1. Smoking Cessation through the Use of The Transtheoretical Model: A Case Study
By: David Shepard
DPT 844

2. Demographics/Background
59 year old male
Married
Father of 2 children
High School Diploma w/Trade School Certification
Lab Technician
Fairly active, enjoys bike riding, outdoor work, landscaping, carpentry

3. Medical History Height: 6’1” Weight: 203 lbs Blood Pressure: 129/89
Heart Rate: 84 bpm
Comorbidities: HTN, hyperlipidemia, MI (2010), stent (2010), triple CABG (2012)
Social: Smoking since 16 years old

4. Health Behavior Quit smoking by the end of a 4 week period.
Case report subject has been advised countless times to stop smoking immediately by cardiologists.
No new complications since CABG. Vitals and lab values have remained stable and within normal ranges since 2012.

5. Transtheoretical Model (TTM)
Subject reported numerous failed attempts at smoking cessation. He has tried multiple approaches but ultimately has resumed smoking a few months later each time.
Interventions based on the TTM model have been shown to increase the smoking cessation rate in individuals who present in the preparation stage.1
Strengths include identification of subjects who are most open to change, recognizes the temporal nature of change, and can address a variety of behaviors.2
Weaknesses include a limited predictive power and tailored interventions to ensure behavior change can be time consuming and expensive.3

6. Assessments
The Change Questionnaire was used to determine readiness to change. An averaged score of 8-10 was shown to be a significant predictor of change.4
The Cigarette Dependance Scale, short version (CDS, 5 Items) was used to establish baseline dependency and to show post intervention progress.5 Total score of greater than 20 = severe dependance, = mild dependance, 8-13 = low dependance.
Based on the questionnaire and self reporting, subject presents in the preparation phase and intends to take action within 1 month.

7. Change Questionnaire

8. Change Questionnaire

9. CDS-5

10. Plan Development
4 week plan created to quit smoking completely using the quitSTART mobile app to track progress and aid in smoking cessation reinforcement.
Week 1 Goal: Limit cigarettes smoked to 6 per day with 8 or less cravings.
Week 2 Goal: Limit cigarettes smoked to 4 per day with 6 or less cravings.
Week 3 Goal: Limit cigarettes smoked to 2 per day with 4 or less cravings.
Week 4 Goal: Limit cigarettes smoked to 0 by end of the week with 2 or less cravings.

11. Plan
Subject used the quitSTART app daily to track how many cigarettes were smoked and how many cravings were reported each day.
Meetings were held at the end of each week to discuss progress made towards goals and difficulties encountered.

12. Created by the National Cancer Institute in collaboration with the U.S. Food and Drug Administration with input from tobacco control professionals, smoking cessation experts, and ex-smokers.
Monitors your progress with badges earned for smoke free milestones and other achievements.
Helps you get back on track if you slip and smoke more then planned.
Manage cravings and bad moods in healthy ways
Distract yourself from cravings with games and challenges
Store helpful tips, inspirations, and challenges in your Quit Kit
Share your progress and favorite tips through social media
quitStart APP

13. Intervention Specifics
Set a specific quit date
Savings are calculated daily to show the user how much money they have saved due to quitting
Inspirational quotes are used as needed along with daily educational health lessons
Cravings managed through distraction and avoidance techniques ie. games, map pinning to avoid smoking triggers, smoking trigger documentation
Exercise program used to manage cravings ie. when cravings are strongest the user can request 15 minute workouts to preoccupy themselves.
Friends and family contact info can be shared through the app and allow them to contact the user for positive reinforcement and support
Daily tracking for cigarettes smoked and craving episodes

14. Week 1

15. Week 2

16. Week 3

17. Week 4

18. Research on APP Programs
Adherent users to smoking cessation apps are over 4 times as likely to quit smoking.6
A content analysis of mobile apps showed that 84% of users were satisfied with their apps, 73% of people would recommend apps to a friend, and 81% of users found app exercises useful for quitting.7
Apps have been shown to recommend more holistic approaches to smoking cessation through the use of exercise, dieting, and smoking avoidance tips as opposed to medications.8
The use of Facebook apps and other social networks consisting of the same features are an untapped treatment strategy that can harness existing social support.9,10

19. CDS-5 (PoST Intervention)

20. Results/Takeaways
Subject was able to decrease smoking significantly to roughly 1-2 cigarettes per day and with limited cravings to roughly 2-3 per day.
Continuing to educate patient on use of all app features to ensure adherence through maintenance phase is vital. (ie. map pinning to avoid places that lead to cravings, accessing exercise programs and modifications)
More frequent meetings could have been helpful for positive reinforcement and app troubleshooting.
This case report has shown me that change is possible no matter how unlikely the situation seems or how long someone has had an unhealthy behavior in their lives. In my future PT practice, I will be able to guide a patient’s health behavior change in manner that fosters independence. I have also learned that the use of technology is a perfect way to guide a change in a non-threatening way that is manageable.

21. References
1) Sharifirad G, Eslami A, Charkazi A, Mostafavi F, Shahnazi H. The effect of individual counseling, line follow‑up, and free nicotine replacement therapy on smoking cessation in the samples of Iranian smokers: Examination of transtheoretical model. Journal Of Research In Medical Sciences [serial online]. December 2012;17(12): Available from: Academic Search Complete, Ipswich, MA. Accessed July 17, 2017.
2) Koyun A, Eroglu K. The effect of transtheoretical model-based individual counseling, training, and a 6-month follow-up on smoking cessation in adult women: a randomized controlled trial. Turkish Journal Of Medical Sciences [serial online]. January 2016;46(1): Available from: Academic Search Complete, Ipswich, MA. Accessed July 17, 2017.
3) Cabezas C, Advani M, Puente D, Rodriguez-Blanco T, Martin C. Effectiveness of a stepped primary care smoking cessation intervention: cluster randomized clinical trial (ISTAPS study). Addiction [serial online]. September 2011;106(9): Available from: Academic Search Complete, Ipswich, MA. Accessed July 17, 2017.
4) Gaume J, Bertholet N, Daeppen J, Gmel G. The Change Questionnaire predicts change in hazardous tobacco and alcohol use. Addictive Behaviors [serial online]. November 2013;38(11): Available from: Academic Search Complete, Ipswich, MA. Accessed July 17, 2017.
5) Etter, J.F., LeHouezec, J., & Perneger, T.V. (in press). A self-administered questionnaire to measure addiction to cigarettes: The Cigarette Dependence [serial online]. January 2011;22(11): Neuropsychopharmacology.
6) Zeng E, Heffner J, Copeland W, Mull K, Bricker J. Get with the program: Adherence to a smartphone app for smoking cessation. Addictive Behaviors [serial online]. December 2016;63: Available from: Academic Search Complete, Ipswich, MA. Accessed July 17, 2017.
7) Bricker J, Copeland W, Heffner J, et al. Single-arm trial of the second version of an acceptance & commitment therapy smartphone application for smoking cessation. Drug & Alcohol Dependence [serial online]. January 2017;170: Available from: Academic Search Complete, Ipswich, MA. Accessed July 17, 2017.
8) Abroms, Lorien C., et al. "A content analysis of popular smartphone apps for smoking cessation." American journal of preventive medicine 45.6 (2013):
9)Jacobs, Megan A., et al. "Facebook apps for smoking cessation: a review of content and adherence to evidence-based guidelines." Journal of medical Internet research 16.9 (2014).
10)Cobb, Nathan K., Amanda L. Graham, and David B. Abrams. "Social network structure of a large online community for smoking cessation." American journal of public health (2010):