‘applying processes like contingenc

‘applying processes like contingency management, counterconditioning,
and stimulus control to people in precontemplation
would represent a theoretical, empirical, and practical mistake’.
From this perspective, it could be argued that the theoretical
advantage of TTM-based materials is that they direct the attention
of users to stage-appropriate processes, whereas standard materials
do not direct users so clearly.
Prochaska and Velicer (1997) suggest that standard ‘actionorientated’
self-help guides will not be read by precontemplators
because they are not appropriate and therefore appealing to
them. A straightforward reading of our control intervention
shows it is orientated towards those who want to stop smoking in
the near future, while the TTM-based guide is different. The TTM
manual talks of a journey, explains how to stage one’s self,
explains the notion of precontemplation, and has exercises, for
example how to resist pressure from others to stop smoking, that
clearly indicate to the precontemplator that stopping smoking is
distant. However, Herzog and Blagg (2007) suggest that assuming
that most people in precontemplation are not interested in
stopping smoking is wrong. Many quit attempts appear
unplanned and they may be more successful than those that
result from planning (West & Sohal, 2006), which challenges the
notion of steady progress through the stages is the norm. Forty six
percent of the UK population try to stop smoking each year (West,
2006), more than half intend to stop in the next year, while only
12% intend to stop in the next month (Taylor, Lader, Bryant, Keyse,
& Joloza, 2006). Among precontemplators in this study, only 22%
expressed no desire to stop smoking, while for 25% desire was
strong or very strong. Among precontemplators, 24% of those who
expressed no intent to quit in the next 6 months actually
attempted to quit within 3 months of reporting this. It might
therefore be the case that the staging algorithm underestimated
the interest of some precontemplators and contemplators. They
were directed by the manual and letter to read the precontemplation
and contemplation chapters that urged processes
of change that were inappropriate for their interest in stopping
and hence mismatched.
Our content analysis of a standard self-help guide to stopping
smoking showed that the booklet urged use of the processes of
change in the pre-quitting section that were appropriate in precontemplation,
contemplation, and preparation. In the post-quitting
section, it was also largely appropriate that use of the
processes of change should be advocated for action and maintenance
as judged by the TTM. We strongly suspect that any similar
analysis of standard self-help materials will reveal that such
materials are largely appropriate for all the stages. For example,
giving reasons to stop smoking (consciousness raising) is
appropriate for precontemplation and contemplation and setting
a quit day (self-liberation) is appropriate for preparation. Advising
people who are just stopping to remove their ashtrays (stimulus
control), save the money they would have spent on cigarettes for
rewards (contingency management), to drink water when they
feel the urge to smoke (counter-conditioning), or to get their
partner to congratulate them and maintain their morale when
stopping smoking (helping relationships) are appropriate for
action. Thus, standard smoking cessation counselling tends to
urge use of processes of change appropriate for pre-cessation
stages to those in precontemplation to preparation and use of
processes of change appropriate for the cessation stages. The key
questions are whether using all the processes of change appropriate
for precontemplation is helpful, but such detail is not
specified currently in the TTM.
Testing the hypothesis that stage matching is more effective
than stage mismatching therefore requires advising deliberately
wrong strategies, as standard materials are somewhat stagematched.
However, this has to be subtle to avoid being absurd. It
would not be credible to advise someone to throw away his or her
ashtrays (stimulus control) until they had stopped smoking or set
a quit day (self-liberation) until they felt ready to do this. Rather,
they need to be advised to re-evaluate their self-image in precontemplation
(mismatched) or be asked to consider the harm
smoking does to others around them and the environment
(matched). Apart from substituting consciousness raising or
dramatic relief for environmental reevaluation in the above
example, it is hard to think of any meaningful test of stage matching
within the TTM that does not include offering absurd advice.
Perhaps this explains why true stage-mismatch studies are rare,
with only one published in the field of smoking cessation (Dijkstra,
Conijn, & De Vries, 2006). This study used social cognitive theory,
not the TTM, and the matched/mismatched interventions were
based on decisional balance and not the processes of change. In the
TTM, the processes of change are described as the independent
variables (Prochaska & Velicer, 1997) and the pros and cons (decisional
balance) as mediators of change (Velicer et al., 1996).
Although Prochaska (2006) has interpreted tests of stage-based
versus non-stage-based materials as mismatch studies, our analysis
shows this is not necessarily the case. Content analyses of these
interventions, as we did, would be needed to substantiate this
assumption.
This study had various strengths and weaknesses. The
advantage of randomised trials is that they distribute confounders
evenly, but with sub-group examining the moderation by baseline
stage, this is not guaranteed. Nevertheless, adjusting for a widerange
of potential confounders made negligible difference to the