Subtypes within the precontemplation stage of adolescent smoking acquisition

Abstract

The present study examined the existence of three possible subtypes within the precontemplation stage of smoking acquisition: committers, immotives, and progressives. The sample of the study included young people from six European countries (mean age=13 years) who had never smoked regularly (n=21 535). A cross-sectional design was used to assess cognitive determinants of smoking behavior: attitudes towards smoking, perceived social influences, and self-efficacy to remain a nonsmoker. Adolescents within the various stages of smoking acquisition were compared with regard to standardized T scores on these risk factors. The results showed that adolescents in the three subgroups of precontemplation differed from each other on every cognitive determinant tested, revealing a higher risk to start smoking among progressives than among immotives. Immotives revealed a higher risk to start smoking than committers. It is concluded that the use of subtypes within acquisition precontemplation in research on adolescent smoking may be a promising tool for investigating the initiation continuum and for improving the quality of both the implementation and evaluation of prevention programs.

Introduction

Although the stages of change construct (SCC; Prochaska & DiClemente, 1983) was originally developed to study adult smoking cessation within the transtheoretical model of change (TTM; DiClemente & Prochaska, 1982, DiClemente et al., 1991, Prochaska & DiClemente, 1983), it has also been applied to adolescent smoking cessation and acquisition Elder et al., 1990, Kelley et al., 1999, Pallonen, 1998, Pallonen et al., 1998, Stern et al., 1987, Werch & DiClemente, 1994. The TTM of smoking acquisition can be regarded as the mirror image of the cessation model (Stern et al., 1987). The SCC distinguishes three stages of smoking acquisition (Pallonen et al., 1998), defined as acquisition precontemplation (no intentions to start smoking in the next 6 months), acquisition contemplation (thinking about starting to smoke in the next 6 months), and acquisition preparation (thinking about starting to smoke in the next 30 days).

Especially among early adolescents, a large majority of the population is in the precontemplation stage of smoking acquisition. The prevalence of acquisition precontemplators within the nonsmoking adolescent population has been found to be over 90% Aveyard et al., 1999, Pallonen et al., 1998. Since a large percentage of adolescents eventually will start smoking, the precontemplating group might be diverse with regard to predictors of smoking initiation. The possibility to provide finer discriminations makes identification of subtypes within a large group of precontemplators desirable (Crittenden, Manfredi, Lacey, Warnecke, & Parsons, 1994). Finer discriminations within acquisition precontemplators enable the possibility to provide accurate health education messages to a target group of nonsmoking adolescents.

Identification of possible subgroups within the precontemplation stage has been the subject of recent research on adult smoking cessation Crittenden et al., 1994, Dijkstra et al., 1997, Dijkstra et al., 1998, Norman et al., 2000, Velicer et al., 1995. Two clearly interpretable subgroups within precontemplation have been identified. Velicer et al. (1995) identified a subgroup of precontemplators ‘clearly ready to move to the contemplation stage’ that was labeled ‘progressives.’ A subgroup of precontemplating smokers who plan not to quit within the next 5 years has been labeled ‘immotives’ (Dijkstra et al., 1997; Velicer et al., 1995). Consequently, immotives are thought to be more remote from contemplation than the progressive subgroup. Norman et al. (2000) recently replicated and externally validated the existence of these subtypes within a representative sample of adult smokers. Perhaps the distinction between immotives and progressives could also be made for the acquisition stages of adolescent smoking.

A third possible subgroup within acquisition precontemplation may consist of adolescents who have a strong commitment not to smoke. The concept of commitment to nonsmoking, labeled as ‘non-susceptibility,’ is introduced by Pierce, Farkas, Evans, & Gilpin (1995). The move to start smoking may be influenced by the absence of a firm decision not to smoke Choi et al., 1997, Pierce et al., 1996, Unger et al., 1997. Measuring the intention to start smoking at some time in the future might not distinguish the children who have really thought consciously about being a nonsmoker from those who have not rationally decided not to smoke. Where immotives also plan never to start smoking, but lack the strong decision not to smoke, adolescents who are firmly committed to nonsmoking (‘committers’) might be more remote from the contemplation stage than immotives.

Over the past decades, much effort has been put into explaining and predicting adolescent smoking initiation Conrad et al., 1992, Tyas & Pederson, 1998. In their review of theories of adolescent substance use, Petraitis, Flay, & Miller (1995) conclude that attitudinal, social, and self-efficacy components are useful motivational (proximal) determinants to predict and explain adolescent smoking behavior. All other levels of influence are believed to exert little effect on adolescent substance use unless they first affect these substance-specific cognitions (Petraitis et al., 1995). For example, the attitude–social influence–efficacy (ASE) model De Vries et al., 1988, De Vries & Mudde, 1998 proved to be of value in explaining and predicting adolescent smoking behavior De Vries et al., 1995, De Vries et al., 1988, Mudde et al., 1999.

Findings in several studies suggest that the stages of change not only differ because of differences in intentions to smoke, but also because of differences in the impact of the cognitive determinants of smoking (Velicer, Norman, Fava, & Prochaska, 1999). Cognitive determinants, referred to as dynamic constructs in the TTM, have been shown to differ between the various stages of change of smoking cessation Prochaska & DiClemente, 1984, Prochaska et al., 1991, Velicer et al., 1999. Findings in studies using the ASE model have resembled these differences, despite the use of different cognitive constructs De Vries & Backbier, 1994, De Vries et al., 1998, Dijkstra et al., 1996.

The objective of the present paper is to investigate the identification of the concepts of commitment, immotivation, and progressiveness as different subtypes within the precontemplation stage of adolescent smoking acquisition. The usefulness of a more detailed description of the acquisition precontemplation stage was tested by assessing differences between the various subgroups regarding cognitive predictors of smoking behavior. It was hypothesized that adolescents in the commitment phase would score higher than immotives with regard to nonsmoking attitudes, perceive less negative social influences with regard to smoking, and have higher self-efficacy with regard to refraining from smoking. Immotives are expected to show the same pattern when compared to progressives.