Critical appraisal of the smoking health behaviour

23 Mar 2015

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Tobacco popularity has risen enormously throughout the last 450 years (Marks, Murry, Willig, Evan, Woodall and Sykes, p.155).The ongoing concerns have amplified, why do individuals make conscious decisions to carry out acts such as smoking when the apparent health concerns are prominent? Numerous research institutes have dedicated immense amounts of time and money, in the hope to find a solution to encourage smokers to refrain from their smoking behaviour (Ogden, p.109). Equally, an increase of illustrated health risks has been displayed on cigarette boxes, which outline the dangers and risks of smoking, although this has not influenced the decision of many smokers (Tobacco health warning, 2007). With this in consideration, how do individuals rationalise their choice to continue an act which can lead to serious long-term health condition?

Smoking is categorised as an addictive behaviour, creating a physical dependency for nicotine, which eventually develops over time (Segan, Borland and Greenwood 2006). This dependency can cause various health consequences which are detrimental to an individual. In 2004, the US surgeon general announced that smoking affects nearly every organ in one's body (Ogden, p156) others have suggested that smoking prompts the development of cancerous cells which can lead to lung cancer, heart disease and in general smoking can interfere with the day to day quality of life such as the level of cardiovascular fitness (Carbonea, Kverndokkb, Rogebergb 2005). The ongoing consensus suggests that quitting this addictive habit has immediate and elongated benefits, such as a reduction in the risk of developing smoking related diseases (Odgen, p156), so why do people continue this act?

In the hope to conceptualise the thoughts and actions of smoker's and ways to develop smoking cessation programmes, researchers have relied on social cognition models, such as the change model of health behaviour, also addressed as the Trantheoretical model (TTM) proposed by James O Prochaska and DiClemente 1984. The TTM has been highlighted as a significant contributor in understanding the different behavioural intention and intervention in relation to smoking cessation over the last decade (Segan and Colleagues 2006). Similarly the TTM is being utilised in several disciplines such as health psychology. Its widespread popularity has increased as its theoretical foundations are being used to guide interventions and allocate treatment resources (Littell and Girvin 2002).

For the purpose of this essay, this paper will critically appraise the Transtheoretical model (TTM) in relation to smoking cessation, in light of its research applicability. The TTM has been established as an integrated model of behaviour change and it encourages one to evaluate the process of an individual's readiness to change, therefore this paper will begin by outlining the stages of TTM. The focus will then shift by relating this model to smoking cessation studies and critically discussing how researchers have utilised this model in understanding addictive behaviour. Alternatively, wider determinates such as internal and external triggers will also be discussed, which may encourage an improved understanding of why some individuals fail to give up their smoking habits.

(Figure 1)The TTM was developed in 1983; its proposer Prochaska and DiClemente introduced this phase model in the hope to guide individuals to understand the processes of behavioural change. Widely used by therapists the TTM guides clients to pursue a stage by stage change of an unhealthy behaviour. Similarly, therapists base their interventions on the TTM and employ it as a reference tool during the treatment process. Furthermore, research has shown that, TTM interventions offer a cohesive package, which is tailored for every individual as it focuses on their "readiness to change" instead of assuming "one size fits all", which is often the case with population based intervention (Norman, Velicer, Fava, & Prochaska, 2000). Studies have suggested that an individual's motivation to change usually fluctuates based on their social dilemmas (Adams & White 2005). This model aims to explain these various problematic changes.

The assumptions and structure of the model includes five broad constitutes, which all hold an importance in understanding the TTM, these are, stages of change, processes of change, decisional balance, self efficacy and temptation (Pattern, Vollman, & Thurston, 2000; Prochaska and Velicer 1997) which will be further discussed in light of research.

Figure 1 illustrates the structure of the TTM. Stage one is known as, precontemplative stage; at this initial point a smoker has not yet decided to take any action to alter their unhealthy behaviour with no specific foreseeable timeline (Prochaska and Velicer 1997). Stage two is labelled as the Contemplative stage, the possibility for making a change is thought provoking, a smoker will begin balancing the pros and cons of altering their specific unhealthy behaviour with an intention to change, for example a smoker may begin to gather thoughts about giving up smoking (Prochaska and Velicer 1997). Once contemplated, the development of a preparation plan will commence. At this stage a serious consideration to alter their behaviour will take place and preparation will begin (Prochaska and Velicer 1997). Once preparation plan are agreed, smokers will progress to the action stage where an initial behaviour change will take place. Small but effective changes will begin to surface for example; a smoker will begin to follow a plan to quit smoking. Following a successful action smoker's will move to the maintenance phase to ensure that the changes remain also known as stage five of the TTM. Once entering maintenance he/she will find ways to prevent relapse and continue with their modification. The final stage of the TTM is known as the relapse or a stage of termination, one can either continue to maintain their new healthier habits and refrain from returning to their negative behaviour or they can enter the stage of relapse, which will result in them returning to their original behavioural habit and the process will begin again (Prochaska and Velicer 1997).

The stages of change discussed prior, exhibit a coherent understanding of how behavioural shifts occur via the six stages, however the TTM assumes that for an individual to move through these six stages they experience specific processes of change (POC) and motivational facet which explicitly describe how these movements occur (Aveyard, Massey, Parsons, Manaseki, Griffin 2008). There are 10 major POC variables which include consciousness raising, dramatic relief, environmental control, self re-evaluation, and commitment. (Prochaska, Redding and Evers 2008) The initial five behavioral processes are commonly emphasized during the pre contemplation, contemplation stages and preparation stage (early stages) whilst the remaining processes, such as commitment, social liberation, helping relationship, reward, countering conditioning and stimulus control, are generally experienced significantly more during the action and maintenance stages (later stages) (Prochaska, Redding and Evers 2008).

Decisional balance and self-efficacy have been noted to be key initial tools which individual's employ during the precontemplation and contemplation stages (Velicer, DiClemente, Rossi and Prochasks 1990). Decisional balance is defined as a process in which an individual weight's out the positive and negative aspects of smoking, together with defining the consequences if decided not to quit and the potential benefits, if a change is determined (Prochaska, Velicer, Rossi, Goldstein, Marcus, Rakowski, Fiore et al (1994). Prochaska et al 1997, suggests that decisional balance occur throughout the stage transition, as individuals continuously questions and re evaluate their motives to change, with the assumptions that individuals pros and cons differ at each stage. Similarly, self efficacy is a prominent process for the TTM. Introduced by Bandura (1994) self efficacy is defined as the method in which people think, behave and motivate themselves to achieve a goal. Bandura (1994) believes that when individuals uphold a belief in their self efficacy, this belief can alter their life choice, quality of functioning and resilience to vulnerability. In relation to the TTM, self efficacy and decisional balance are important facet which are targeted by the therapist throughout the process of change. The manner in which these are implemented will be discussed further.

The TTM upholds a variety of assumptions which drive this model. Prochaska et al (1997) suggests that the TTM allows the movement of interchangeable, bio directional behaviour, which other models may not permit. The TTM also assumes that without stage matching individuals to a specific phase there would be no intrinsic motivation for them to change (Prochaska, DiClemente and Norcross, 1992). In similar respect, stage based interventions are reasonably popular and widely acknowledged as a resource which aids in altering a behaviour habit such as smoking. Models such as the TTM "closes the gap" for many standard smoking cessation interventions, which only usually support potential quitters at the preparation stage, whist the TTM assists throughout the pre contemplation to maintenance stage (Aveyard, Massey, Parsons, Manaseki and Griffin, 2008).

The applicability of the TTM is not questionable the model has been applied to a range of differential health behaviours, such as smoking, diet (Spencer, Wharton, Moyle and Adam, 2007), alcohol misuse (Migneault, Adams and Read, 2005) and many other facets of behavioural change. Researches devoted to understanding how beneficial the TTM is when applied to health behaviours such as smoking are limitless to date. The general argument for this model suggests that interventions such as smoking cessation programmes should be developed based on the stage which the smoker is currently on (Prochaska and Goldstein, 1991), for example if they are precontemplating about giving up smoking, the therapist should encourage the smoker to think about the cost and benefits of giving up their smoking habit (decisional balance). In comparison to other smoking cessation techniques the TTM differs significantly. Previous stop smoking strategies have taken a more explicit action orientated stance, these models believed that every individual is ready to quit and by simply following specific guidelines of the cessation program they would successfully quit smoking (Fava, Velicer and Prochaska, 1995). However, the TTM differs; its theoretical concepts suggest that every individual is not from a homogenous stance in regards to their readiness to change. Which implies that standard smoking cessation programs would not be so effective as previously thought (Velicer and DiClemente, 1993).

This leads to a vital question, is a stage by stage process of behaviour change (TTM) more effective than a standard intervention for smoking cessation?

A study carried out by Aveyard and Colleagues (2008) compared both interventions, one which was theoretically developed based on the TTM in comparison to a conventional smoking cessation programme. They found no significant difference between both interventions, they suggested that previous effects of TTM may have occurred because TTM interventions were more intense in comparison to standard smoking cessation intervention, yet, no apparent difference was noted. However, in its defence, Prochaska (2009) claims that the apparent criticism of the TTM is wrongly justified, he believes that the study undertaken by Aveyard and colleagues (2008) has many flaws and the study itself is problematic. In support of Prochaska's claims, a systematic review carried out by Riemsma, Pattenden, Bridle, Sowden, Mather, Watt, et al (2003), suggested that research which has examined the usefulness of TTM approached interventions may have only found limited effectiveness due to the way in which the model was being implemented in practice and not the model itself. Others feel that the TTM has serious flaws which are being ignored as many practitioners appeal to the model due to its accessibility and not because of its theoretical presence (Etter and Perneger, 1999). However, Riemsma and colleagues (2003) suggested that interventions which employ the processes of change appropriately and competently with smokers, obtained more successful outcomes for smoking cessation via a stage based approach.

Which coincide with the assumption of the TTM Prochaska et al (1997), proclaimed that in order to demonstrate successful outcomes via this approach, specific processes of change need to be expertly applied at each stage (Prochaska et al 1997). A study carried out by Plummer, Velicer, Redding, Prochaska, Rossi, Pallonen and Meier (2001) tested the decisional construct of the TTM by examining adolescent smokers and non smokers, they administrated the stage of change assessments to both groups. Participants were than measured via the decisional balance scale, the pro scale (advantages of smoking) and con scale (disadvantages of smoking). Some of the cons identified were, "smoking affects health" and pros, "smoking relieves tension and it's pleasurable". Plummer and colleagues (1997) also identified social pros such as, "kids who smoke, go out more on dates and kids who smoke have more friends". The results suggested that adolescences at the precontemplation stage had significantly lower cons in comparison to the other stages. These findings suggest that individuals decisional balance to quit smoking differs depending on their perception of importance, i.e. does the fact that, "smoking affects health" exhibit more importance for adolescence then "kids who smoke go out more on dates?" the choice may be quite obvious. Nevertheless, research such as this support the notion of tailored (stage approach) interventions, which proposes that strategies such as decisional balance scale can be one of the best predictors for future change, if implemented correctly within a population.

Models such as the TTM are accompanied by criticism from all disciplines, West (2005) believes that a replacement behavioural model is required, which accurately reflects the process of behavioural change, which the TTM lacks. This alternative model should be able to describe how people change with apparent unexpectedness. West (2005) believes that the TTM does not stimulate research as it's just a simplistic decision making model of behaviour, which has coincidentally become an important feature of understanding human behavioural change, instead adopting a common sense approach would be a more coherent model than the TTM.

In similar respect Adams and White (2004) have also criticised the stage boundaries of TTM. They believe that the lines between each stage are somewhat ambiguous. For instance, Prochaska (1997) claims that when a smoker decides to quit smoking they are by all means at the "preparation stage" if this is within the next 30 days however, they would be at the contemplation stage if this was within the next 31 days (Sutton 2001). These rigid boundaries between the stages are questionable which has encouraged researchers to question the theoretical structure of the TTM. Can human behaviour be assigned to stages which are so arbitrary?

However, numerous finding have supported the TTM evidently it has shown to provoke short term behavioural change (Adams and White 2004). Therefore, researches implementing the TTM have found it to be a good predictor of human behaviour (Prochaska et al 1997, 1994, 1993, 1991). Like other models, the TTM is static and as a psychological theory it does not completely account for other determinates, such as structural and environmental issues which can influence an individual's decision not to quit smoking.

Wider determinates such as individual and cultural differences, mental health, social circumstances, age and many other factors should be considered when addressing human behaviour, as it may clarify why some progress or fail to make alterations.

Which leads to a vital question, can the TTM be applied to specific population and different cultures? Is the TTM a cross cultural model?

Ma, Tan, Toubbeh and Su (2003) examined four Asian subgroups and established a significant difference between these groups. Their finding suggested that Cambodians were more likely to contemplate quitting within the next 6 months; whilst, Vietnamese were more likely to make a change within the month suggesting that they were already at the preparation stage. Finding such as these suggest that Cambodian folk may hold deferential belief about smoking in comparison to Vietnamese's and their perception of inhibiting a change may be dissimilar. Ma and Colleagues (2003) believe that the foundations of the TTM can be applicable within these populations, however the strategies employed i.e. processes of change differ within each culture, which should be considered in order to effectively target a wider population. Cross cultural research permits researchers to related models to wider populations to determine its applicability.

Similarly, age differences were also evidently significant Ma and colleagues (2003) found that 44 years plus individuals were 10 times more likely to quit in comparison to 24 years old and below. This difference can be better understood via the Health Belief Model (Rosenstock, Strecher and Becker, 1994) instead of the TTM. This Health belief model suggests that behavioral change occurs when the overall threat of the unhealthy actions outweighs its perceived benefits (Stecher and Rosenstock's 1997); in this instance younger individuals may not believe that they can develop cancer due to smoking in comparison to older smokers.

The applicability of the TTM has also been tested within a psychiatric population. Acton, Prochaska, Kaplan, Small and Hall (2001) examine the usefulness of the TTM by applying it to depressed individual who smoked. The results highlighted a correlation between the stages of change (TTM) in a clinical and a non clinical sample. The findings suggested that the movements between stages were quite similar and the use of behavioural processes (PCO) such as self efficacy, decisional balance, conscious raising and others increased individuals to shift from precontemplation to maintenance. Finding such as this supports the TTM applicability within a clinical population and can be successfully implemented.

Several prior researches mentioned have found that the TTM can be applied cross culturally and with a non clinical population. Nevertheless, it can be assumed that other models can also be incorporated within the TTM, such as the health belief model (Rosenstock and Colleagues 1994). The model can be applied within the precontemplation and contemplation stage for smoking cessation. The health belief model emphasis's on the notion of balancing the benefits, barriers and cues to action, which corresponds with the TTM readiness to change, which fits well with decisional processes of the TTM (Armitage and Conner 2001).

To conclude, this paper has suggested that a single model alone can not fully describe the process of human behavioral change; many facets contribute to individual's readiness to change and ultimately their level of self efficacy which was evident via Plummer and colleagues (1997) and Ma and colleagues (2003) age difference study.

Undoubtedly the model's underlying concepts have gained widespread popularity in health psychology (Littell and Girvin 2002). As its accessibility for therapist to assign individuals to a stage has encouraged many to adopt this model. Similarly the TTM encourages a coherent description when understanding smoking cessation and its powerful predictability has proven to be useful for many smoking cessation interventions (Crittenden, Manfredi, Warnecke, Cho and Parsons 1998). The dynamic and recurring process of the TTM suggests that the days of it being acknowledged as a linear model have far gone (Prochaska, DiClemente and Norcross (1992).

However, every model has its limitation and unfortunately human behavior is so sporadic that the efforts of one models trying to explain this would be unrealistic. With the belief that the TTM is just a simplistic model (West 2005) of complex behaviour and the ambiguous boundaries between stages (Adams and White 2004), researchers are encouraging many to abandon this model and search for an alternative.

Alternative models should be developed which examine individual's wider determents and the biological aspects which may alter or enhance ones self efficacy. This should encourage a deeper and holistic understanding of the complex mechanism of behavioral change.

Nonetheless, the TTM was developed on the basis of observing the process of how individuals quit smoking on their own and its overall efforts and its applicability has been useful (Prochaska, DiClemente, Velicer and Rossi, 1993). Taking this into account the TTM should be noted as a simple method in which to understand complex psychological and behavioural movements (Brug, Conner, Harré, Kremers, McKellar and Whitelaw 2004) as it hold an importance in behavioural literature.

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