Psychology Ph.D. Dissertations

A Stepped-care Approach to Smoking Cessation and Harm Reduction

Date of Award


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)



First Advisor

Robert Carels


Smoking is the most preventable cause of death in the US (American Cancer Society, 2004). Despite a significant public health need for effective cessation interventions, the efficacy of smoking cessation interventions has declined over the past 15 years (Piasecki & Baker, 2001; Irvin and Brandon, 2000). The purpose of this study was to examine a stepped-care approach to smoking cessation and harm reduction. Stepped-care has been proposed as a promising, yet relatively unexplored approach to smoking cessation (Piasecki & Baker, 2001). In a stepped-care program, participants who are not responding therapeutically to the current level of treatment (i.e. experience significant difficulties or failure) are stepped-up to a more intensive form of treatment. In this study, individual problem solving therapy (PST) was used as the stepped-care component. The participants in this study were 40 smokers from the community. While all participants were engaged in an 8-session cognitive-behavioral group smoking cessation program, half of the participants were eligible to be stepped-up to individual PST when they experienced difficulties meeting their smoking reduction goals. Alternative measures of success (i.e., harm reduction) included progression along the stages of change model as measured by the Stages of Change Algorithm, Processes of Change Inventory, Decisional Balance Inventory, Self-Efficacy/Temptation Inventory, and the Self-Efficacy Questionnaire (SEQ-12), as well as reductions in nicotine exposure and the ability to achieve a 24-hour quit attempts. Results revealed that 56% of all participants were able to quit by the end of the intervention and participants made significant progress along the stages of change as measured by the processes of change and self-efficacy. Participants were also able to achieve significant reductions in nicotine exposure and an increase in 24-hour quit attempts. No significant differences were found between the treatment and control groups or the treatment group participants who received PST (Treatment + PST) and those matched on stepped-care eligibility in the control group (Control + PST eligible). Despite the lack of significant findings, effect size estimates revealed a moderate to large effect size for self-efficacy/temptation, achieving a 24-hour quit attempt, and abstinence in favor of the treatment group. Implications and future directions are discussed.