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Stages of Change: Smoking Cessation as an Example

It is important to remember that behavior change does not involve a single act, but can
occur over time in stages. According to one widely-used model, behavior change has six
stages: pre-contemplation, contemplation, preparation, action, maintenance, and
termination (1). Realize that patients may move back and forth between the stages of
change in the process of quitting smoking or other habit changes.(2)

Pre-contemplation is the stage in which people, though aware of the risks of

smoking, does not intend to quit immediately. Many smokers are afraid they will
be unable to quit, may be discouraged because they have been unsuccessful in the
past, and/or have suffered withdrawal symptoms.
Contemplation is the stage in which people intend to change their behavior in the
next six months, but are ambivalent, weighing the benefits of quitting with the
Preparation is the stage in which people intend to take action in the immediate
future (usually within a month). You can help move your patient from
contemplation to preparation. Use open-ended questions (Why would you like to
quit smoking?), affirming statements (Its great that you were able to quit once
before.), reflective listening (It sounds like quitting smoking has been
frustrating for you.), and offer NRT and/or pharmacotherapy). If a patient is not
yet ready to make a quit attempt, reiterate that quitting smoking is the most
important thing you can do for your health" at each future visit.
Preparation is the stage in which a person has a firm intention to take action in
the immediate future. They are more likely to initiate and respond to counseling
with a physician, and may have taken other steps on their own, such as online
smoking cessation programs.
Action: Once a person has quit smoking they have moved into to the action stage.
Maintenance is the most crucial and difficult stage, where people struggle to
maintain behavior change. Support and continued counseling from a physician
can be crucial to preventing smoking relapse.
Termination: By this stage, patients may no longer succumb to the temptation to
smoke and have confidence in their continued ability to avoid tobacco. Use of this
behavioral change model has proven successful in smoking cessation. (3)

Prochaska, JO & DiClemente, CC. Stages and processes of self-change of smoking:

Toward an integrative model of change. Journal of Consulting and Clinical
Psychology. 1983; 51, 390-395
Stages of Change and Your Patient (Appendix E, Smoking Cessation), 2001, AHRQ.
Available at:
Prochaska, J et al, Counselor and Stimulus Control Enhancements of a Stage-Matched
Expert System Intervention for Smokers in a Managed Care Setting. Preventive
Medicine. 2001b;32: 23-32.