This document provides information on brief tobacco cessation counseling. It discusses the three-link chain of tobacco dependence, including biological, psychological, and socio-cultural factors. It describes the five stages of change in the transtheoretical model: precontemplation, contemplation, preparation, action, and maintenance. The 5 A's approach to brief counseling is explained as Ask, Advise, Assess, Assist, and Arrange. Under each step, techniques for counseling patients on quitting tobacco are outlined, including setting a quit date, developing a quit plan, and providing resources and support.

2. Brief Tobacco Cessation Counseling For physicians and healthcare professionals to use in clinical practice

4. Tobacco Dependence
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5. Three-Link Chain of Tobacco Dependence
1.Biological Dependence
2.Psychological Dependence
3.Socio-cultural Factors
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7. Three-Link Chain of Tobacco Dependence

8. The Three Link Chain
 A is the addiction of nicotine – the “King” of addictions
B is the behaviours or cues or triggers- a smoker “trains” to smoke
C is the socio-cultural aspects of people around you

9. No two smokers are similar , In some smokers the addiction is very strong, others it is weak.
 Some smokers smoke a few cigarettes per day; others are multi pack smokers. And, some smokers are surrounded by other smokers, while others have very few people around them who smoke.

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Bulding a cessation system

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Not everyone has money for cessation drugs, but… …every country can do brief advice!

14. Brief tobacco cessation Counseling is effective, by itself.
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16. Change is not something you do to people, but with people.

22. The Stages of Change
Prochaska and DiClemente, 1984
?
Precontemplation
Contemplation
Preparation
Action
Maintenance

23. The Five Stages of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance

24. Pre-Contemplation Stage
Not ready to quit
Not interested in changing
Are defensive
“I can’t quit”
“It will not happen to me”
“I enjoy it to much”

25. Precontemplation
Person shows no intent to change a problem or behavior.
Person is either unaware of the problem or unwilling to change.
Individual sees more positive about the behavior than negative.
Person sees behavior as under control or manageable.
Any attempt to suggest that change is necessary is likely to be met with immediate resistance.

26. Contemplation
Thinking about changing
Aware of the need to quit
Taking small steps to quit
“I know I need to quit”
“You know, I should quit”
“I want to quit within the next 6 months”

27. Contemplation
Person is willing to consider changing.
Person will engage in weighing pros and cons of change.
Person shows some discomfort/distress with the ongoing behavior.
Person is still strongly ambivalent and can still easily move back into a resistance mode if defenses are triggered.

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29. If we want to change something that we do, we have to actively make a decision. It won’t happen just by wishing.
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30. The Basic For & Against Decision Making Chart

32. Preparation
Person is getting ready to make the change.
Person clearly intends to change soon
 “Planning to quit within the next 30 days”
There can be some evidence of actual change beginning, such as “cutting down”.
Ambivalence is not apparent.
Defenses are not triggered when professional is supporting the need to change.

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34. Action
The change process has begun.
The behaviors and attitudes in question are actively being changed.
The individual is learning and practicing the skills necessary to be successful.
This stage may last for months or even years in persons with co-occurring conditions.
Ambivalence is gone

35. Action Stage
Ready for change
Prepared mentally to change
“I am going to quit smoking”
“I want to live to see my grandchildren”
Last approximately 6 months

36. Maintenance Stage
Has quit smoking
Prepares for stress
Handles temptation
Reminds themselves of what they have accomplished
Continues to be smoke-free

37. Maintenance
Person continues to sustain and strengthen change.
Continues to practice skills to avoid a return to old habits or ways of thinking.
Continues to receive encouragement and support to solidify change process.

38. Relapse Stage
Most experience
Sees oneself as a failure
A normal event
A person may go through the stages of change several times before complete cessation.

39. Stage of Change for Smoking Cessation
•Precontemplation = Current smokers who are not planning on quitting smoking in the next 6 months
•Contemplation = Current smokers who are planning on quitting smoking in the next 6 months but have not made a quit attempt in the past year
•Preparation = Current smokers who are definitely planning to quit within next 30 days and have made a quit attempt in the past year
•Action = Individuals who are not currently smoking and have stopped smoking within the past 6 months
•Maintenance = Individuals who are not currently smoking and have stopped smoking for longer than 6 months but less than 5 years
DiClemente, 2003

40. People do not move in a linear fashion through the cessation process
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41. Cessation is explained as a process, rather than a single discrete event and smokers cycle through the stages of being ready, quitting and relapsing on an average of three to four times, before achieving long term success.
Smokers will be in different stages of readiness when the clinician sees them at different times, so readiness needs to be constantly re-evaluated.

42. Cyclical Model for Intervention
Most smokers will recycle through multiple quit attempts and multiple interventions.
However successful cessation occurs for large numbers of smokers over time.
Keys to successful recycling
1.Persistent efforts
2.Repeated contacts
3.Helping the smoker take the next step
4.Bolster self-efficacy and motivation
5.Match strategy to patient stage of change

43. Barriers to quitting
When quitting, people have a hard time because they…
Fear weight gain
Fear withdrawal symptoms
Give up a social activity to do with friends
Expect failure- may be they failed in the past
Think they cannot cope with tension and anxiety
Do not know enough about the benefits of quitting
Have a hard time changing daily routines that include smoking

44. 44 The 5 A’s Approach for Smoking Cessation

45. Brief Intervention for Tobacco: The 5 A’s Approach
The 5 A’s approach is a simple, brief way to address tobacco use with every patient.
Altogether, the 5 A’s may take 1 – 5 minutes.
They do not need to be applied in a rigid manner, and entire office/clinical staff should be involved.
The 5 A’s:
1.Ask
2.Advise
3.Assess
4.Assist
5.Arrange

46. Brief Counseling Intervention
–5 A’s for Brief Smoking Cessation Counseling
(U.S. Department of Health and Human Services)
•Ask
•Advise
•Assess
•Assist
•Arrange

47. The 5 ‘A’s
Ask
Assess
Advise
Assist
Arrange
Fiore MC, et al. Treating tobacco use and dependence: US Department of Health and Human Services, 2000
A
A
A

48. Presented by Health Care Education & Training, Inc.
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The “5 A’s” Model
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pd f

49. The 5A’s of Tobacco Cessation
Ask about tobacco use
Advise patient to quit
Assess readiness to quit
Assist in quit attempt
Arrange follow-up
―Preferably within 1 week after the quit date

50. #1 ASK
Systematically identify all tobacco users
Identify and document smoking status for every client at each visit
Make identification/documentation as a vital sign
Client about tobacco use...

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52. Ask: “Do you smoke?” and “Have you ever smoked?” Once the current smoker is identified you can take a brief smoking history as follows:
― Number of cigarettes smoked per day and the year of starting smoking.
―For exsmokers the quit date should be recorded.
―Previous quit attempts and what happened.
―Presence of smoking related disease.
#1 ASK

53. #2 ADVISE
Need for change – given in a non- authoritarian and supportive style
client of…
Health hazards of smoking
Benefits of quitting

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Health hazards of smoking

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57. Blood pressure & pulse return to normal
Oxygen levels return to normal
Risk of heart attack begin to decrease
Sense of taste & smell improve
20 Minutes
8 Hours
24 Hours
48 Hours
Start Living Healthier

58. Improvements in lung function and circulation
Risk of heart disease is reduced by 1/2
Risk of lung cancer is reduced by 1/2
Lungs improve capacity to clear & reduce infection
Risk of stroke is reduced
Risk of heart disease is similar to a person who never smoked
2 Weeks
9 Months
1 Year
5 Years
10 Years
15 Years
Start Living Healthier

59. Advise
Clear, Strong, Personalized
“Quitting smoking ...
―...is the single best thing you can do for your health”
―...will reduce your risk of …”
Employ the teachable moment:

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61. –Clear—“It is important that you quit smoking , and I can help you.“Cutting down while you are ill is not enough.” “Occasional or light smoking is still dangerous.”
–Strong—“As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you.”
–Personalized—Tie tobacco use to current symptoms and health concerns, and/or its social and economic costs, and/or the impact of tobacco use on children and others in the household. “Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health.” “Quitting smoking may reduce the number of ear infections your child has.”
Advice should be:

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Advise Examples
Appropriate:
“Ms. Smith, it is important for you to quit smoking. As your Resource Mother, I need you to know that quitting smoking increases your chances of having a healthy baby. Your health will also improve...”
Inappropriate:
“Ms. Smith, you need to quit smoking.”

63. Assess
After providing a clear, strong, and personalized message to quit, you must determine if the patient is willing to quit at this time.

64. Assess readiness to quit
1. Assess stage of change
2. Assess nicotine dependence
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65. Assess stage of change
Copied with permission,
Ottawa Heart Institute, The Ottawa Model

66. Smoking Cessation: Readiness to change

67. How important is it for you to quit smoking?
How confident are you that you could succeed in quitting for good?
1 2 3 4 5
Assess…Readiness
1 2 3 4 5

68. Readiness Ruler My Readiness to Quit Score
(10 Score out of 10)

69. Confidence Ruler
How confident are you that if you wanted to change your smoking habit, you could do so? If 0 was “not confident,” and 10 was “very confident,” what number would you give yourself ?
0 1 2 3 4 5 6 7 8 9 10
MI Basic Training

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74. Assess
Assess willingness to make quit attempt now, e.g., within next 30 days
“On a scale of 1 to 10, how motivated are you?”
„ If patient is willing to quit
 Provide assistance
„ If patient is unwilling to quit
Provide motivational intervention (5 Rs )

75. Presented by Health Care Education & Training, Inc.
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Assess Decision Flow
Yes
Does patient currently smoke?
Patient willing to quit?
Provide appropriate cessation techniques (Step 4 of 5A approach)
Yes
No
Provide motivational materials and counseling

76. Presented by Health Care Education & Training, Inc.
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Assess Decision Flow (cont)
Yes
Does patient currently smoke?
Has patient smoked in the past?
Assist with cessation maintenance (Step 4 of 5A approach)
No

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Three patient types
Current smoker who wants to quit.
Recent non-smoker
Current smoker who does not want to quit.
Target of Assess step

78. Assist: Provide help to move the individual toward a successful quit attempt
Former Tobacco Users (Action or Maintenance) For those who have successfully quit using tobacco, you can Assist by affirming their success to support self-efficacy, and discussing any challenges to staying quit and methods to prevent relapse.
Current Tobacco Users with High Readiness to Quit (Preparation or Action) You can Assist by helping him/her develop a personalized quit plan with a quit date and offer an array of effective treatment options:
Current Tobacco Users with Low Readiness to Quit (Precontemplation or Contemplation) You can Assist by enhancing willingness or motivation and ability or confidence through these methods:
1.Offer personalized, relevant feedback about the importance of quitting
2.Explore the individuals’ perceived pros and cons of smoking and quitting
3.Discuss the 5 R’s of quitting tobacco use

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For the Patient Willing To Quit

81. Determine the tobacco user’s willingness to make a quit attempt.
―Within the next 30 days
―If willing, ASSIST.
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82. Assist
Develop a quit plan
STAR:
- Set a quit date (within 2 weeks)
- Tell family, friends, coworkers
- Anticipate challenges to quitting
- Remove tobacco products from
environment

83. Helping the patient set a QUIT DATE.
The quit date should be soon; ideally within 2 weeks in order to give the patient time to prepare to stop
Advise against stopping at high-stress times; suggest instead a significant date (i.e. the patient's or spouse's birthday or the first day of the month).
Remove cigarettes from the environment. Prior to quitting, avoid smoking in places where a lot of time is spent (i.e. home, car).
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84. Get ready to quit
Get rid of all cigarettes, ashtrays, and lighters in your home, car, and workplace.
Make it a rule never to let anyone smoke in your home.
Write down why you want to quit and keep this list as a handy reminder.
Inform family, friends, and co-workers of quitting and request understanding and support.
Review previous quit attempts. "What helped you?" "What led to relapse?"
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85. Helpful hints
Involve someone else as a support person.
You may want more than one support person. Talk over with each support person how you want him or her to help.
Cigarettes keep your hands busy. So when you quit, your hands will miss having a, cigarette to handle. Keep them busy with, pens, pencils, rubber bands, or squeeze balls. Items like these are sometimes called “handling substitutes.”
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86. Smoking also keeps your mouth busy. Use low- calorie or no-calorie items such as hard candy, sugarless gum, fresh fruits and vegetables, or menthol cough drops. These items are sometimes called “oral substitutes.”
It also may be helpful to brush teeth frequently, use breath spray, or drink plenty of water.
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87. Additional ideas to help you in your process:
Limiting your smoking:
―Don’t carry cigarettes with you
―Decide on less cigarettes each day or week
―Only buy one pack at a time
―Only roll the number that you are allowing for yourself in a day
Aversion:
―Smell a dirty ashtray
―Keep a jar of used cigarettes and smell or touch them when feeling the urge to smoke
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88. Change the way you smoke:
―Change the hand that you hold the cigarette
―Create non-smoking areas in the home
―Only smoke in areas that feel uncomfortable to you
―Do not allow other people to smoke with you
 Change your routine
–Take a different route to work
–Drink tea instead of coffee
–Eat breakfast in a different place
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89. Learn New Skills & Behaviors
Change your routine:
―Change when you smoke
―Start a new activity that occupies your hands
―Stop drinking alcohol or caffeine
―Practice refusing cigarettes
―Practice relaxation and visualizing yourself as a non-smoker
―Get your teeth cleaned
―Clean your house and clothes
―Brush your teeth before having a cigarette
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90. Learn New Skills & Behaviors
―Reduce stress – take a hot bath, exercise, or read a book
―Plan something enjoyable to do every day
―Drink a lot of water and other fluids

91. Learn New Skills & Behaviors
Distract yourself from urges to smoke
–Talk to someone
–Go for a walk
–Get busy with a task
–Go somewhere you’re not allowed to smoke

92. key advice on successful quitting.
Abstinence--total abstinence is essential.Not even a single puff after the quit date
Alcohol--Inform the patient that drinking alcohol is highly associated with relapse.
Other smokers in the household--The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. If another smoker lives in the home, urge the patient to quit with the other smoker and/or develop specific plans to stay quit in a household where others still smoke
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93. Identifying triggers
It also is important to identify triggers that tend to make you want to smoke.
Once you know your triggers, you can either avoid them or change your behavior.
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95. Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include NICOTINE WITHDRAWAL SYMPTOMS.
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96. D
D Nicotine withdrawal: Duration
1 week
Sleep disturbance
2 weeks
Poor concentration Craving for nicotine
4 weeks
Irritability or aggression
Depression
Restlessness
2 days
Lightheadedness
10 weeks
Increased appetite

97. DD
Nicotine withdrawal: the
4‘D’s
Delay acting on the urge to smoke
Drink water slowly
Deep breathe.
Do something else (eg exercise)

98. Coping with Withdrawal
Cravings:
It takes 72 hours of abstinence to purge our blood of nicotine. Cravings are more a response to conditioning than to actual physical withdrawal.
 Cravings are the mind’s way of warning us that it is time to ingest nicotine to avoid physical discomfort. For most smokers the brain starts to send gentle reminders about every 20-30 minutes.
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99. Eliminating cravings
Cravings are urges to smoke.
Cravings can be intense at times.
 Important facts about cravings are listed below:
―They occur close together in the early days of quitting.
―Each craving is like a wave. It arrives reaches a peak, and goes away even if you don’t smoke.
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100. Cravings go away with time as long as you do not smoke.
As time passes, you will have more time between cravings, and they will be shorter.
Cravings increase after a slip or relapse.
 Respond to cravings with cognitive (thinking) and behavioral (doing) coping skills.
The chart below lists several examples of coping skills to quit smoking.
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102. Managing withdrawal
If you crave a cigarette
Wait out the craving (usually less than five minutes)
Try deep breathing
Use distractions
Try to do something different - talk to a friend, go for a walk, or do something you enjoy like gardening or going to the movies
Chew gum
Brush your teeth
Drinking lots of water or other fluids

103. Managing withdrawal
If your appetite has increased
Eat healthy snacks
Don’t delay regular meals
Drink more water
Exercise regularly

104. Steps to quitting
Avoid Relapse
Most relapses occur within the first three months
Avoid drinking alcohol – drinking lowers your chances of success
Avoid being around other smokers – can make you want to smoke

105. Steps to quitting
Avoid Relapse
Expect a small weight gain (usually less than 10 pounds)
Eat a healthy diet
Stay active
Look for ways to improve your mood other than smoking

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For the Patient Unwilling To Quit

107. 5R’s for Patients Not Ready To Make a Quit Attempt
Relevance
Risks
Rewards
Roadblocks
Repetition

108. RELEVANCE: Tailor advice and discussion to each patient
RISKS: Outline risks of continued smoking
REWARDS: Outline the benefits of quitting
ROADBLOCKS: Identify barriers to quitting
REPETITION: Reinforce the motivational message at every visit
5R’s for Patients Not Ready To Make a Quit Attempt

109. Arrange
Schedule a follow-up contact within one week after the quit date
The majority of relapses occur in the first two weeks after quitting
Arrange a second follow-up visit in 1-2 months.

110. Set a followup visit within 2 weeks after the patient's quit date, preferably in the first week.
Most relapses happen within the first two weeks.
Continued support through this time is critical to success. The first two weeks are most difficult because of physical withdrawal and the breaking of multiple habits surrounding the smoking experience.
Identify problems/anticipate challenges
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Arrange

111. If patient is still abstinent, congratulate success, emphasize your continued support, and ask about difficulties and coping strategies.
If patient has relapsed, discuss circumstances of the relapse, try to identify triggers and brainstorm ways to prevent future relapses.
Emphasize that a relapse is a learning experience, not a failure. Explain that most people require several quit attempts before they finally succeed and relapses are part of the normal process of stopping smoking.
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Arrange

113. Readiness to quit
Follow-up
•Documentation
•phone call (2 wks.)
ASK
ADVISE
ASSESS
ARRANGE
In quitting
ASSIST
•Health effects
•Need for change
5 A’s
Smoking status
StagesofChangePrecontemplationContemplationPreparationActionMaintenance

114. NoAsk: Do you use tobacco? Have you ever used tobacco? NoNo interventionEncourage continued cessation & re-evaluate next visitAccess Readiness to quitYesYesDo you want to quit? YesAdvise to quitAssist and ArrangeCall _____ at ______to make appt. NoFollowup next visit5 “R’s” RelevanceRisksRewardsRoadblocksRepetitionDo you want to quit within the next 30 days? YesNoRe-evaluate next visitTobacco Use Assessment Protocol

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