7.3 The process of quitting
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In simple terms, quitting smoking has two major components: making an attempt and maintaining cessation once quit. These two tasks do not necessarily have the same predictors. For example, nicotine dependence is the most important predictor of smoking cessation, whereas motivational factors are only related to the likelihood of making an attempt to quit.11
For most people, changing from being a smoker to a non-smoker is a complex and difficult journey rather than a single event. One widely used way of describing this process is the 'stages of change' or Transtheoretical Model (TTM) of Prochaska and DiClemente.43 Without going into the model in detail, the core stage definitions used are:
1. Precontemplation, during which a smoker is not thinking about quitting in the next six months.
2. Contemplation, when a smoker begins to think seriously about quitting in the next six months.
3. Preparation, when a quit attempt is planned within the next 30 days.
4. Action, when a quit attempt is made lasting for at least 24 hours.
5. Maintenance, when the person becomes a non-smoker for at least six months.
These stage definitions are a useful framework for thinking about the different challenges facing a smoker. Inherent in the TTM and related conceptualisations is that a smoker may go back to earlier stages or cycle through a number of times before permanently quitting, although they may not follow the stages in sequential order.44–46
The Transtheoretical Model, or modifications of it, has been used in structuring or evaluating cessation programs and media campaigns. For example, the Smoking Cessation Guidelines for Australian General Practice instruct GPs to identify a patient's stage of readiness to change in order to tailor information.47, 48
Although this model has many critics, it remains widely used to understand cessation49–53 because it draws attention to the challenges in getting smokers interested in quitting, not just in implementing attempts. However, a major problem with the model is that the definitions of the stages are arbitrary,54 based either on time frames of intention or length of time quit. The exception is the transition between preparation and action, which occurs at an important milestone—when a quit attempt is made.55 The other stage classifications are unlikely to be optimal, and alternatives have been proposed.50, 51 For example, pre-quitting, it may be more useful to just use simplified categories of not interested, open to the possibility and actively planning. Post quitting, there is no consensus on what categories, if any, should be considered, but some evidence that the first month or so when strong cravings to smoke occur at least daily may be different to the subsequent period when cravings are less common.52
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