Health Psychology, 2nd Edition

time) and maintenance of action (e.g. trying to stay quit). In contrast, in stage models
psychological determinants may change across such stages of behaviour change (see
Sutton, 2005, 2015 for a review). An important implication of the ‘stages’ view is that
different cognitions may be important determinants at different stages in promoting
health behaviour. The most widely used stage model is Prochaska and DiClemente’s
(1984) transtheoretical model of change (TTM). Their model has been widely applied
to analyse the process of change in alcoholism treatment and smoking cessation.
DiClemente et al. (1991) identify five stages of change: pre-contemplation (not think -
ing about change), contemplation (aware of the need to change), preparation (intending
to change in the near future and taking action in preparation for change), action (acting
to change) and maintenance (of the new behaviour) (see Figure 7.6). Individuals are
seen to progress through one stage to the next to eventually achieve successful main -
tenance. In the case of smoking cessation, it is argued that in the pre-contemplation
stage the smoker is unaware that their behaviour constitutes a problem and has no
intention to quit. In the contemplation stage, the smoker starts to think about chang -
ing their behaviour, but is not committed to try to quit. In the preparation stage, the
smoker has an intention to quit and starts to make plans to quit. The action stage is
characterized by active attempts to quit and after 6 months of successful abstin ence
the individual moves into the maintenance stage. This stage is characterized by attempts
to prevent relapse and to consolidate the newly acquired non-smoking status.
While the model is widely applied, the evidence in support of stage models and
different stages is relatively weak (see Sutton, 2000, 2005, 2015). Sutton (2000) con -
cludes that the distinctions between TTM stages are ‘logically flawed’ and based on
‘arbitrary time periods’. Moreover, even Prochaska and DiClemente’s (1984) own data
do not suggest that smokers typically progress through the TTM stages sequentially.
For example, in one study, Prochaska et al. (1991) found that only 16 per cent of
participants progressed from one stage to the next without reversals over a two-year
period and that 12 per cent moved backwards during the same period! In addition, it
has proved especially difficult to support the key prediction that there are different
determinants of behaviour change in different stages. The best evidence for stage
models would be where we showed that interventions matched to individuals’ stage
of change were more effective in producing behaviour change than interventions mis -
matched to an individual’s stage (although see also Abraham, 2008). So, for example,
in a matched intervention, outcome expectancies might be targeted in individuals in

HEALTH COGNITIONS AND BEHAVIOURS 153

Pre-contemplation Contemplation Preparation Action Maintenance

Movement through stages

FIGURE 7.6The transtheoretical model of change stage theory.