for Health Care Providers
The 5 A's for Patients Unwilling to Quit
These strategies are designed to be brief (<3 minutes of direct clinician time). They need not be delivered by the same clinician; for example, a clinic nurse may ask about tobacco use, whereas a prescribing clinician (eg, MD, PA, or NP) may advise, assess, and assist, with referral to another provider for counseling services.
- All patients about tobacco use at every clinic visit:
- If a patient has never used, you do not need to ask again.
- If a patient quit years ago, congratulate and check in periodically.
- Consider making it a part of your office practice to ask about and record tobacco use while patients are having vital signs recorded.
- Smokers with clear, strong, and personalized suggestions:
- Clear: "I think it is important that you quit smoking. I can help."
- Strong: "Quitting smoking is one of the most important things you can do to protect your health."
- Personalized: Associate smoking with something that is important to the patient, such as exposure of children to tobacco smoke, the expense of cigarettes, or pulmonary and cardiovascular comorbidities. "Remember the time you had that terrible pneumonia?" "Do you realize that you can save almost $2,000 a year on cigarette expenses if you quit?"
- Smokers' readiness to quit within 30 days: "Are you willing to give quitting a try in the next 30 days?"
- If not ready, consider using motivational interviewing to increase patient's readiness to quit (see the 5 R's for Patients Unwilling to Quit, below*).
- If ready, assist and arrange (following).
- A patient's preparations for quitting:
- Setting a quit date. Ideally, the quit date should be within 2 weeks.
- Telling family, friends, and coworkers about quitting, and requesting understanding and support.
- Anticipating challenges to the upcoming quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms.
- Removing tobacco products from the environment. Before quitting, avoiding smoking in places where a lot of time is spent (eg, work, home, car). Making the home smoke free.
- Offer nicotine replacement or, if appropriate, bupropion, varenicline, or other medication (see below for more details on medication options).
- Provide practical counseling (problem-solving/skills training; see below).
- Offer intensive treatment options (smoking cessation intervention programs and groups).
- Offer readily available counseling and support services: phone support, clinic counselors.
- Enrollment in a VHA-based smoking cessation clinic, if the patient wishes.
- Referral to appropriate counseling services.
- Referral to evidence-based cessation program in the community or to phone quit lines if VHA-based interventions are not convenient for the patient or if the patient is interested (800-QUIT-NOW is a national portal for state programs).
- Follow-up contact during the first week after quit date (in person or by phone).
- Follow-up visit 1 month after quit date.
- Subsequent follow-up visits; congratulate upon success in quitting; anticipate further support with relapses (approximately 35-40% patients relapse 1-5 years after quitting).
From Smoking Cessation
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009