Tobacco Abuse

Doctors play a crucial role in smoking cessation by providing the necessary support, information, and interventions to assist patients who smoke in quitting.

The “5 A’s” approach is a set of evidence-based steps clinicians can use to conduct an effective tobacco cessation intervention quickly. This model provides a systematic method for interacting with patients who smoke, aiming to prompt quit attempts and provide assistance in the process. The 5 A’s are:

  1. Ask: Systematically identify all tobacco users at every visit. This involves inquiring about the patient’s tobacco use in a nonjudgmental way as a routine part of their care.
  2. Advise: Strongly urge all tobacco users to quit. Give clear, strong, and personalized advice to patients about the risks of tobacco use and the benefits of quitting.
  3. Assess: Determine the patient’s willingness to make a quit attempt. Find out if the tobacco user is ready to quit within the next 30 days, considering his or her readiness to change.
  4. Assist: Aid the patient in quitting. This involves providing resources, counseling, developing a quit plan, discussing pharmacotherapy options, and addressing barriers to quitting.
  5. Arrange: Ensure follow-up contact to prevent relapse. Schedule follow-up contacts, starting within the first week after the quit date.

Using the 5 A’s model is associated with increased cessation rates. It is designed to be integrated into routine clinical care, and healthcare providers should use each of the steps at every opportunity to encourage patients to stop using tobacco.

  1. Ask
    1. Identify Smokers: Regularly ask all patients about their smoking status as part of routine vital signs.
  2. Advise
    1. Strong Message: Clearly state the health benefits of quitting smoking in a personalized manner.
    2. Health Risks: Educate about the specific risks of continued smoking, such as heart disease, stroke, cancer, and respiratory problems.
    3. Supportive Tone: Deliver advice in a non-judgmental and empathetic manner.
  3. Assess
    1. Assess Willingness: Gauge the patient’s readiness to quit (using the stages of change model: precontemplation, contemplation, preparation, action, and maintenance).
    2. Explore Smoking Habits: Understand the patterns and triggers for smoking, the number of cigarettes smoked per day, and any previous quit attempts.
  4. Assist
    1. Set a Quit Date: Encourage the patient to set a quit date, preferably within the next two weeks.
    2. Develop a Quit Plan: Help create a tailored quit plan, which may involve preparing the environment, identifying triggers, and planning coping strategies.
    3. Pharmacotherapy:
      1. NRT
        1. Patches 21->14mg/24 hours
        2. Gum/Lozenge 4->2mg PRN
        3. Spray 1mg/spray i-ii PRN
        4. Can combine patches and other NRT and is more effective
        5. Pre-cessation patch increases quit rates
      2. Verenacline (Champix) 1mg BD
        1. 0.5mg OD for 3/7
        2. 0.5 mg BD for 4/7
        3. s/e nausea 30%, neuropsych
      3. Buproprion (Zyban) 150mg BD
        1. 150mg OD for 3/7 to start
        2. s/e seizures so c/i seizures
      4. Nortriptyline 25->75mg oral OD
    4. Behavioral Therapy: Provide resources for counseling or recommend digital tools such as apps or websites.
  5. Arrange
    1. Referrals: Refer to specialized cessation programs or support groups when available.
    2. Follow-Up: Schedule subsequent appointments to discuss the challenges and successes of the quit attempt.
    3. Continuous Support: Offer continuous support throughout the process, acknowledging that relapse can be a part of the journey to quitting.
  6. Addressing Relapse
    1. Discuss: Talk about what led to the relapse and strategize how to overcome these challenges in the future.
    2. Encourage Persistence: Emphasize that it often takes multiple attempts to quit smoking permanently and that each attempt is a learning experience.
  7. Promote a Healthy Lifestyle
    1. Exercise: Encourage regular physical activity to manage weight and withdrawal symptoms.
    2. Nutrition: Provide guidance on maintaining a healthy diet during the quit process.
  8. Documentation
    1. Record Keeping: Document the patient’s smoking status and quit plan in their medical record for continuity of care.
  9. Advocacy and Policy
    1. Advocate for Smoke-Free Environments: Support policies and efforts that promote smoke-free workplaces and public spaces.
  10. Motivational Interviewing
    1. Use brief intervention and motivational interviewing techniques to help patients explore their ambivalence and enhance their motivation to quit.
    2. FLAGS
      1. Feedback
      2. Listen with empathy
      3. Advise
      4. Goals
      5. Strategy
    3. RULE & OARS
      1. Resist the righting reflex
      2. Understand the patient’s motivation
      3. Listen with empathy
      4. Empower the patient
      5. Open ended questions
      6. Affirmations
      7. Reflective listening
      8. Summaries

By taking a comprehensive and patient-centered approach, doctors can significantly increase their patients’ chances of successfully quitting smoking. It is also important to remember that the process is often challenging, and a strong doctor-patient alliance can be the key to a successful quit attempt.