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Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Stages of Change - Smoking Cessation

Purpose : Visualisation tool explaining where the individual fits along their journey of recovery


Admin time :  x min variable

User Friendly :  High

Administered by : GP or nurse 


Content : Illustration of stages of change, with explanations of mindeset, interventions and processed for each stage


Author : Prochaska JO, 1992  access

Adapted by CGA Toolkit Plus, 2023

Copyright : free to use

Stages of Change - Smoking Cessation

stages change.png



In the process of changing drinking behaviour, individuals are observed to pass through five stages.

Understanding the five stages is helpful for both the individual and the carer  :


1.  Pre-contemplation

2,  Contemplation

3.  Determination  

4.  Action

5.  Maintenance

6.  Relapse





Mindset : 

Unaware of problems associated with behaviour.

Certain that the positives of the behaviour out­weigh the negative.

Not interested in change.

Unwilling to change.

No intention to change.

Four main types of pre-contemplator (the four R’s) - reluctance, rebellion, resignation and rationalization:

  • Reluctant pre-contemplators are those who through lack of knowledge or inertia do not want to consider change. The impact of the problem has not become fully conscious.

  • Rebellious pre-contemplators have a heavy investment in drinking and in making their own decisions. They are resistant to being told what to do.

  • Resigned pre-contemplators have given up hope about the possibility of change and seem overwhelmed by the problem. Many have made many attempts to quit or control their drinking.

  • Rationalizing pre-contemplators have all the answers; they have plenty of reasons why drinking is not a problem, or why drinking is a problem for others but not for them.


Carer Intervention :

The goal for patients at the pre-contemplation stage is to begin to think about changing a behavior.
The task for physicians is to empathetically engage patients in contemplating change
During this stage, patients appear argumentative, hopeless or in "denial," and the natural tendency is for physicians to try to "convince" them, which usually engenders resistance.
Patient resistance is evidence that the physician has moved too far ahead of the patient in the change process, and a shift back to empathy and thought-provoking questions is required.
Physicians can engage patients in the contemplation process by developing and maintaining a positive relationship, personalizing risk factors and posing questions that provoke thoughts about patient risk factors and the perceived "bottom line."
The wording of questions and the patient's style of "not thinking about changing" are also important. As pre-contemplators respond to questions, rather than jumping in and providing advice or appearing judgmental, the task for physicians is to reflect with empathy, instill hope and gently point out discrepancies between goals and statements. Asking argumentative patients, "Do you want to die from this?" may be perceived as a threat and can elicit more resistance and hostility. On the other hand, asking patients, "How will you know that it's time to quit?" allows patients to be their "own expert" and can help them begin a thought process that extends beyond the examination room. Well-phrased questions will leave patients pondering the answers that are right for them and will move them along the process of change





Mindset :

Becomes aware of problems associated with behaviour.

Ambivalent regarding positives and negatives.

Explores the potential to change.

Desires to change behaviour but lacks confidence and commitment.

Intends to change before 6 months.


Carer Intervention :

With the help of a treatment professional, contemplators may make a risk-reward analysis.

They may be led to consider the pros and cons of their behaviour, and the pros and cons of change.

They may be helped to think about the previous attempts they have made to stop the substance abuse, and consider what has caused failure in the past.

It is not unusual for some patients to spend years in the contemplation stage, which physicians can easily recognize by their "yes, but" statements.

Empathy, validation, praise and encouragement are necessary during all stages but especially when patients struggle
with ambivalence and doubt their ability to accomplish the change. Physicians may find statements such as the
following to be useful: "Yes, it is difficult. What difficult things have you accomplished in the past?" or "I've seen you handle some tough stuff, I know you'll be able to conquer this."

A successful approach calls for physicians to ask patients about possible strategies to overcome barriers and then arrive at a commitment to pursue one strategy before the next visit.

It is also productive to ask patients about their previous methods and attempts to change behavior. Barriers and gaps in patients' knowledge can then surface for further discussion




Mindset :

Accepts responsibility to change behaviour.

Evaluates and selects techniques for behaviour.

Develops a plan.

Builds confidence and commitment.

Intends to change within one month.


Carer Intervention :

Commitment to change without appropriate skills and activities can create a fragile and incomplete action plan.

With the help of a professional, individuals may make a realistic assessment of the level of difficulty involved in stopping the substance abuse.
They will begin to anticipate problems and pitfalls and come up with concrete solutions that will become part of their ongoing treatment plan.


When patients experiment with changing a behavior, such as cutting down on smoking or starting to exercise, they are shifting into more decisive action.

Physicians should encourage them to address the barriers to full-fledged action. While continuing to explore patient ambivalence, strategies should shift from motivational to behavioral skills




This is an event, not a stage.

The individual concludes that the negatives of the behaviour out-weigh the positives and chooses to change behaviour.





Mindset :

Engages in self-directed behaviour change effort.

Gains new insights and develops new skills.

Consciously chooses new behaviour.

Learns to overcome the tendencies for unwanted behaviour.

Active in action stage for less than six months.

Carer Intervention :

During the action and maintenance stages, physicians should continue to ask about successes and difficulties--and be generous with praise and admiration.

If they have not done so already, individuals in this stage may start to attend support group meetings or tell their family members and friends about their decision.




Mindset :

Masters the ability to sustain new behaviour with minimum effort.

Establishes desired new behaviour patterns and self-control.

Remains alert to high-risk situations.

Focus is on lapse prevention.

Has changed behavior for six months.


Carer Intervention :

A person who has implemented a good plan begins to see it work and experiences it working over time, making adjustments along the way.

The many things that the smoking may have taken from the person begin to be restored, along with hope and self-confidence and continued determination not to smoke.





This is an event, not a stage.

May occur at any time.


Personal distress or social pressures are allowed to interrupt the behaviour change  process.

There is emporary loss of progress which may then resumes at one of the an earlier stages of change.

The experience ican be educational and useful to help prevent further recurrence.


Carer Intervention :

People at the maintenance stage of change should be armed with a variety of relapse prevention skills.

They should know where to get the supports they need.

Smokers who relapse learn from the relapse.

The experience of relapsing and returning to abstinence often strengthens a person’s determination to remain abstinant.

Relapse is common during lifestyle changes.
Physicians can help by explaining to patients that even though a relapse has occurred, they have learned something new about themselves and about the process of changing behavior. For example, patients who previously stopped smoking may have learned that it is best to avoid smoke-filled environments.
Focusing on the successful part of the plan ("You did it for six days; what made that work?") shifts the focus from failure, promotes problem solving and offers encouragement. The goal here is to support patients and re-engage their efforts in the change process. They should be left with a sense of realistic goals to prevent discouragement, and their positive steps toward
behavior change should be acknowledged




For people to progress they need :

•  A growing awareness that the advantages (the "pros") of changing outweigh the disadvantages (the "cons“)

•  Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behaviour

•  Processes that can help them make and maintain change

The ten processes of change include:

1.Consciousness-raising (Get the facts) — increasing awareness via information, education, and personal feedback about the healthy behaviour.


2.Dramatic relief (Pay attention to feelings) — feeling fear, anxiety, or worry because of the unhealthy behaviour, or feeling inspiration and hope when hearing about how people are able to change to healthy behaviours.


3.Self re-evaluation (Create a new self-image) — realizing that the healthy behaviour is an important part of who they want to be.


4.Environmental re-evaluation (Notice your effect on others) — realizing how their unhealthy behaviour affects others and how they could have more positive effects by changing.


5.Social liberation (Notice public support) — realizing that society is supportive of the healthy behaviour.


6.Self-liberation (Make a commitment) — believing in one's ability to change and making commitments and re-commitments to act on that belief.


7.Helping relationships (Get support) — finding people who are supportive of their change.


8.Counter-conditioning (Use substitutes) — substituting healthy ways of acting and thinking for unhealthy ways.


9.Reinforcement management (Use rewards) — increasing the rewards that come from positive behaviour and reducing those that come from negative behaviour.


10.Stimulus control (Manage your environment) — using reminders and cues that encourage healthy behaviour and avoiding places that don't.

There are many strategies that may be utilised for each process, and tailored for the specific individual.

This Tool is used in the assessment of Smoking in Late Life

Back To : Smoking in Late Life

smoker's hand
Thorny Issues

Back To : Thorny Issues

This is one of several topics presented in the Thorny Issues sector of this toolkit

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