Steps to Help Patients Quit Smoking

Steps of Smoking Cessation
(Practical Part)
Dr. Badr Bin Himd
ABFM & SBFM

To learn how to help your patient to quit smoking
using 5As counselling technique

1. Size of the problem
2. 5As (Ask ,Advise, Assess, Assist ,Arrange for follow up)
3. 5 Stages of change (Precontemplation , Contemplation ,
Determination , Action, Maintenance
4. The model of 5 Rs (Relevance, Risks, Rewards, Roadblocks,
Repetition)

• The prevalence of current smoking in Saudi Arabia ranges from 2.4-
52.3% (median = 17.5%).
According to WHO Tobacco fact sheet October 2014
• Tobacco kills up to half of its users.
• Tobacco kills nearly six million people each year,
• The annual death could rise to more than eight million by 2030.
• Nearly 80% of the world's one billion smokers live in low- and
middle-income countries.

1. Ask about smoking .
2. Advise every smoker to stop smoking .
3. Assess readiness to quit .
4. Assist the smoker in stopping smoking .
5. Arrange for follow up and monitor the progress of the smoker .

• Implement a system that ensures that, for every patient at
every clinic visit, tobacco-use status is queried and
documented.
• Repeated assessment is not necessary in the case of the adult
who has never used tobacco or has not used tobacco for many
years, and for whom this information is clearly documented in
the medical record.

Are you a
smoker ?
No Yes

• Since how long you became a smoker ?
• What type of smoke you are using ?
• Why you are smoking ?
• How many cigarette per day ?
• What is frequency of smoking ?
• What is the preferred times for smoking ?
• What are the behaviors associated with smoking ?
• How long you take after walkup in the morning to smoke?

• Congratulate him .
• Encourage him to continue as non-smoker .
• Advice to avoid indirect smoking ( second – hand smoker ) .
• Encourage him to participate in smoking cessation .

• Any attempt to stop before ? ( take details about this attempt).
• Do you have any medical problem due to smoking?
• Is there any smoker around you ( home , work ) ?
• Is there any family member or friend who had any medical
problem due to smoking ?
• Are you married ? Do you have children ?
• Are you convinced about the risk of smoking?
• Are you willing to quit ?

• A smoker’s dependence on nicotine can be estimated from:
1. The duration of smoking history .
2. The number of cigarettes smoked daily .
3. How soon after waking up the smoker has his or her first
morning cigarette.
• More dependent smokers have:
1. Smoked for many years .
2. Smoke more cigarettes daily .
3. Smoke within the first 30 minutes of awakening .

Advice should be:
1. Clear - "I think it is important for you to quit smoking now and I
can help you." "Cutting down while you are ill is not enough.“
2. 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.“
3. Personalized - Tie tobacco use to current health/illness, and/or its
social and economic costs, motivation level/readiness to quit,
and/or the impact of tobacco use on children and others in the
household.

• Determine the patient's willingness to quit smoking within the next
30 days:
- If the patient is willing to make a quit attempt at this time, provide
assistance.
- If the patient will participate in an intensive treatment, deliver such a
treatment or refer to an intensive intervention.
- If the patient clearly states he or she is unwilling to make a quit
attempt at this time, provide a motivational intervention.
- If the patient is a member of a special population (e.g., adolescent,
pregnant smoker), provide additional information specific to that
population.

Stages of Change

1. Precontemplation: The patient states he/she is not ready to
quit. The patient's motivation status should be documented
and monitored at every subsequent visit.
2. Contemplation: The patient is considering smoking cessation
at some point in the future.
3. Determination: The patient is actively considering cessation
soon and is engaging in some quit-oriented behavior.
4. Action: The patient is actively involved in a quit attempt and
has quit smoking within the last six months.
5. Maintenance: The patient has quit for at least six months.

meta-analyses of clinical trials to study the Effectiveness
of the 5-As Tobacco Cessation Treatments. It showed
smoking cessation was twice as likely when smokers
• Attended classes,
• Received counseling, or
• Used pharmacotherapies

• The clinician's role is to assess the patient's perspective (of the
risks and benefits of continuing to smoke) in order to help the
smoker to begin to think about quitting.
• Most smokers have a general desire to stop smoking, but may
not be ready to take specific action to quit, for a variety of
reasons.
• Asking a smoker what he or she likes and does not like about
smoking is a way to start.

• Clinicians can use motivational interviewing techniques to
explore a smoker’s feelings, beliefs, ideas, and values regarding
tobacco use.
• The model of "5 Rs" (Relevance, Risks, Rewards, Roadblocks,
Repetition) is helpful to motivate smokers who are not ready
to quit

Motivational information has the greatest impact if it is
relevant to a patient's disease status or risk, family or social
situation (e.g., having children in the home), health concerns,
age, gender, and other important patient characteristics (e.g.,
prior quitting experience, personal barriers to cessation).

• Ask the patient to identify potential negative consequences of
tobacco use.
• The clinician may suggest and highlight those that seem most
relevant to the patient.
• Examples of risks are:
- Acute risks - Shortness of breath, exacerbation of asthma,
harm to pregnancy, impotence, infertility, and increased serum
carbon monoxide.

• Long-term risks - Heart attacks and strokes, lung and other
cancers (larynx, oral cavity, pharynx, esophagus, pancreas,
bladder, cervix), chronic obstructive pulmonary diseases
(chronic bronchitis and emphysema), long-term disability, and
need for extended care.
• Environmental risks - Increased risk of lung cancer and heart
disease in spouses; higher rates of smoking in children of
tobacco users; increased risk for low birth weight, Sudden Infant
Death Syndrome, asthma, middle ear disease, and respiratory
infections in children of smokers.

• Ask the patient to identify potential benefits of stopping
tobacco use. The clinician may suggest and highlight those that
seem most relevant to the patient.
Examples of rewards include:
– Improved health
– Food will taste better
– Improved sense of smell
– Feel better about yourself
– Home, car, clothing, breath will smell better
– Not worry about exposing others to smoke
– Feel better physically and perform better in physical activities
– Reduced wrinkling/aging of skin

• Ask the patient to identify barriers to quitting and note
elements of treatment that could address barriers.
• Typical barriers might include:
– Withdrawal symptoms
– Fear of failure
– Weight gain
– Lack of support
– Depression
– Enjoyment of tobacco

• The motivational intervention should be repeated every time
an unmotivated patient visits the clinic setting.
• Tobacco users who have failed in previous quit attempts
should be told that most people make repeated quit attempts
before they are successful.

• The patient at this stage should be encouraged to
select a specific quit date and to engage in
preparation toward that date.
• Apply (5 Rs) .

(Decided to quit now)
1. Set a quit date. Ideally, the quit date should be within 2 weeks. He
can select a special date in his life or in the year .
2. Write this date in the patient file .
3. Tell family, friends, and coworkers about quitting and request
understanding and support.
4. Anticipate challenges /triggers to planned quit attempt, particularly
during the critical first few weeks. These include nicotine
withdrawal symptoms.
5. Prior to quitting , avoid smoking in places where you spend a lot of
time (e.g., work, home, car) .

6. Remove tobacco products and smell from your environment the
day before quitting .
7. Total abstinence is essential. "Not even a single puff after the quit
date."
8. Review past quit attempts including identification of what helped
during the quit attempt and what factors contributed to relapse.
9. Alcohol can cause relapse, the patient should consider
limiting/abstaining from alcohol while quitting.
10. Quitting is more difficult when there is another smoker in the
household. Patients should encourage housemates or his
colleagues to quit with them or not smoke in their presence.

11. Provide a supportive clinical environment while encouraging the
patient in his or her quit attempt. "My office staff and I are
available to assist you.“
12. Help the patient develop social support for his or her quit attempt
in his or her environments outside of treatment. "Ask your
spouse/partner, friends, and coworkers to support you in your quit
attempt.“
13. Assess behaviors associated with smoking ( you can use smoker
diary ) to concentrate on them in the quitting process.

14. Recommend the use of pharmacotherapies found to be effective.
Give him the options ,details and what is suitable for his condition
15. Explain how these medications increase smoking cessation success
and reduce withdrawal symptoms .
16. Always remind him about quitting rewards and keep encouraging
him .
17. Tell him that relapse can happen . So, he can know the weaknesses
and try again and again until he succeed .
18. Determination and the will are the cornerstone in the quitting
process.

Non-nicotine Medications
• Bupropion was the first non-nicotine medication shown to be
effective for smoking cessation.
• Its recommended use is 1-2 weeks before quitting smoking and can
be used for long term therapy up to 6 months post quitting.
• Varenicline is a non-nicotine medication that was approved by the
FDA for the treatment of tobacco dependence in 2006.
• It should be started 1 week before the quit date at .5 mg once a day
for 3 days, followed by .5 mg twice daily for 4 days. The quit day
should be on day 8 and then Varenicline should be taken at 1 mg
twice daily for 3 months. It is approved for a maintenance indication
up to 6 months.

Nicotine Replacement Therapy
Nicotine Patch (Strength of Evidence: A)
• Several types and different strengths of patches are available.
• Typical treatment duration is from 6-14 weeks, with patches
normally being worn 24 hours/day.
Nicotine Gum (Strength of Evidence: A)
• The gum is packaged in 2 mg and 4 mg strengths.
• Those who smoke more than a pack per day should start off with the
4 mg strength.
Nicotine Nasal Spray (Strength of Evidence: A)
• The nasal spray is designed to immediately relieve withdrawal
symptoms.
• It is recommended that the spray be prescribed for 3-month periods
and not used for longer than 6 months.

Nicotine Inhalers (Strength of Evidence: A)
• Inhalers are the most expensive form of nicotine replacement
therapy on the market today.
• It is recommended that inhalers be used for up to 6 months, with
patients tapering their dosages towards the end of their treatments.
Nicotine Lozenges (Strength of Evidence: B)
• It is available in 2 strengths: 2 mg and 4 mg.
• The 2 mg is recommended for ‘low-dependence’ smokers and the 4
mg is recommended for ‘high-dependence’ smokers
• Nicotine lozenges should be dissolved in the mouth rather than
chewed and swallowed.

(Follow up)

• Schedule follow-up contact, either in person or by telephone.
• Follow-up contact should occur soon after the quit date, preferably
during the first week.
• A second follow-up contact is recommended within the first month.
• Schedule further follow-up contacts as indicated.
• Congratulate success during each follow-up and encourage him to
remain abstinent.
• Remind the patient that a relapse can be used as a learning
experience.
• Consider use or referral to more intensive treatment if needed .

• The clinician should encourage the patient's active discussion
of the topics below : ( this will prevent relapse )
1. The benefits, including potential health benefits, that the patient
may derive from cessation.
2. Any success the patient has had in quitting (duration of
abstinence, reduction in withdrawal, etc.) .
3. The problems encountered or anticipated threats to maintaining
abstinence (e.g., depression, weight gain, alcohol, other tobacco
users in the household) .
4. Pharmacotherapy use and problems.

Relapse to Smoking After 1 Year of Abstinence: A Meta-analysis
estimated the annual incidence of relapse after 1 year to be 10%
The Role of the physician:
• Schedule follow up visits or telephone calls with the patient.
• Help the patient identify sources of support within his or her
environment .
• Refer the patient to an appropriate organization that offers cessation
counseling or support .
• Negative mood or depression If significant, provide counseling,
prescribe appropriate medications, or refer the patient to a
specialist

• If the patient is complaining of strong or prolonged withdrawal
symptoms consider extending the use of an approved
pharmacotherapy or adding/combining pharmacologic medication
to reduce strong withdrawal symptoms .
• For weight gain :
1. start or increasing physical activity; discourage strict dieting .
2. Reassure the patient that some weight gain after quitting is
common and appears to be self-limiting.
3. Emphasize the importance of a healthy diet.
4. Maintain the patient on pharmacotherapy known to delay weight
gain (e.g., bupropion SR, nicotine-replacement
pharmacotherapies, particularly nicotine gum) .
5. Refer the patient to a specialist or program

For flagging motivation/feeling deprived :
1. Reassure the patient that these feelings are common .
2. Recommend rewarding activities.
3. Probe to ensure that the patient is not engaged in periodic tobacco
use.
4. Emphasize that beginning to smoke (even a puff) will increase
urges and make quitting more difficult .

Evidence shows that 5 A’s are effective in many ways:
• Minimal intervention lasting less than three minutes increases
overall tobacco abstinent rates.
• Clinician advice and follow-up are not only clinically effective
but highly cost effective.
• Clinical settings that fully implement all of the 5 A’s show
better results than those with partial or inconsistent use of the
5 A’s .

• Smoking is a major health problems in KSA
• 5As counselling technique is practice and effective
• Personal approach is needed according to the stage of change of
every patient

1. Uptodate
2. WHO Tobacco fact sheet Updated: October 2014
http://www.wpro.who.int/mediacentre/factsheets/fs_201203_tobacco/en/
3. http://www.ksu-symposium-2010.sa-
tcp.com/pdf/smokinginsaudiarabiapaper.pdf
4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628990/
5. Effectiveness of the 5-As Tobacco Cessation Treatments in Nine HMOs
6. Gen Intern Med. Feb 2009; 24(2): 149–154. Published online Dec 13, 2008. doi:
7. Relapse to Smoking After 1 Year of Abstinence: A Meta-analysis Addict Behav. Dec
2008; 33(12): 1516–1520 John R. Hughes,1 Erica N. Peters,1 and Shelly Naud

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