Brief art

Stages of change and p

a,b,4

h.D

s Hos

Medi

Wom

arva

Brig

rvard

06; a

changes in drinking

Journal of Substance Abuse Treatmen4 Corresponding author. Brigham and Womens Hospital, Departmentof Psychiatry, 75 Francis Street, Boston, MA 02115, USA. Tel.: +1 617 7321. Introduction

The transtheoretical model of intentional behavioral

change has been an important and influential attempt to

characterize disengagement from harmful behaviors such as

smoking or drinking (Allsop, 2003; DiClemente, 2003;

DiClemente, Bellino, & Neavins, 1999). In this model,

stages of change depict the motivational and dynamic

fluctuations of the change process over time. Because

motivation is a key element in treatment and recovery,

stage-based interventions that take into account the current

stage an individual has reached have been widely used,

although empirical justification may be lacking (Riemsa

et al., 2002).

The enduring popularity of the transtheoretical model

notwithstanding, the need for further evaluation has been

increasingly appreciated due to apparent limitations (Sutton,

2001; West, 2005). For example, Kavanagh, Sitharthan, and

Sayer (1996) examined the predictive utility of stage of

change, self-efficacy, and alcohol dependence among a

group of 166 adults enrolled in a correspondence treatment

for alcohol abuse. Whereas self-efficacy predicted both

treatment retention and later alcohol consumption, and

previous alcohol consumption constituted the best predictor

of subsequent intake, the role of stage of change was

considerably weaker. Maisto et al. (2001) found that

This study was supported by grants (R01 AA12548 and K24 AA

00289, to G.C.) from the National Institute on Alcohol Abuse

and Alcoholism.Abstract

This study evaluated stage of change as a predictor of alcohol use in a sample of 301 pregnant women who were either in the

precontemplation (62%) or in the action (38%) stage of change in their first trimester. Stage of change distinguished between different

patterns of alcohol consumption before and after pregnancy. Those in the precontemplation stage drank more per episode and more often

before pregnancy than those in the action stage. The precontemplation group also had a significantly greater quantity of alcohol after

pregnancy. However, stage of change did not directly predict subsequent prenatal alcohol use. Previous alcohol use, age, and education were

the most significant predictors of prenatal drinks per drinking day. Temptation to drink alcohol was the best predictor of prenatal drinking

frequency after study enrollment. Women in both stages of change reduced the quantity and the frequency of their alcohol consumption while

pregnant and achieved comparable rates of abstinence. D 2007 Elsevier Inc. All rights reserved.

Keywords: Stages of change; Prenatal alcohol useGrace Chang, (M.D., M.P.H.)

Louise Wilkins-Haug, (M.D., PaDepartment of Psychiatry, Brigham and Women

bDepartment of Psychiatry, HarvardcDepartment of Obstetrics and Gynecology, Brigham and

dDepartment of Obstetrics and Gynecology, HeDepartment of General Medicine and Primary Care,

fDepartment of Medicine (Biostatistics), Ha

Received 17 May 200740-5472/07/$ see front matter D 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jsat.2006.07.003

6775; fax: +1 61

E-mail address: gchang@partners.org (G. Chang).icle

renatal alcohol use

, Tay McNamara, (Ph.D.)a,

.)c,d, E. John Orav, (Ph.D.)e,f

pital, 75 Francis Street, Boston, MA 02115, USA

cal School, Boston, MA 02115, USA

ens Hospital, 75 Francis Street, Boston, MA 02115, USA

rd Medical School, Boston, MA 02115, USA

ham and Womens Hospital, Boston, MA 02115, USA

Medical School, Boston, MA 02115, USA

ccepted 4 July 2006

t 32 (2007) 105109omized to standardreadiness to change was not related to

by primary care study participants rand7 264 6364.

care or motivational enhancement interventions.

The T-ACE questionnaire is a four-item screening ques-

nce APossible limitations in the transtheoretical model may be

explained by difficulties in measuring readiness to change.

Five stages of change were originally conceptualized, but

the model has since been modified to three stages (Sutton,

2001). Readiness to change begins with precontemplation,

the stage at which there is no intention to change in the

foreseeable future. Contemplation is the next stage, the stage

when an individual is aware of the problem and is

considering making a change in response to the problem

but has not yet made a commitment to effect such a change.

The action stage occurs when an individual modifies ones

behaviors (Prochaska, DiClemente, & Norcross, 1992).

The Readiness to Change Questionnaire (RCQ) is the

most popular measure of the stages of change and assigns

drinkers to the precontemplation, contemplation, or action

stage (Rollnick, Heather, Gold, & Hall, 1992). It was

specifically developed for use in brief opportunistic

interventions among excessive drinkers and has been

studied in at least five countries, in as many different

languages and cultures, but among a more limited range of

subjects (Defuentes-Merillas, Dejong, & Schippers, 2002;

Forsberg, Halldin, & Wennberg, 2003; Hannover et al.,

2002; Rodriguez-Martos et al., 2000). Findings have been

almost as diverse, with some since questioning the three-

stage model and instead advocating for either a continuous

(Budd & Rollnick, 1996) or a two-stage alternative

(precontemplation and contemplation/action; Willoughby

& Edens, 1996).

Furthermore, the transtheoretical model of change may

not be relevant to all groups of drinkers, such as pregnant

women. A few studies have examined the utility of the

transtheoretical model among pregnant smokers, but not

among pregnant drinkers. A comparison of 103 econom-

ically disadvantaged pregnant smokers and 103 matched

community smokers found that the majority of pregnant

smokers were not highly motivated to quit smoking simply

because they were pregnant (Ruggiero, Tsoh, Everett, Fava,

& Guise, 2000). A study of 54 low-income pregnant

smokers randomized to either motivational intervention or

usual care found that stage of change did not progress in the

course of treatment, thus failing to support the investigators

hypothesis that a motivational intervention would increase

motivation for change (Stotts, DeLaune, Schmitz, &

Grabowski, 2004). Although findings from a cross-sectional

study of 637 pregnant women who were either current or

previous cigarette smokers supported the overall relevance

of the transtheoretical model of change, the investigators

also concluded that a staged approach was less necessary for

pregnant women (Slade, Laxton-Kane, & Spiby, 2006).

Because no amount of alcohol is safe during pregnancy, a

better understanding of why some women avoid alcohol and

others do not is therefore highly desirable (Kost, Landry, &

Darroch, 1998; Mukherjee, Hollins, & Abou-Salah, 2005).

The overall prevalence of any prenatal alcohol consumption

is 13%, with rates of binge drinking (defined as five or more

G. Chang et al. / Journal of Substa106drinks on any one occasion) and frequent drinking (definedtionnaire based on the CAGE questionnaire that asks:

How many drinks does it take to make you feel high

(tolerance, T)?

Have people ever annoyed you by criticizing your

drinking (annoyed, A)?

Have you ever felt you ought to cut down on your

drinking (cut down, C)?

Have you ever had a drink first thing in the morning to

steady your nerves or to get rid of an hangover (eye

opener, E)?

The tolerance question is given two points if the respondent

states that more than two drinks are needed to feel theas seven or more drinks per week, or five or more drinks on

any one occasion) during pregnancy estimated to be about

6% (Centers for Disease Control and Prevention, 2002).

Thus, screening and brief interventions for prenatal alcohol

use may help to reduce, if not eliminate, fetal risk and to

maximize pregnancy outcome (Chang, 2004/2005).

The purpose of this study is to evaluate stage of change

as a predictor of alcohol use in a sample of alcohol-screen-

positive pregnant women who participated in a randomized

trial of brief interventions. Thus, if the transtheoretical

model is applicable, then pregnant women in the action

stage should demonstrate alcohol use less than that of those

assigned to other stages.

2. Materials and methods

2.1. Setting

This study took place at the Brigham and Womens

Hospital (Boston, MA). A screening survey with questions

about health habits such as diet, exercise, sleep, and usual

drinking, and the T-ACE questionnaire (a four-item alcohol

screening instrument) were given to patients initiating

prenatal care at one of three hospital obstetric practices

(clinic, faculty, and private group affiliate), as well as to

those responding to e-mail and other study announcements.

2.2. Subjects

The subjects were 301 (99%) of 304 pregnant women

who were enrolled in a randomized trial of brief inter-

ventions for prenatal alcohol use (Chang et al., 2005). The

women were eligible to participate if they satisfied the entry

criteria, which included a positive T-ACE alcohol screen (a

score of 2 or more) and risk for prenatal alcohol use, as

defined by any of the following: (1) alcohol use while

pregnant in the 3 months before study enrollment; (2)

consumed at least one drink per day in the 6 months before

study enrollment; or (3) drank during a previous pregnancy.

buse Treatment 32 (2007) 105109effects, and affirmative replies to the A, C, and E questions

appropriate. The frequency and the quantity of prenatal

alcohol use after study enrollment were the dependent

variables in ordinary least squares regression models. The

models included demographic data (e.g., age, marital status,

education, and race), clinical history (e.g., first pregnancy

and history of obstetric problems), prior drinking history (as

lagged dependent variable), and other study variables (e.g.,

brief intervention status and AASE temptation score) as

predictors. Multiple imputations (five imputations) were

used to manage missing data. All analyses were replicated

with mean substitution to verify findings from multiple

imputations (Rubin, 1987). The purpose of multivariate

analyses was to focus on the impact of stage of change on

the quantity and the frequency of alcohol use in this sample

of pregnant women. Because the primary purpose of this

study is limited to investigating these two relationships

(stage of change vs. quantity and frequency), no formal

correction for multiple testing was used.

3. Results

Three hundred four participants were assigned to the

precontemplation (61.5%), contemplation (1%), and action

stages (37.5%) based on RCQ responses for drinking at

present (in the first trimester). Results will focus on women

African American (%) 6.4 6.3 .96

Mean years 16.5 16.7 .33

nce Abuse Treatment 32 (2007) 105109 107are each given one point. The T-ACE questionnaire has been

well studied and validated in diverse clinical populations

(Chang et al., 1998; Sokol, Martier, & Ager, 1989).

Participants gave written informed consent for this study,

which was reviewed and approved by the Institutional

Review Board of the Brigham and Womens Hospital.

A Certificate of Confidentiality for the project was granted

by the Department of Health and Human Services.

2.3. Interviews and intervention

The participants completed two interviews. The first

interview was conducted upon study enrollment, which

occurred at a median of 11.5 weeks gestation. The pregnant

participants completed: (1) the RCQ, a 12-item instrument

that assigns nontreatment-seeking people to the precontem-

plation, contemplation, or action stage of change based on

how they feel about their drinking at present (in the case of

the participants, this would include the first trimester of

pregnancy; Rollnick et al., 1992); (2) the Alcohol Timeline

Follow Back (TLFB), a tool to obtain estimates of daily

drinking for the 6 months before study enrollment, which

would have included drinking before pregnancy and during

early pregnancy (Sobell & Sobell, 1992); and (3) the

Alcohol Abstinence Self-Efficacy (AASE) Scale, a tool to

evaluate an individuals perceived temptation to drink (a

measure of cue strength) and efficacy (confidence) in

abstaining from drinking in 20 common situations at present

(in the first trimester; DiClemente, Carbonari, Montgomery,

& Hughes, 1994). Scores on the temptation and confidence

scales range from a minimum of 20 to a maximum of 100.

The second interview occurred at an average of 78 days

after delivery. At that time, 95% of the participants

completed the Alcohol TLFB interview to provide informa-

tion about alcohol consumption from the time of study

enrollment until delivery.

Randomly selected participants received a brief inter-

vention after the first interview. Masters-level nurses or the

first author gave brief interventions to randomly selected

participants and reviewed the impact of health habits such as

smoking and drinking on pregnancy outcome in the course

of 25 minutes. Two main results have been reported. First,

brief interventions for prenatal alcohol reduced subsequent

consumption most significantly for women with the highest

consumption initially. Second, the effects of brief inter-

ventions were significantly enhanced when a partner

participated. Additional details are available elsewhere

(Chang et al., 2005).

2.4. Data analysis

Data were analyzed using univariate and multivariate

techniques with SAS 8.2 (SAS Institute, Cary, NC).

Descriptive statistics are reported as percentages and means.

The characteristics of pregnant women by stage of change

G. Chang et al. / Journal of Substawere compared using the t-test or the chi-square test, asof education

First pregnancy (%) 48.7 35.4 .04

History of obstetric

problems (%)

20.1 31.8 .05

AASE score

Confidence 93.8 93.7 .95

Temptation 27.4 30.0 .04

Drinking frequency (mean % drinking days)

Before pregnancy 18.6 13.4 .02

Early pregnancy,

before enrollment

2.9 2.1 .31

Pregnancy,

after enrollment

2.1 2.0 .89

After pregnancy 11.6 10.2 .49

Drinking quantity (mean drinks per drinking day)

Before pregnancy 2.1 1.6 b .01Early pregnancy,

before enrollment

0.43 0.38 .65

Pregnancy,

after enrollment

0.34 0.37 .68

After pregnancy 1.45 1.02 b .01Abstinent after 57 52 .44Table 1

Demographic data, clinical history, and drinking characteristics, by stage

of change

Variables

Precontemplation

(n = 187)

Action

(n =114)

p (t-test or

chi-square)

Mean age (years) 30.5 30.6 .67

Married (%) 77.6 86.5 .08enrollment (%)

nce Ain the precontemplation (n = 187) and action (n = 114)

stages. When compared to those assigned to the action

stage, precontemplation-stage women were significantly

more likely to be pregnant for the first time (48.7% vs.

35.4%), with a less frequent history of obstetric problems

(20.1% vs. 31.8%) and with less temptation to drink (27.4

vs. 30.0). However, there were no other systematic differ-

ences between the two groups in terms of age, marital status,

racial background, years of education, or gestational age

upon enrollment.

With regards to drinking, precontemplation-stage women

consumed significantly more alcohol before pregnancy, for

both frequency (18.6% vs. 13.4%) and quantity (2.1 vs.

Table 2

Predictors of prenatal alcohol consumption after study enrollment

Predictors

Drinking frequency

(% drinking days)

Drinking quantity

(drinks per drinking day)

B Pr B Pr

Intercept 0.31 .33 8.0 .0008Action stage 0.11 .27 1.03 .17

Brief intervention 0.096 .31 0.20 .76

Interaction between

action stage and

brief intervention

0.95 .53 1.4 .20

African American 0.10 .50 1.0 .37History of obstetric

problems

0.03 .74 0.81 .22

First pregnancy 0.04 .60 0.13 .83Married 0.07 .49 0.18 .80

Age in years 0.00004 .09 0.0003 .036

Education in years 0.0004 .72 0.021 .023Previous alcohol

consumption

0.54 .17 0.49 b .0001

Temptation 0.008 .03 0.026 .33

G. Chang et al. / Journal of Substa1081.6 drinks per drinking), when compared to action-stage

women. The precontemplation-stage women also had

significantly more drinks per drinking day (1.5 vs. 1.0),

but not more frequent drinking after pregnancy, than the

action-stage women. Women from both stages reduced the

quantity and the frequency of their alcohol consumption

while pregnant and achieved comparable rates of absti-

nence. Table 1 summarizes the comparison between the

women assigned to the precontemplation stage and the

women assigned to the action stage.

The stage of change was compared to demographic data

(e.g., age and years of education), clinical history (e.g., past

alcohol use and obstetric history), and AASE temptation

score as predictors of the frequency and the quantity of

prenatal alcohol use after study enrollment in regression

models. The AASE temptation score was included because

it differed by stage-of-change group, but the confidence

score did not. Three predictors of drinks per drinking day

were identified: age in years ( p = .04), education in years

( p = .02), and past drinking ( p b .0001). Temptation todrink was the only statistically significant predictor of

drinking frequency ( p = .03). Stage of change was not

Maisto, 2000; Fleming, Barry, Manwell, Johnson, &London, 1997). Finally, stage of change was not measured

serially; thus, it was not possible to ascertain stage

progression in this sample.

Although stage-of-change designation did differentiatepredictive of either the subsequent frequency or the quantity

of prenatal alcohol use. The results of the analysis are

summarized in Table 2.

4. Discussion

Stage of change distinguished between different patterns

of alcohol consumption prior to pregnancy in this sample of

301 pregnant women. Those designated to be in the

precontemplation stage drank more per episode and more

often before pregnancy than those in the action stage.

However, stage of change did not directly predict subse-

quent prenatal alcohol use. Previous alcohol use, age, and

education were the most significant predictors of prenatal

drinks per drinking day. Temptation to drink alcohol was the

best predictor of prenatal drinking frequency after study

enrollment. The precontemplation group also had a signifi-

cantly greater quantity of alcohol after pregnancy.

Explanations for the lack of direct association between

stage of change and subsequent prenatal alcohol use are

speculative. A possible explanation is that, although stage

designation was associated with prepregnancy drinking, the

study allowed a prospective evaluation with minimal loss to

follow-uptwo factors that have been cited as short-

comings in other investigations (DiClemente et al., 1999).

Unexpectedly, the action group reported more temptation to

drink, perhaps because they had made greater reductions in

alcohol consumption. Temptation to drink has been found

to predict responses to alcohol cues, even when the effects

of typical drinking patterns were taken into account (Palfai,

2001). Another possible explanation may involve the very

high levels of confidence expressed by both groups of

women in managing their drinking. Half of the participants

in the study sample became abstinent after study enroll-

ment. Finally, it is possible that the difficulties in measuring

stage of change are exacerbated when pregnant women are

being assessed. Pregnant women have long been consid-

ered to be highly motivated to alter behaviors such as

smoking (Boyd, 1985).

Potential limitations to the generalizability of the study

findings include sample characteristics. Higher education,

non-Hispanic background, and employment have been

shown to be associated with greater prenatal alcohol use

(Centers for Disease Control and Prevention, 2002).

Participants did not appear to be heavy drinkers, but they

drank in excess of all recommendations for abstinence

during pregnancy. Underreporting of alcohol use is

possible. Reactivity to research protocols and regression

to the mean are possibilities to consider as well (Clifford &

buse Treatment 32 (2007) 105109between prepregnancy levels of alcohol use, it was not

predictive of subsequent prenatal consumption. Thus, the

definitive role of stage of change as a predictor of prenatal

drinking behavior requires further study. Nonetheless,

because no amount of alcohol consumption can be

considered safe during pregnancy, results from this study

and Alcoholism, 38, 279280.

Kavanagh, D. J., Sitharthan, T., & Sayer, G. P. (1996). Prediction of results

from correspondence treatment for controlled drinking. Addiction, 91,

15391545.

Kost, K., Landry, D. J., & Darroch, J. E. (1998). Predicting maternal

behaviors during pregnancy: Does intention status matter? Family

Planning Perspectives, 30, 7988.

Maisto, S. A., Conigliaro, J., McNeil, M., Kraemer, K., Conigliaro, R. L., &

G. Chang et al. / Journal of Substance Abuse Treatment 32 (2007) 105109 109Hannover, W., Thyrina, J. R., Hapke, U., Rumpf, H. J., Meyer, C., & John,

U. (2002). The Readiness to Change Questionnaire in subjects with

hazardous alcohol consumption, alcohol misuse and dependence in a

general population survey. Alcohol and Alcoholism, 37, 362369.alcohol use, even among those who appear to enjoy the

apparent advantages of age and education (Office of the

Surgeon General, 2005).

References

Allsop, S. (2003). Addiction and change: How addictions develop and

addicted people recover (Book review). Addiction, 98, 17821783.

Boyd, M. D. (1985). Patient motivation during pregnancy. Maryland

Medical Journal, 34, 977981.

Budd, R. J., & Rollnick, S. (1996). The structure of the Readiness to

Change Questionnaire: A test of Prochaska and DiClementes trans-

theoretical model. British Journal of Health Psychology, 1, 365376.

Centers for Disease Control and Prevention. (2002, April). Alcohol use

among women of childbearing ageUnited States, 19911999.

Morbidity and Mortality Weekly Report, 51, 273276.

Chang, G. (2004/2005). Screening and brief intervention in prenatal care

settings. Alcohol Research and Health, 28, 8084.

Chang, G., McNamara, T. K., Orav, E. J., Koby, D., Lavigne, A., Ludman,

B., et al. (2005). Brief intervention for prenatal alcohol use:

A randomized trial. Obstetrics and Gynecology, 105, 991998.

Chang, G., Wilkins-Haug, L., Berman, S., Goetz, M. A., Behr, H., & Hiley,

A. (1998). Alcohol use and pregnancy: Improving identification.

Obstetrics and Gynecology, 91, 892898.

Clifford, P. R., & Maisto, S. A. (2000). Subject reactivity effects and

alcohol treatment outcome research. Journal of Studies on Alcohol, 61,

787793.

Defuentes-Merillas, L., Dejong, C., & Schippers, G. (2002). Reliability and

validity of the Dutch version of Readiness to Change Questionnaire.

Alcohol and Alcoholism, 37, 9399.

DiClemente, C. C. (2003). Addiction and change: How addictions

develop and addicted people recover (pp. 361). New York, NY7Guilford Press.

DiClemente, C. C., Bellino, L. E., & Neavins, T. M. (1999). Motivation for

change and alcoholism treatment. Alcohol Health and Research, 23,

8692.

DiClemente, C. C., Carbonari, J. P., Montgomery, R. P. G., & Hughes, S. O.

(1994). The Alcohol Abstinence Self-Efficacy scale. Journal of Studies

on Alcohol, 55, 141148.

Fleming, M. F., Barry, K. L., Manwell, L. B., Johnson, K., & London, R.

(1997). Brief physician advice for problem alcohol drinkers. Journal of

the American Medical Association, 277, 10391045.

Forsberg, L., Halldin, J., & Wennberg, P. (2003). Psychometric properties

and factor structure of the Readiness to Change Questionnaire. AlcoholKelley, M. E. (2001). Effects of two types of brief interventions and

readiness to change on alcohol use in hazardous drinkers. Journal of

Studies on Alcohol, 62, 605614.

Mukherjee, R. A. S., Hollins, S., & Abou-Salah, M. T. (2005). Low

level alcohol consumption and the fetus. British Medical Journal, 330,

375376.

Office of the Surgeon General (2005, February 21). The surgeon general

releases advisory on alcohol use in pregnancy (Press release). Bethesda,

MD7 Department of Health and Human Services (Available atwww.hhs.gov/surgeongeneral/pressreleases/sg02222005.html).

Palfai, T. P. (2001). Individual differences in temptation and responses to

alcohol cues. Journal of Studies on Alcohol, 62, 657666.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of

how people change: Applications to predictive behaviors. American

Psychologist, 47, 11021114.

Riemsa, R. P., Pattenden, J., Bridle, C., Sowden, A. J., Mather, L., &

Walker, A. (2002). A systematic review of the effectiveness of

interventions based on a stages of change approach to promote

individual behaviour change. Health Technology Assessment, 6, 155.

Rodriguez-Martos, A., Rubio, G., Auba, G., Santo Domingo, J., Rorralba,

L., & Campilo, M. (2000). Readiness to Change Questionnaire:

Reliability study of the Spanish version. Alcohol and Alcoholism, 35,

270275.

Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a

short bReadiness to ChangeQ questionnaire for use in brief opportunisticbrief interventions. British Journal on Addiction, 87, 745754.

Rubin, D. B. (1987). Multiple imputation for nonresponse in surveys. New

York, NY7 Wiley and Sons.Ruggiero, L., Tsoh, J. U., Everett, K., Fava, J. L., & Guise, B. J. (2000).

The transtheoretical model of smoking: Comparison of pregnant and

nonpregnant smokers. Addictive Behaviors, 25, 239251.

Slade, P., Laxton-Kane, M., & Spiby, H. (2006). Smoking in pregnancy:

The role of the transtheoretical model and the mothers attachment to

the fetus. Addictive Behaviors, 31, 743757.

Sobell, L. C., & Sobell, M. B. (1992). Timeline followback: A technique

for assessing self-reported alcohol consumption. In J. P. Allen, & R. Z.

Litten (Eds.), Measuring alcohol consumption: Psychosocial and

biochemical methods (pp. 4172). Totowa, NJ7 Humana Press.Sokol, R. J., Martier, S. S., & Ager, J. W. (1989). The T-ACE questions:

Practical prenatal detection of risk-drinking. American Journal of

Obstetrics and Gynecology, 160, 863871.

Stotts, A. L., DeLaune, K. A., Schmitz, J. M., & Grabowski, J. (2004).

Impact of a motivational intervention on mechanisms of change in low-

income pregnant smokers. Addictive Behaviors, 29, 16491657.

Sutton, S. (2001). Back to the drawing board? A review of applications of

the transtheoretical model to substance use. Addiction, 96, 175186.

West, R. (2005). Time for a change: Putting the transtheoretical (stages of

change) model to rest. Addiction, 100, 10361039.

Willoughby, F. W., & Edens, J. F. (1996). Construct validity and predictive

utility of the stages of change for alcoholics. Journal of Substance

Abuse, 8, 275291.support the importance of identifying previous patterns of

Stages of change and prenatal alcohol useIntroductionMaterials and methodsSettingSubjectsInterviews and interventionData analysis

ResultsDiscussionReferences