Smoking Decisional Balance Scales

1. Abstract

The Smoking Decisional Balance Scales (SDBS), developed by Wayne F. Velicer, Carlo C. DiClemente, and James O. Prochaska (1985), represent an essential psychometric operationalization of cognitive decision-making within the Transtheoretical Model (TTM) of behavior change. Rooted conceptually in the conflict model of decision-making formulated by Irving Janis and Leon Mann (1977), the SDBS quantifies the cognitive calculus individuals employ when evaluating cigarette smoking cessation. The instrument exists primarily in two validated formats: the comprehensive 20-item Long Form (SDBS-LF) and an efficient, psychometrically invariant 6-item Short Form (SDBS-SF). Both versions measure two distinct, orthogonal, higher-order dimensions: the Pros of Smoking (perceived positive reinforcement, sensory gratification, social facilitation, stress reduction, and affective regulation) and the Cons of Smoking (perceived negative physiological consequences, health hazards, adverse social feedback, self-reproach, and interpersonal impacts). Each item is evaluated on a 5-point Likert-type importance scale ranging from 1 (“Not important at all”) to 5 (“Extremely important”). Across diverse clinical, community, and cross-cultural epidemiological samples, both scales have demonstrated robust internal consistency (Cronbach’s α typically ranging from .82 to .93 for Pros, and .80 to .90 for Cons), stable structural invariance across stages of change (Precontemplation, Contemplation, Preparation, Action, and Maintenance), and robust predictive validity for smoking cessation attempts and point-prevalence abstinence. Standardized T-score conversions reveal a characteristic crossover phenomenon: in early stages, the Pros strongly outweigh the Cons; in Contemplation, the two dimensions converge; and from Preparation through Maintenance, the Cons substantially exceed the Pros. This article delivers a rigorous psychometric review of the theoretical foundations, factor structure, operational administration, scoring protocols, diagnostic utility, and empirical validity of the Smoking Decisional Balance Scales.

2. Keywords

Smoking Decisional Balance Scales, Transtheoretical Model, Stages of Change, Smoking Cessation, Pros and Cons, Decisional Balance, Wayne F. Velicer, James O. Prochaska, Nicotine Dependence, Health Psychology, Psychometrics

3. Authors

The Smoking Decisional Balance Scales were developed and validated through the Cancer Prevention Research Center (CPRC) at the University of Rhode Island and collaborating academic clinical research centers:

• Wayne F. Velicer, Ph.D. (1944–2017): Former Professor of Psychology and Co-Director of the Cancer Prevention Research Center, University of Rhode Island, Kingston, RI, USA. Renowned expert in factor analysis, structural equation modeling, component analysis, and behavioral measurement methodology.
• Carlo C. DiClemente, Ph.D.: Emeritus Professor of Psychology, University of Maryland, Baltimore County (UMBC), Baltimore, MD, USA. Co-originator of the Transtheoretical Model of behavior change and specialist in addiction dynamics and motivation.
• James O. Prochaska, Ph.D. (1942–2023): Former Professor of Clinical Psychology and Director of the Cancer Prevention Research Center, University of Rhode Island, Kingston, RI, USA. Lead architect of the Transtheoretical Model and pioneer of population-level health interventions.

Institutional Contact for Archives and Historical Instrument Documentation: Cancer Prevention Research Center (CPRC), Department of Psychology, University of Rhode Island, 130 Flagg Road, Kingston, RI 02881, USA. Digital resources and behavioral assessment repositories are maintained via the UMBC Habits Lab.

4. Purpose

The fundamental purpose of the Smoking Decisional Balance Scales is to systematically assess and quantify the cognitive, psychological, and motivational factors underlying an individual’s decision to continue or discontinue tobacco cigarette consumption. While nicotine dependence involves substantial neurobiological reinforcement, human behavioral cessation is deeply mediated by cognitive decision processes. In clinical practice, public health initiatives, and longitudinal experimental research, measuring an individual’s implicit and explicit balance sheet regarding smoking provides critical empirical leverage over the transition from active addiction to intentional behavior change.

Traditional addiction models often presupposed that individuals possess a binary, unvarying awareness that smoking is deleterious to health. However, clinical interventions frequently falter when attempting to deliver universal health risk communications to individuals who are unmotivated to quit. The SDBS addresses this problem by recognizing that human decision-making is characterized by a balance between advantages and disadvantages. Clinicians use the scale to identify a client’s motivational profile, determine their current stage of change, and tailor interventions accordingly. For instance, in Motivational Interviewing (MI) and cognitive-behavioral therapy (CBT), elevating the salience of the Cons while de-emphasizing or developing non-pharmacological substitutes for the Pros represents the primary therapeutic lever during early change stages.

In behavioral epidemiology and health economics, the scale serves as a predictive marker for cessation readiness, relapse risk, and response to clinical pharmacology (such as nicotine replacement therapy, bupropion, or varenicline). Researchers use the instrument to evaluate whether public health communication campaigns, workplace smoking bans, or package warning labels effectively tip the decisional balance by increasing the perceived importance of smoking Cons or reducing the perceived benefits (Pros). Consequently, the scale serves dual utility: as an idiographic clinical diagnostic instrument that pinpoints an individual’s specific cognitive rationalizations, and as a nomothetic outcome variable in clinical trials evaluating stage-matched interventions.

5. Psychological Construct

The Smoking Decisional Balance construct comprises two distinct, higher-order cognitive-evaluative dimensions: the Pros of Smoking and the Cons of Smoking. Rather than operating as opposite ends of a single continuum, empirical data consistently indicate that Pros and Cons are two independent, quasi-orthogonal constructs. An individual can simultaneously place high importance on the reinforcing benefits of smoking while also viewing its adverse health, financial, and interpersonal costs as profoundly serious.

5.1. Pros of Smoking Dimension

The Pros dimension reflects the cognitive appraisal of positive utilities, functional values, and affective benefits attributed to cigarette consumption. Within the 20-item SDBS-LF, this construct encompasses several subordinate psychological domains:

• Affect Regulation and Tension Reduction: Items such as “Smoking cigarettes relieves tension” (Item 15) and “I am relaxed and therefore more pleasant when smoking” (Item 5) reflect negative reinforcement mechanisms. Smokers rely on nicotine to alleviate distress, quiet autonomic hyperarousal, and reduce negative affect.
• Sensory and Hedonic Gratification: Items such as “Smoking cigarettes is pleasurable” (Item 1) and “After not smoking for a while a cigarette makes me feel great” (Item 19) measure immediate positive reinforcement and neurochemical reward anticipation.
• Cognitive Facilitation and Performance: Evaluated by items such as “Smoking helps me concentrate and do better work” (Item 13), capturing the user’s reliance on nicotine-induced dopaminergic and cholinergic stimulation to sustain attentional focus and occupational performance.
• Social and Identity Management: Captured by statements such as “I like the image of a cigarette smoker” (Item 3), “I like myself better when I smoke” (Item 11), and “By continuing to smoke I feel I am making my own decisions” (Item 17). These items reflect autonomy, personal identity, and peer affiliation.
• Interpersonal Buffer against Withdrawal: Items like “If I try to stop smoking I’ll be irritable and a pain to be around” (Item 7) and “My family and friends like me better when I am happily smoking than when I am miserable trying to quit” (Item 9) capture the belief that smoking preserves social harmony by warding off cessation-induced irritability.

5.2. Cons of Smoking Dimension

The Cons dimension evaluates the cognitive salience of the negative consequences, costs, and psychological liabilities associated with smoking. It reflects five primary negative evaluative themes:

• Personal Health and Physical Degradation: Measured by items such as “Smoking cigarettes is hazardous to my health” (Item 8) and “I would be more energetic right now if I didn’t smoke” (Item 20), indexing awareness of chronic disease vulnerability, mortality, and diminished physical stamina.
• Interpersonal Burden and Secondhand Harm: Items including “My smoking affects the health of others” (Item 2), “Others close to me would suffer if I became ill from smoking” (Item 4), and “My cigarette smoking bothers other people” (Item 12) evaluate guilt, interpersonal accountability, and awareness of environmental tobacco smoke.
• Social Disapproval and Stigmatization: Manifested in items such as “People close to me disapprove of my smoking” (Item 16) and “People think I’m foolish for ignoring the warnings about cigarette smoking” (Item 14), tapping perceived social norm violation and marginalization.
• Self-Evaluative Deficit and Characterological Shame: Items such as “I’m embarrassed to have to smoke” (Item 10) and “Because I continue to smoke, some people I know think I lack the character to quit” (Item 6) evaluate internalized shame, perceived loss of self-efficacy, and perceived weakness of will.
• Cognitive Dissonance and Self-Reproach: Indexed by “I’m foolish to ignore the warnings about cigarettes” (Item 18), measuring direct cognitive conflict between knowledge of health consequences and continued compulsive behavior.

6. Theoretical Framework

The theoretical architecture of the SDBS unites two prominent paradigms: the decision-making model of Janis and Mann (1977) and the Transtheoretical Model of Behavior Change developed by Prochaska, DiClemente, and colleagues.

6.1. Janis and Mann’s Conflict Model of Decision Making

Janis and Mann (1977) proposed that all consequential human choices involve psychological conflict, hesitation, and a systematic appraisal of anticipated gains and losses. They formulated an eight-cell “decisional balance sheet” comprising four broad categories split across two perspectives (self versus significant others):

1. Utilitarian gains and losses for self.
2. Utilitarian gains and losses for significant others.
3. Self-approval or self-disapproval (e.g., self-esteem, moral integrity).
4. Approval or disapproval from significant others (e.g., social praise, ostracism).

When Velicer, DiClemente, and Prochaska (1985) set out to operationalize this schema for addictive behaviors, they generated an initial pool of items covering all eight hypothetical cells. However, rigorous factor analytic evaluations revealed that human cognition does not reliably preserve an eight-factor structure for smoking behavior. Instead, empirical analyses yielded a far more parsimonious two-factor orthogonal model: positive utilities collapse into a general Pros construct, and negative utilities collapse into a general Cons construct.

6.2. Integration into the Transtheoretical Model (TTM)

Within the TTM framework, behavior change is conceptualized not as an acute, all-or-nothing event, but as a dynamic progression across five distinct temporal and motivational stages:

• Precontemplation (PC): Individuals do not intend to quit smoking in the foreseeable future (typically within the next six months). Pros of smoking clearly dominate over the Cons.
• Contemplation (C): Individuals recognize the problem and intend to quit within six months, but remain ambivalent. The Cons rise sharply to approximate the Pros (the point of decisional ambivalence).
• Preparation (PR): Individuals intend to take behavioral action within thirty days and have typically made an unsuccessful cessation attempt within the past year. Cons surpass Pros.
• Action (A): Individuals have altered their overt behavior and attained zero tobacco use for less than six months. Cons remain high, while Pros continue to decline.
• Maintenance (M): Individuals have sustained continuous abstinence for greater than six months and work to prevent relapse. Cons stabilize as a supportive cognitive rationale, while Pros drop to their lowest levels.

A central tenet across TTM investigations (Prochaska et al., 1994) is that the shift from Precontemplation to Contemplation requires approximately a 1 standard deviation ($1.0, SD$) increase in the Cons of smoking, while the transition from Contemplation to Action requires approximately a 0.5 standard deviation ($0.5, SD$) decrease in the Pros of smoking. This principle demonstrates that cognitive modification of the decisional balance is a mandatory precursor to overt behavioral cessation.

7. Validity

The Smoking Decisional Balance Scales have been extensively validated across four decades of psychometric and clinical research, demonstrating exemplary construct, criterion, convergent, and discriminant validity.

7.1. Construct and Structural Validity

Construct validity was established by Velicer et al. (1985) across three sequential empirical samples ($N = 960$). When exploratory and confirmatory factor analyses were applied to the item pool, the two-factor solution demonstrated exceptional stability across samples differing in age, gender, smoking intensity, and cessation readiness. The independence of the Pros and Cons factors confirms that positive and negative cognitive evaluations operate as distinct mental processes rather than opposite poles of an unipolar continuum.

7.2. Criterion and Stage-Congruent Predictive Validity

The scale’s criterion-related validity is supported by its consistent ability to discriminate between smokers in different stages of change. In a foundational cross-sectional and longitudinal study of 12 distinct health-risk behaviors ($N = 4,144$; Prochaska et al., 1994), the SDBS demonstrated an unmistakable crossover effect:

• In the Precontemplation stage, standardized T-scores for Pros averaged approximately $55$ to $60$, whereas Cons averaged $40$ to $45$ (Pros > Cons by $>1.0, SD$).
• In the Contemplation stage, Pros and Cons scores converged near the population mean of $50, T$-score units (Pros ≈ Cons), reflecting active cognitive ambivalence.
• In the Preparation and Action stages, Cons scores averaged $52$ to $55$, while Pros scores dropped to $45$ to $48$ (Cons > Pros).
• In the Maintenance stage, Pros scores decreased to approximately $38$ to $40$, while Cons remained elevated above Pros.

In prospective longitudinal trials, baseline decisional balance scores consistently predict which smokers will make an attempt to quit over 6-, 12-, and 24-month follow-up windows. Individuals with elevated Cons relative to Pros are significantly more likely to initiate cessation attempts and achieve sustained biochemically confirmed carbon monoxide abstinence.

7.3. Convergent and Discriminant Validity

The SDBS demonstrates robust convergent validity when correlated with related behavioral and cognitive constructs:

• Processes of Change: As demonstrated by Prochaska, Velicer, DiClemente, and Fava (1988), increases in Cons correlate strongly with the experiential processes of change, including Consciousness Raising ($r = .48$), Environmental Reevaluation ($r = .56$), and Self-Reevaluation ($r = .52$).
• Situational Temptation / Self-Efficacy: The Pros scale correlates positively ($r = .40$ to $.60$) with the Smoking Situational Temptations Scale, especially in positive-affect, relaxation, and social situations.
• Nicotine Dependence: The Pros scale correlates positively with the Fagerström Test for Nicotine Dependence (FTND), particularly for items measuring habitual and morning smoking.
• Discriminant Validity: The scales demonstrate low or near-zero correlations with general social desirability measures, state anxiety inventories, and non-health-related locus of control constructs, confirming that the tool specifically measures cognitive smoking evaluations rather than general psychological distress or response distortion.

8. Reliability

Empirical evaluations across diverse clinical and non-clinical cohorts confirm high internal consistency and temporal stability for both the Long Form and Short Form of the SDBS.

8.1. Internal Consistency

In the original validation study by Velicer et al. (1985), the 20-item Long Form demonstrated excellent internal consistency coefficients:

• Pros of Smoking Scale (10 items): Cronbach’s $\alpha = .87$ (sample 1), $\alpha = .89$ (sample 2), and $\alpha = .88$ (sample 3).
• Cons of Smoking Scale (10 items): Cronbach’s $\alpha = .87$ (sample 1), $\alpha = .89$ (sample 2), and $\alpha = .90$ (sample 3).

For the 6-item Short Form developed by Velicer and colleagues and later examined by Ward, Velicer, and Rossi (2004), internal consistency estimates remained robust despite the substantial reduction in item count:

• Short Form Pros Scale (3 items): Cronbach’s $\alpha = .81$ to $.84$.
• Short Form Cons Scale (3 items): Cronbach’s $\alpha = .72$ to $.79$.

Average inter-item correlations within each scale typically fall within the optimal range of $.40$ to $.60$, indicating that items share a substantial common core without introducing excessive item redundancy.

8.2. Test-Retest Reliability and Temporal Stability

Test-retest stability was evaluated across stable precontemplators and established maintainers over intervals ranging from two to six weeks. Intra-class correlation coefficients (ICCs) and Pearson stability coefficients routinely exceed $r_{tt} = .85$ for both Pros and Cons scales when participants do not undergo active clinical interventions. Over longer periods without intervention, decisional balance profiles show high stability, confirming that the scales capture enduring cognitive attitudes rather than fleeting situational moods.

9. Factor Analysis

The dimensional structure of the Smoking Decisional Balance Scales was established through a series of rigorous Exploratory Factor Analyses (EFA) and Confirmatory Factor Analyses (CFA), accompanied by formal tests of measurement invariance across diverse demographics and stages of change.

9.1. Exploratory Factor Analysis (EFA)

During the original development phase (Velicer et al., 1985), an initial 24-item inventory derived from the eight Janis-Mann cells was subjected to Principal Component Analysis (PCA) and Common Factor Analysis with Varimax (orthogonal) and Promax (oblique) rotations. Across sequential samples:

• The scree test clearly indicated a two-component solution that accounted for approximately $45%$ to $50%$ of the total item variance.
• Varimax and Promax rotations yielded nearly identical solutions, as the factor correlation between Pros and Cons was minimal ($r = -.11$ to $-.18$), confirming that the two constructs are essentially orthogonal.
• Four psychometrically weak or complex items with secondary cross-loadings ($> .35$) were removed, yielding the final 20-item Long Form (10 Pros items, 10 Cons items). Item loadings on their respective primary latent dimensions were high, ranging from $.52$ to $.79$, with cross-loadings rarely exceeding $.20$.

9.2. Confirmatory Factor Analysis (CFA) and Model Fit

Subsequent investigations verified the two-factor model using CFA framework methodologies. Ward, Velicer, and Rossi (2004) tested the factorial validity of both the Long Form and the 6-item Short Form across large epidemiological cohorts ($N > 2,000$). The two-factor orthogonal model delivered superior fit statistics compared to alternative unipolar or multidimensional structures:

• Comparative Fit Index (CFI): $ge .95$ for both forms.
• Tucker-Lewis Index (TLI): $ge .94$.
• Root Mean Square Error of Approximation (RMSEA): $le .052$ (90% CI [.045, .059]), indicating excellent fit.
• Standardized Root Mean Square Residual (SRMR): $le .041$.

9.3. Factorial Invariance

Multigroup confirmatory factor analyses have demonstrated that the SDBS exhibits strict measurement invariance (configural, metric, and scalar invariance) across:

1. Gender: Factor loadings and item intercepts do not differ significantly between men and women.
2. Age Cohorts: The measurement structure remains stable when applied to adolescents, young adults, and older adult smokers.
3. Stages of Change: Crucially, tests of measurement invariance indicate that the scale measures the identical latent dimensions in Precontemplation as it does in Action and Maintenance, ruling out measurement artifact as the cause of observed stage differences.

10. Instrument / Measurement Tool

The Smoking Decisional Balance Scales are self-administered psychometric inventories that evaluate the subjective importance of various reasons for and against cigarette smoking.

10.1. Instrument Characteristics

• Instrument Name: Smoking Decisional Balance Scales (SDBS)
• Alternative Titles: Decisional Balance Inventory for Smoking Cessation; Pros and Cons of Smoking Scale
• Authors: Wayne F. Velicer, Carlo C. DiClemente, and James O. Prochaska (1985)
• Format Variations:
  • Long Form (SDBS-LF): 20 items (10 Pros, 10 Cons). Best suited for comprehensive clinical intake, deep behavioral diagnostics, and in-depth clinical trials.
  • Short Form (SDBS-SF): 6 items (3 Pros, 3 Cons). Optimized for broad public health surveys, computerized screening, and brief phone assessments.
• Administration Modality: Self-administered pencil-and-paper, computer-assisted self-interview (CASI), or digital survey.
• Target Population: Adolescent and adult cigarette smokers across all levels of consumption and readiness to quit.
• Completion Time: 3 to 5 minutes for the Long Form; under 1 minute for the Short Form.

10.2. Response Format and Instructions

• Prompt / Question Stem: “How important is this to me?” / “Importance in making a decision about smoking:”
• Scale Type: 5-point Likert-type response scale.
• Anchors:
  • 1 = Not important at all
  • 2 = Slightly important
  • 3 = Moderately important
  • 4 = Very important
  • 5 = Extremely important

10.3. Scoring Protocols

• Raw Scale Scores:
  • 20-Item Long Form:
    • Pros Raw Score: Sum of items 1, 3, 5, 7, 9, 11, 13, 15, 17, and 19 (Score range: 10 to 50). Alternatively calculated as a mean item score (range: 1.0 to 5.0).
    • Cons Raw Score: Sum of items 2, 4, 6, 8, 10, 12, 14, 16, 18, and 20 (Score range: 10 to 50). Alternatively calculated as a mean item score (range: 1.0 to 5.0).
  • 6-Item Short Form:
    • Pros Raw Score: Sum of items 1, 3, and 5 (Score range: 3 to 15; mean range: 1.0 to 5.0).
    • Cons Raw Score: Sum of items 2, 4, and 6 (Score range: 3 to 15; mean range: 1.0 to 5.0).
• Standardized T-Score Conversion: Raw scores are typically converted to standardized T-scores ($Mean = 50, SD = 10$) using baseline reference cohorts of active smokers:
  $$T = 50 + 10 \left( \frac{X – \bar{X}}{SD} \right)$$
  This transformation enables direct comparisons between the Pros and Cons dimensions on a common scale.
• Decisional Balance Difference Score (Cons − Pros): Subtracting the standardized Pros T-score from the Cons T-score ($T_{\text{Cons}} – T_{\text{Pros}}$) produces a single index of motivational readiness. A negative differential indicates an unreadiness to quit (Precontemplation), a score near zero reflects ambivalence (Contemplation), and a positive differential reflects high cognitive readiness for cessation (Preparation/Action).

11. Permissions & Fee and Test Year

Initial Publication Year: 1985 (Long Form, Velicer et al., 1985); 1994/2004 (Short Form configurations, Prochaska et al., 1994; Ward et al., 2004).

Licensing and Availability: The Smoking Decisional Balance Scales are considered public-domain psychometric instruments developed under federal research grants from the National Institutes of Health (NIH), specifically the National Cancer Institute (NCI). They are freely accessible for clinical practice, educational instruction, and academic research without royalty fees. Full instruments, scoring algorithms, and stage-matching criteria are hosted openly by the University of Maryland, Baltimore County (UMBC) Habits Lab and preserved within CPRC archival repositories.

Commercial Integration and Digital Health Usage: Commercial entities seeking to integrate the scales into fee-based commercial platforms, mobile digital health applications, or commercial smoking cessation services are advised to credit the original developers and contact the Cancer Prevention Research Center (CPRC) or lead investigators regarding proper attribution and derivative works.

12. References

Carey, K. B., Maisto, S. A., Carey, M. P., & Purnine, D. M. (2001). Measuring readiness to change substance misuse among psychiatric outpatients: Reliability and validity of self-report measures. Journal of Studies on Alcohol, 62(1), 79–88. https://doi.org/10.15288/jsa.2001.62.79

Collins, S. E., Carey, K. B., & Otto, J. M. (2009). A new decisional balance measure of motivation to change among at-risk college drinkers. Psychology of Addictive Behaviors, 23(3), 464–471. https://doi.org/10.1037/a0015841

Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. Free Press.

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 processes 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

Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., Fiore, C., Harlow, L. L., Redding, C. A., Rosenbloom, D., & Rossi, S. R. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13(1), 39–46. https://doi.org/10.1037/0278-6133.13.1.39

Velicer, W. F., DiClemente, C. C., & Prochaska, J. O. (1985). Decisional balance measure for assessing and predicting smoking status. Journal of Personality and Social Psychology, 48(5), 1279–1289. https://doi.org/10.1037/0022-3514.48.5.1279

Ward, R. M., Velicer, W. F., & Rossi, J. S. (2004). Factorial invariance and internal consistency for the Decisional Balance Inventory – Short Form. Addictive Behaviors, 29(5), 953–958. https://doi.org/10.1016/j.addbeh.2004.02.040

13. Items of the Scale (Questionnaire)