Steps to Change: Smoking, Teens, and the Transtheoretical Model

A useful model that can be used to guide behavior change in teens (and adults) is the Transtheoretic Model (TTM). This model has been employed in research and clinical practice for at least the past thirty years. Created and used primarily to understand and treat persons with any addiction, the TTM defines at least five stages leading to sustainable behavior change. It has also been used to describe how an individual might begin to use a substance or engage in unhealthy behavior as a means to design prevention programs. For the purposes of this website, the TTM is used as the template for engaging and assisting teens towards eliminating tobacco from their life. First described by Prochaska and colleagues in 1983, the TTM defined five key stages of change. A brief summary is offered here, followed by a case study demonstrating how Prochaska’s stages of change relate to the terminology and design of this website.

The time before an individual is aware of the need for changing an unhealthy behavior is termed precontemplation. A teenager who is using tobacco may initially receive some positive feedback from peers, or find that use helps him or her to feel more autonomous from parents or a peer group. While teens have probably learned about the adverse health effects of tobacco use, this knowledge may not be a factor in their decision to use tobacco because they do not perceive any immediate health consequences.

Certainly, many teens suffer from mental health problems, including Depression, Anxiety, and Post Traumatic Stress Disorder. For these teens, tobacco use might offer some temporary relief from symptoms through a variety of mechanisms, both physiologic and social. Therefore, during the precontemplative phase, a teen may be resistant to discussing the risks of use or even talking at all about tobacco use directly. They will, however, often be willing to talk about other issues and behaviors of which they may not be aware as related to tobacco use. For example, a teen may complain of headaches, chest symptoms, or musculoskeletal pain.

Teens are typically also willing to talk about personal problems with a trusted adult who can assure a confidential and non-judgmental discussion. This is a key time for health care providers to show flexibility and skill by offering subtle messages that help the teen to think about the adverse effects of tobacco use without feeling that he or she is being subjected to lecture or condescension. For example, statements demonstrating empathy while offering support for developing healthier coping skills can set the stage for a later discussion about tobacco use. Many experts recommend open-ended questions and statements, such as:

“I really see that you are dealing very well with a difficult situation. When you are ready, I am available to talk about ways to cope with stress and also take better care of your body.”

“It sounds like your headaches are difficult to deal with and are affecting your life. Is there anything you are exposed to at home or in school that could be contributing to them?”

“You have certainly been through a lot of change and have grown a lot since the last time I saw you. I can see you are faced with a lot of complicated adult decisions. Is there anything you would like to talk more with me about?”

It is common to experience resistance from teens in the precontemplative stage, and therefore important to remember that their resistance is more than likely universal and not directed at an individual clinician or adult. Direct confrontation or taking a very rigid stance will likely be mutually frustrating, hence many experts talk about ‘rolling with resistance.’ Thus the goal should be to keep the teen engaged and not necessarily to get him or her to agree to quit tobacco use in the span of one visit. It is important to recognize resistance and acknowledge it without jeopardizing your relationship with the teen.

Once the teen is willing to talk about tobacco use as something that needs to change, they have entered the contemplation phase of behavior change. While there is no discrete event that signals when an individual is ready to consider quitting, signs include a less defensive attitude towards discussing tobacco use and proactive questioning about ways to quit. Typically, the teen has been educated and has accepted the immediate and long term consequences of continuing tobacco use. They may be open to positive messages about the benefits of quitting. This is also a time when they can begin exploring alternative coping strategies or other lifestyle changes to replace the perceived benefits of continuing tobacco use. This is the optimal time to expose the teen to successful quit stories, information about various strategies to quitting, and helping them to identify the situations, acquaintances, and other factors that lead to them using tobacco.

Once an individual has made the decision to quit, they have entered the preparation phase. This is the time to begin forming and implementing a concrete quit plan. Anticipating withdrawal effects from decreased nicotine and other chemicals, and planning for continued cravings is crucial to successfully navigating the quit plan. A specific quit date should be identified by the patient, ideally during a period when little or no additional stressors are expected and when social support can be maximized.

The teen who wants to try a ‘cold turkey’ approach as an impulsive decision poses an interesting challenge. While the decision is a positive one, going ‘cold turkey’ without preparing for the after effects of sudden discontinuation can lead to frustration and hopelessness. It is usually best to take a non-judgmental, supportive approach with any quit plan so that the teen does not feel that he has let anyone down if he is not successful at quitting on the first or repeat attempt. Reassurance that it takes several times before most adults are ultimately successful can encourage them to keep trying.

Including family members can be crucial, particularly if a member of the household is a current tobacco user. Little research exists to determine whether having a ‘quit buddy’ is helpful, whether the buddy is a close family member or a peer. Nicotine replacement therapy (NRT) can be used while they are cutting down with care that they are not getting nicotine above their usual tobacco intake. Ideally, teens will understand that nicotine replacement is to minimize withdrawal effects from nicotine, and does not replace the urge for oral stimulation, the positive psychological and cardiovascular effects of deep breathing, or the role that tobacco use might play in social contexts. Additionally, increasing attention is being paid to the role smoking may have in teens and adults who suffer from depression and/or anxiety. Therefore any mood or anxiety symptoms should be monitored by a health care provider while a teen is reducing and eliminating tobacco.

Successful completion of a quit plan leads to the action phase, typically referring to the first 6 months after quitting. While many experts refer to the time before quitting as ‘taking action’, it is the immediate period after quitting that new patterns of behavior must be firmly established in order to prevent relapse. For example, after a teen has recovered from nicotine withdrawal, much of which may have been ameliorated by cutting down before quitting or NRT, there may be a feeling of disappointment or disillusionment. As their lungs clear mucus and foreign materials, they may actually report feeling more respiratory symptoms than when they were smoking. Curtailing tobacco use might also affect the quality of peer relationships, or result in increased feelings of anxiety in social situations.

These negative symptoms and feelings may lead to doubts about the wisdom of quitting. Therefore, specific behaviors should be addressed in order to address these factors. For example, an exercise plan can be very helpful in helping a teen feel better about their body, experience the positive effects of deep breathing and cardiovascular activity, and serve as a way to diffuse anxiety and stressful feelings. Journaling and/or counseling can help a teen to establish better coping mechanisms. Ideally, by exposing the teen to resources and information, they will explore activities that will appeal to their emerging individuality.

After the initial months after quitting, the young adult enters the maintenance phase and will always be at increased risk of relapse. Therefore, patients who have quit smoking should be monitored and reminded of ways to stay tobacco free. They can be encouraged to self-monitor for negative patterns of behavior that have lead to tobacco use in the past. Taking ownership of peer relationships can be a crucial step in staying tobacco free. As they transition from your care to other primary care providers, they should be encouraged to inform future health care providers of their prior tobacco use so that monitoring can continue well into adulthood.

For full references of published articles about the TTM and cessation, please go to the
“Tools and Handouts” section of the website, or click here.

Case example:

Rex is a 16 year old patient who you have known for many years.  His parents have always been very attentive to his medical care, to their credit he has received all of his immunizations and has never missed an annual check-up.  Prior to a pre-sports participation physical exam, his father tells you that he has been aware of signs of cigarette smoking for several weeks.  He has attempted to talk with Rex, but Rex has been evasive.  He wonders if you would be willing to help Rex quit.

Due to expanded adolescent immunization recommendations, requirements for sports participation physicals, pre-drivers exam physicals, and pre-college physicals, there are many opportunities to screen and advise teens around tobacco use.  After making sure that the patient understands the benefits and limitations of provider-patient confidentiality, it is best to ask open ended, non-judgmental questions in a routine manner.  If her ardently denies tobacco use, or is evasive in spite of evidence that he is using, he may not trust that you will not discuss with his parents or not be ready to talk about it within someone he assumes will judge or try to change his behavior.  Clearly he is in a precontemplative stage of change, so it is best to simply offer reassurance about the nature of your relationship and information on getting the most of his health care visits.  You can then offer advice to the concerned parent about directly confronting their son when the find evidence or smell tobacco, as well as reminding them that you are available to work with Rex once he is willing.

Alternatively Rex may be willing to talk with you about his tobacco use. After Rex has indicated that he has tried cigarettes, one could start an intervention by asking whether he thinks his tobacco use is a problem.  A follow-up or alternative approach is to ask if he thinks cigarette use relates to other problems he is having. If Rex indicates that it is not a problem for him in any way, and that there is no reason to change, he is in the precontemplative stage. In the precontemplative stage, clinicians can aim to challenge assumptions and stimulate the patient to think more about how the recommended change can be beneficial (rewards) as well as risks of not changing.  If he indicates that is a problem, or causing problems, but he is not convinced this is the right time to cut down or quit, he may be in the contemplative stage.  During this time, Rex may begin thinking more concretely about ways he can improve his health.  Here, the clinician can assist with helping him set priorities and guide him to thinking about changing his dietary routines, physical activity, and building other healthy coping methods.  As he moves to the preparation stage, it is wise to identify and anticipate barriers.  For example, Rex may express concern that discontinuing tobacco use will interfere with his social life or cause withdrawal symptoms such as insomnia.  Once he identifies barriers, it provides an opportunity to challenge him to think about alternatives to social norms, ways to talk with peers, parents, and other trusted adults, and to explore new ways to spend time with friends.  Rex is in the action phase when he is ready to commit to a concrete quit plan.  This is the time when a clinician may realize optimal benefits from nicotine replacement therapy or referrals to programs to assist with quitting. After Rex has successfully quit, he has entered the maintenance phase of behavior change.  This is the time to continue providing regular follow-up and encouragement, as well as monitor for relapse.  An adjunct to the TTM involves helping Rex to identify how his unhealthy behaviors are useful to him as a means of dealing with stress.  Reviewing with him ways that he copes with stress, both when there is identifiable problem to solve and in dealing with stress in general.  He may benefit from developing new coping mechanisms.  Involving his family or anyone else close to him can be very helpful.