Processes of Change Questionnaire – Smoking

Abstract

The Processes of Change Questionnaire – Smoking (POC-S) is a foundational psychometric instrument developed within the Transtheoretical Model of Behavior Change (TTM) to measure the covert and overt cognitive, affective, and behavioral activities that individuals use to modify their smoking habits. Initially operationalized by James O. Prochaska, Wayne F. Velicer, Carlo C. DiClemente, and Joseph L. Fava (1988), the instrument quantifies ten distinct processes of change divided into two higher-order dimensions: Experiential (Cognitive-Affective) Processes (Consciousness Raising, Dramatic Relief, Environmental Re-evaluation, Self-Re-evaluation, and Social Liberation) and Behavioral Processes (Reinforcement Management, Counter Conditioning, Helping Relationships, Self-Liberation, and Stimulus Control). The standard assessment comprises 40 items (4 items per subscale), with a validated 20-item short-form inventory (2 items per subscale) frequently utilized in epidemiological, clinical, and ecological momentary research.

Each item is rated on a 5-point Likert scale ranging from 1 (“Never”) to 5 (“Repeatedly”), evaluating the frequency with which a participant utilizes specific cognitive strategies or behavioral modifications over a defined temporal referent (typically the past month). Psychometric investigations have repeatedly confirmed robust internal consistency, with subscale Cronbach’s alpha coefficients routinely ranging from .69 to .92 across clinical and community samples. Confirmatory factor analysis has demonstrated strong empirical support for a hierarchical model specifying ten correlated first-order factors subsumed under two correlated second-order constructs. The POC-S exhibits exceptional predictive, convergent, and discriminant validity, serving as an indispensable tool for characterizing stage-process interactions, tailoring stage-matched smoking cessation interventions, and tracking dynamic mechanisms of therapeutic change in both clinical trials and population health initiatives.

Keywords

Processes of Change Questionnaire, Transtheoretical Model, Smoking Cessation, Experiential Processes, Behavioral Processes, Psychometrics, Prochaska, DiClemente, Cognitive-Affective Strategies, Stimulus Control, Self-Liberation, Nicotine Dependence, Construct Validity, Factor Analysis.

Authors

The Processes of Change Questionnaire for Smoking was developed and validated by a consortium of leading clinical psychologists and quantitative psychometricians associated with the Cancer Prevention Research Center (CPRC) at the University of Rhode Island and subsequent research collaborative sites:

• James O. Prochaska, Ph.D. — Emeritus Professor of Psychology and former Director of the Cancer Prevention Research Center, University of Rhode Island, Kingston, RI, USA. A primary architect of the Transtheoretical Model of Behavior Change.
• Wayne F. Velicer, Ph.D. — Late Professor of Psychology and Co-Director of the Cancer Prevention Research Center, University of Rhode Island, Kingston, RI, USA. Renowned for quantitative psychometrics, structural equation modeling, and longitudinal data analysis in health psychology.
• Carlo C. DiClemente, Ph.D. — Emeritus Professor of Psychology, University of Maryland, Baltimore County (UMBC), Baltimore, MD, USA. Co-originator of the Transtheoretical Model, specializing in addictive behaviors, alcoholism, and smoking cessation.
• Joseph L. Fava, Ph.D. — Senior Research Associate and Quantitative Psychologist, Cancer Prevention Research Center, University of Rhode Island, Kingston, RI, USA. Specialized in behavioral epidemiology, intervention measurement, and statistical design.
• Joseph S. Rossi, Ph.D. — Professor of Psychology and Director of Research Methodology, Cancer Prevention Research Center, University of Rhode Island, Kingston, RI, USA. Expert in health promotion measurement, psychometrics, and quantitative methodology.

Purpose

The primary clinical and empirical purpose of the Processes of Change Questionnaire – Smoking (POC-S) is to identify and measure the psychological and behavioral mechanisms through which individuals modify their nicotine consumption and achieve long-term abstinence. While the stages of change within the Transtheoretical Model delineate when an individual intends or attempts to change a behavior (Precontemplation, Contemplation, Preparation, Action, Maintenance), the processes of change measure how that transition occurs. Understanding these mechanisms is vital for overcoming the limitations of uniform, “one-size-fits-all” smoking cessation programs.

Theoretical Rationale and Clinical Utility

Early behavior change paradigms frequently treated cessation as a binary, discrete event: an individual was either actively smoking or abstinent. In contrast, the theoretical rationale underlying the POC-S posits that successful self-change or guided clinical cessation requires an individual to initiate specific internal cognitive appraisals and external behavioral adjustments in a dynamic sequence. Clinical applications of the POC-S include:

• Diagnostic Baseline Profiling: Assessing an individual’s reliance on specific coping strategies upon entry into clinical treatment to detect deficits in cognitive motivation or behavioral preparedness.
• Stage-Matched Intervention Design: Tailoring therapeutic interventions directly to the client’s current process profile. For instance, individuals in Precontemplation or Contemplation require consciousness-raising and emotional arousal (dramatic relief), whereas individuals in Action require concrete behavioral strategies like counter conditioning and stimulus control.
• Process Tracking and Relapse Prevention: Monitoring changes in process utilization throughout active treatment to evaluate intervention compliance and identify premature tapering of behavioral processes, which typically precedes smoking relapse.
• Comparative Effectiveness Research: Serving as a standardized mediator variable in clinical trials evaluating pharmacotherapies, cognitive behavioral therapy (CBT), motivational interviewing, and digital cessation platforms.

Psychological Construct

The psychological construct measured by the POC-S consists of the Processes of Change, defined as covert (internal cognitive and affective appraisals) and overt (external actions and environmental manipulations) activities that individuals engage in to modify experiences, emotional reactions, behavior, or living conditions related to smoking. The instrument operationalizes ten distinct processes grouped into two overarching higher-order domains.

Experiential (Cognitive-Affective) Processes

Experiential processes involve internal shifts in attitudes, values, emotional reactions, and social perceptions. These processes predominate during the early, deliberative stages of smoking cessation:

1. Consciousness Raising (CR): The acquisition and processing of information regarding the causes, consequences, and solutions for tobacco dependency. Individuals read articles, assimilate educational material, and engage in cognitive recall of cessation benefits (e.g., Item 10: “I think about information from articles and advertisements on how to stop smoking”).
2. Dramatic Relief (DR): Experiencing and expressing affective and emotional arousal prompted by the negative consequences of smoking. It entails emotional responses to health warnings, personal fear of illness, and cathartic relief when considering cessation (e.g., Item 30: “Warnings about the health hazards of smoking move me emotionally”).
3. Environmental Re-evaluation (ER): Appraising the affective and physical impact of one’s smoking behavior on one’s social and physical environment, including secondhand smoke hazards and ecological pollution (e.g., Item 21: “I stop to think that smoking is polluting the environment”).
4. Self-Re-evaluation (SR): Cognitive and affective appraisal of one’s self-image with and without the smoking habit. It involves examining personal values, feelings of self-disappointment, and resolving the dissonance between one’s self-concept and one’s dependence on cigarettes (e.g., Item 38: “My dependency on cigarettes makes me feel disappointed in myself”).
5. Social Liberation (SL): Noticing and utilizing public and social opportunities that support smoking-free lifestyles, such as smoke-free legislation, public smoking bans, and changing cultural norms favoring nonsmokers (e.g., Item 24: “I find society changing in ways that make it easier for the nonsmoker”).

Behavioral Processes

Behavioral processes involve active, overt actions implemented to alter the immediate environment, manage contingencies, and establish alternative behaviors. These processes become dominant as individuals transition into preparation, action, and maintenance:

6. Counter Conditioning (CC): Substituting healthier cognitive or physical behaviors for cigarette smoking. Common substitutes include physical activity, relaxation exercises, or using one’s hands for alternative tasks (e.g., Item 5: “Instead of smoking I engage in some physical activity”).
7. Helping Relationships (HR): Seeking, establishing, and trusting supportive interpersonal connections wherein significant others provide emotional validation and open discussion regarding cessation challenges (e.g., Item 14: “I have someone who listens when I need to talk about my smoking”).
8. Reinforcement Management (RM): Implementing explicit rewarding contingencies for remaining smoke-free. This incorporates self-praise, self-rewards, and receiving positive reinforcement or praise from significant others for not smoking (e.g., Item 19: “I reward myself when I don’t smoke”).
9. Self-Liberation (SLb): The belief that one can change, coupled with the explicit commitment to act. This encompasses the enhancement of self-efficacy and making personal resolutions or formal pledges not to smoke (e.g., Item 18: “I make commitments not to smoke”).
10. Stimulus Control (SC): Restructuring the physical and social environment to remove triggers, cues, and antecedents associated with smoking, while introducing prompts that encourage smoke-free behavior (e.g., Item 15: “I remove things from my home that remind me of smoking”).

Theoretical Framework

The POC-S is anchored in the Transtheoretical Model of Behavior Change (TTM), formulated by James O. Prochaska and Carlo C. DiClemente in the late 1970s and early 1980s. The TTM originated from a comparative comparative integration of over 300 psychotherapy theories—including psychoanalytic, humanistic, gestalt, cognitive, and behavioral traditions—synthesizing their core intervention techniques into a comprehensive model of human self-change.

Core Dimensions of the Transtheoretical Model

The TTM operates across four distinct theoretical dimensions:

• Stages of Change: Represents the temporal and motivational dimension across five progressive epochs: Precontemplation (no intention to quit within 6 months), Contemplation (considering quitting within 6 months), Preparation (planning to quit within 30 days and taking initial steps), Action (overt abstinence for less than 6 months), and Maintenance (sustained abstinence exceeding 6 months).
• Processes of Change: Represents the strategic independent variables (the cognitive, affective, and behavioral engines) that individuals apply to navigate transitions between stages.
• Decisional Balance: Derived from Janis and Mann’s decision-making model, evaluating the cognitive weighing of the “Pros” versus the “Cons” of smoking.
• Self-Efficacy / Temptation: Adapted from Albert Bandura’s social cognitive framework, measuring an individual’s situation-specific confidence that they will not smoke when confronted with diverse relapse triggers.

The Stage × Process Interaction Hypothesis

A central theoretical postulate of the TTM is that the effective utilization of processes depends strictly upon the current stage of change. Longitudinal and cross-sectional investigations (DiClemente et al., 1991; Perz et al., 1996) demonstrated that movement from Precontemplation to Contemplation is mediated by marked increases in experiential processes (Consciousness Raising, Dramatic Relief, Environmental Re-evaluation). Moving from Contemplation to Preparation involves heightened Self-Re-evaluation and emerging Self-Liberation.

Conversely, the transition from Preparation to Action, and the subsequent consolidation of Maintenance, necessitates a substantial increase in behavioral processes (Counter Conditioning, Stimulus Control, Reinforcement Management, and Helping Relationships). The theoretical mismatch—such as forcing behavioral strategies (e.g., stimulus control) onto individuals in Precontemplation—reliably induces client resistance and therapeutic failure. The POC-S provides the exact psychometric parameters needed to monitor and align these stage-process dynamics.

Validity

The psychometric validity of the POC-S has been evaluated across diverse epidemiological cohorts, outpatient clinical samples, and randomized clinical trials, confirming robust construct, convergent, discriminant, and predictive validity.

Construct and Structural Validity

In the seminal psychometric validation by Prochaska, Velicer, DiClemente, and Fava (1988), structural equation modeling (SEM) and confirmatory factor analysis (CFA) across a split-sample development and cross-validation cohort (total N = 970) validated the existence of the 10 first-order factors. When contrasting alternative measurement topologies, the correlated 10-factor model demonstrated superior goodness-of-fit over competing unifactorial or simple cognitive-versus-behavioral orthogonal structures. Subsequent cross-validation by Perz, DiClemente, and Carbonari (1996) confirmed the invariant loading patterns of the 40 items across both sexes, across varied socioeconomic brackets, and across treatment-seeking versus non-treatment-seeking smokers.

Predictive and Criterion Validity

The predictive validity of the POC-S is demonstrated by its capacity to forecast smoking cessation outcomes over 6-, 12-, and 24-month longitudinal follow-ups. Studies by DiClemente et al. (1991) revealed that contemplation-stage smokers who reported significantly elevated scores on Self-Re-evaluation and Self-Liberation were significantly more likely to advance to the Preparation and Action stages at 6-month follow-up compared to those with low process scores. Furthermore, Perz et al. (1996) tested the “doing the right thing at the right time” hypothesis, showing that individuals whose process utilization matched their baseline stage had significantly higher validated abstinence rates (odds ratios ranging from 1.8 to 2.4) than individuals utilizing mismatched processes.

Convergent and Discriminant Validity

Convergent validity is substantiated by significant correlations between the POC-S behavioral subscales (e.g., Counter Conditioning, Stimulus Control) and validated measures of self-efficacy (such as the Smoking Self-Efficacy Questionnaire, r = .42 to .58). Experiential subscales exhibit strong positive associations with the Decisional Balance “Cons of Smoking” subscale (r = .48 to .65) and measures of perceived vulnerability to illness. Discriminant validity has been demonstrated by showing that POC-S subscale scores correlate only weakly (typically r < .15) with measures of general social desirability, trait neuroticism, and negative affectivity, confirming that the scale reflects deliberate change-oriented coping rather than generalized distress.

Reliability

The reliability of the POC-S has been evaluated using classical test theory metrics, including internal consistency and temporal test-retest stability across various intervention contexts.

Internal Consistency

In the initial psychometric standardization by Prochaska et al. (1988), Cronbach’s alpha reliability coefficients for the ten 4-item subscales demonstrated high internal consistency across both the development sample (N = 574) and validation sample (N = 396):

• Consciousness Raising: α = .83 to .85
• Dramatic Relief: α = .80 to .83
• Environmental Re-evaluation: α = .82 to .86
• Self-Re-evaluation: α = .87 to .90
• Social Liberation: α = .69 to .73
• Counter Conditioning: α = .80 to .84
• Helping Relationships: α = .84 to .88
• Reinforcement Management: α = .80 to .84
• Self-Liberation: α = .79 to .83
• Stimulus Control: α = .78 to .82

The 20-item short-form inventory exhibits slightly reduced yet acceptable Spearman-Brown corrected reliability estimates, with subscale alphas generally ranging from .68 to .82, making it well-suited for large-scale epidemiological panels where survey length is constrained.

Test-Retest Stability

Because the POC-S is designed to capture state-dependent, dynamic change strategies rather than fixed personality traits, test-retest reliability varies logically as a function of the measurement interval and client stage stability. Across short, non-interventional intervals (1 to 2 weeks), Pearson correlation coefficients range from r = .78 to .89 across subscales among individuals remaining within the same stage. Over longer, 6-month clinical intervals, test-retest correlations decrease appropriately (r = .35 to .55), reflecting the natural and expected fluctuation of process utilization as individuals progress through the behavioral stages.

Factor Analysis

The underlying factor structure of the POC-S was established through a series of Exploratory Factor Analyses (EFA) and Confirmatory Factor Analyses (CFA), which elucidated both the primary dimensional structure and its hierarchical organization.

Exploratory Factor Analysis (EFA)

During scale development, an initial pool of over 100 candidate process statements was administered to adult smokers and ex-smokers. Principal Components Analysis (PCA) accompanied by oblique (Promax and Oblimin) and orthogonal (Varimax) rotations identified ten clean, interpretable factors with eigenvalues greater than 1.0. Four items per construct were selected based on high primary factor loadings (λ ≥ .55) and minimal cross-loadings (λ ≤ .25), yielding the definitive 40-item scale.

Confirmatory Factor Analysis (CFA) and Hierarchical Architecture

Subsequent structural modeling by Prochaska, Velicer, et al. (1988) tested competing structural configurations:

• Model 1: Single-Factor General Coping Model: Posited that all items loaded onto an undifferentiated change factor; this model was rejected due to poor fit (χ²/df > 5.8; RMSEA > .11; CFI < .60).
• Model 2: Uncorrelated 10-Factor Model: Assumed ten fully independent processes; also rejected due to substantial inter-factor covariances.
• Model 3: Correlated 10-Factor First-Order Model: Exhibited good fit across multiple sample splits (χ²/df = 1.84; RMSEA = .042; CFI = .94; TLI = .93), demonstrating that the ten constructs are distinct yet intercorrelated.
• Model 4: Hierarchical Second-Order Model: Positioned two correlated second-order factors—Experiential Processes and Behavioral Processes—to account for the correlations among the ten first-order processes. This hierarchical model demonstrated excellent statistical fit and parsimony (χ²/df = 1.96; RMSEA = .044; CFI = .93; SRMR = .048).

In this hierarchical framework, Consciousness Raising, Dramatic Relief, Environmental Re-evaluation, Self-Re-evaluation, and Social Liberation load strongly onto the second-order Experiential factor (loadings from .62 to .86). In contrast, Counter Conditioning, Helping Relationships, Reinforcement Management, Self-Liberation, and Stimulus Control load onto the second-order Behavioral factor (loadings from .58 to .88). The correlation between the two second-order factors is moderate to high (r ≈ .60 to .75), reflecting their collaborative operation throughout recovery.

Instrument / Measurement Tool

The Processes of Change Questionnaire – Smoking exists primarily as a 40-item full-scale inventory, complemented by a psychometrically validated 20-item short form. It is a standardized, self-administered questionnaire that can be completed on paper, via computer, or through mobile digital assessment.

Key Structural Characteristics

• Administration Format: Paper-and-pencil or computerized self-report assessment.
• Number of Items: 40 items in the primary instrument; 20 items in the brief research inventory.
• Completion Time: Approximately 8 to 12 minutes for the 40-item version; 3 to 5 minutes for the 20-item version.
• Target Population: Adult and adolescent smokers, recent quitters, and individuals participating in smoking cessation programs.
• Temporal Referent: Current frequency of behaviors, typically evaluated with respect to the preceding month.
• Response Scale: 5-point Likert scale:
  • 1 = Never
  • 2 = Seldom
  • 3 = Occasionally
  • 4 = Often
  • 5 = Repeatedly

Subscale Scoring Mapping (40-Item Version)

Subscale scores are calculated by summing or averaging the items belonging to each process (each subscale ranges from 4 to 20 for raw sum scores, or 1.0 to 5.0 for mean scores). Standardized T-scores (Mean = 50, SD = 10) are frequently computed using normative stage-based tables.

• Experiential Processes:
  • Consciousness Raising: Items 6, 8, 10, 17
  • Dramatic Relief: Items 11, 30, 31, 32
  • Environmental Re-evaluation: Items 9, 21, 34, 39
  • Self-Re-evaluation: Items 25, 35, 36, 38
  • Social Liberation: Items 2, 7, 20, 24
• Behavioral Processes:
  • Reinforcement Management: Items 12, 19, 22, 33
  • Counter Conditioning: Items 5, 26, 27, 28
  • Helping Relationships: Items 1, 3, 14, 40
  • Self-Liberation: Items 4, 13, 16, 18
  • Stimulus Control: Items 15, 23, 29, 37

Subscale Scoring Mapping (20-Item Short Form)

The 20-item short-form inventory employs two items per subscale:

• Experiential Processes:
  • Consciousness Raising: Items 4, 11
  • Dramatic Relief: Items 7, 18
  • Environmental Re-evaluation: Items 6, 12
  • Self-Re-evaluation: Items 8, 15
  • Social Liberation: Items 3, 14
• Behavioral Processes:
  • Reinforcement Management: Items 5, 20
  • Counter Conditioning: Items 1, 17
  • Helping Relationships: Items 10, 16
  • Self-Liberation: Items 2, 13
  • Stimulus Control: Items 9, 19

Permissions & Fee and Test Year

The 40-item Processes of Change Questionnaire – Smoking was published in its definitive psychometric form in 1988 in the Journal of Consulting and Clinical Psychology by James O. Prochaska, Wayne F. Velicer, Carlo C. DiClemente, and Joseph L. Fava. The scale is protected under academic copyright held by the authors and the American Psychological Association (APA).

The original authors and the Cancer Prevention Research Center (CPRC) at the University of Rhode Island, along with the HABITS Laboratory at the University of Maryland, Baltimore County (UMBC), have historically placed these assessment materials in the public domain for non-profit academic research, clinical education, and healthcare program evaluation. Researchers and practitioners may administer the scale without licensing fees, provided that standard APA scholarly attribution is maintained. Commercial applications, proprietary software integrations, or for-profit clinical distribution require formal licensing permission from the copyright holders or authorized institutional repositories.

References

• DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59(2), 295–304. https://doi.org/10.1037/0022-006X.59.2.295
• Perz, C. A., DiClemente, C. C., & Carbonari, J. P. (1996). Doing the right thing at the right time? The interaction of stages and processes of change in successful smoking cessation. Health Psychology, 15(6), 462–468. https://doi.org/10.1037/0278-6133.15.6.462
• Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. https://doi.org/10.1037/0022-006X.51.3.390
• Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102–1114. https://doi.org/10.1037/0003-066X.47.9.1102
• Prochaska, J. O., Velicer, W. F., DiClemente, C. C., & Fava, J. L. (1988). Measuring the process of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology, 56(4), 520–528. https://doi.org/10.1037/0022-006X.56.4.520
• Velicer, W. F., Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. (1998). Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis, 38, 216–233.

13. Items of the Scale (Questionnaire)