chesterfield saw 16%, and Powhatan saw 25%.9,10,11 This is interesting, because Goochland and
Powhatan are more rural than the other locales and are directly neighboring counties. However,
they are at odds. Hopewell City and Petersburg City came in at 35% and 25% respectively.9,10,11
Both of these cities are older and more historic locales that would be considered more rural.
With this in mind, it would appear that perhaps there is more education and anti-smoking
programming with the Richmond City limits and rural locales are impacted more highly by an
adult smoker prevalence.
Considering the fact that 52.4% of Richmonds population is female, and 50.1% is
racially classified as Black Alone, this cross-section of Richmonds adult population gives the
largest portion of Richmonds affected population. Black females will make up the largest
portion of Richmonds affected population. Also, since smoking is legal at the age of eighteen
(18), the program will be aimed specifically at adults, with a special focus on Adult Female
Smokers that are racially classified as Black Only. By addressing the need for education and a
reduction in adult smoking prevalence amongst Black females, we would see the largest possible
decrease in Richmonds total prevalence of adult smokers.
Summary and Conclusions
It cannot be ignored that there are a lot of unknowns about the TTM framework in
general but definitely when it comes to smoking cessation. However, the fact that newer
research has identified the benefits of developing the stages of cessation is promising. More
research is needed in the development of stage matched interventions and preventing
mismatched interventions. Not all smokers are going to be at the same level of readiness to seek
cessation. Therefore, we must be able to develop a wide variety of interventions that are
matched and can be utilized to the various stages. This approach will better prepare both health
care professionals to support smokers on the path of cessation and the smokers themselves to
continue their cessation efforts. We need to educate persons about each stage they will
encounter, because the stages of cessation are fluid and continuous. As with any addiction,
smoking cessation is a lifelong undertaking; it never ends.

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References
1. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease:
The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the
Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health, 2010.
http://www.ncbi.nlm.nih.gov/books/NBK53017/pdf/Bookshelf_NBK53017.pdf. October
14, 2015.
2. Diclemente, R., Salazar, L., and Crosby, R. Health Behavior Theory for Public Health,
2013. Burlington, MA: Jones & Bartlett Learning.
3. Linda E Carlson, Paul Taenzer, Jan Koopmans, Ann Casebeer, Predictive value of aspects
of the Transtheoretical Model on smoking cessation in a community-based, large-group
cognitive behavioral program, Addictive Behaviors, Volume 28, Issue 4, June 2003,
Pages 725-740, ISSN 0306-4603, http://dx.doi.org/10.1016/S0306-4603(01)00268-4.
4. Diemert L, Bondy S, Brown K, Manske S. Young adult smoking cessation: predictors of
quit attempts and abstinence. American Journal Of Public Health [serial online]. March
2013;103(3):449-453. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed
November 18, 2015.
5. Philip DeCicca, Don Kenkel, Alan Mathios, Cigarette taxes and the transition from youth
to adult smoking: Smoking initiation, cessation, and participation, Journal of Health
Economics, Volume 27, Issue 4, July 2008, Pages 904-917, ISSN 0167-6296,
http://dx.doi.org/10.1016/j.jhealeco.2008.02.008.
6. Paul Aveyard, Louise Massey, Amanda Parsons, Semira Manaseki, Carl Griffin, The
effect of Transtheoretical Model based interventions on smoking cessation, Social
Science & Medicine, Volume 68, Issue 3, February 2009, Pages 397-403, ISSN 02779536, http://dx.doi.org/10.1016/j.socscimed.2008.10.036.
7. Saime Erol, Semra Erdogan, Application of a stage based motivational interviewing
approach to adolescent smoking cessation: The Transtheoretical Model-based study,
Patient Education and Counseling, Volume 72, Issue 1, July 2008, Pages 42-48, ISSN
0738-3991, http://dx.doi.org/10.1016/j.pec.2008.01.011.
8. McKinney, B., & Maxey, H. (2014). Problems & possibilities: smoking prevalence &
cessation efforts in Virginia. VAHPERD Journal, 35(1), 4+. Retrieved from
http://ezproxy.liberty.edu:2048/login?
url=http://go.galegroup.com.ezproxy.liberty.edu:2048/ps/i.do?id=GALE
%7CA368472078&v=2.1&u=vic_liberty&it=r&p=AONE&asid=fd2d205dbaadca82447e
09150cc2ac48
9. United States Census Bureau (2015). Richmond City, Virginia. Retrieved July 7, 2015,
from State and County Quick Facts:
http://quickfacts.census.gov/qfd/states/51/51760.html
10. Centers for Disease Control and Prevention (2015). Adult Smoking. Retrieved July 7,
2015, from CHSI: Improving Community Health:
http://wwwn.cdc.gov/CommunityHealth/profile/currentprofile/VA/Richmond%20City/13

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11. County Health Rankings (2015). Virginia. Retrieved July 7, 2015, from County Health
Rankings and Roadmaps:
http://www.countyhealthrankings.org/app/virginia/2015/overview