The 5As Counseling Method

We have developed a series of treatment algorithms for quick navigation through the 5 As counseling method, detailing approximate length of time to complete each step. Work with your patient to choose the best treatment algorithm for them.

What are the 5A's?

Tab/Accordion Items

Ask all patients about tobacco use at every visit.

Asking about tobacco use can take less than one minute of your time and can have a lasting impact on your patients. To make asking about tobacco use easy we have developed the following customizable tools for your office.

Patient Tobacco Use Screeners

Tobacco Use Screening & Documentation Form for General Population (PDF)
Postpartum Tobacco Use Screening & Documentation Form (PDF)
Pregnancy Tobacco Use Screening & Documentation Form (PDF)
Secondhand Smoke and Vape Screening Questions (PDF)

In a clear, strong, and personalized manner, urge every tobacco user to quit.

Studies have shown that patients are more likely to quit when their doctor (and the health care team) advises them to, and that when they do, the patients are also more satisfied with their health care.

Clear:
"I think it is important for you to quit smoking (tobacco use) now and I (or our clinic staff) can help you."

 "Quitting tobacco is the single most important thing you can do for your health and the health of those around 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: 

"Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health." 

Tie tobacco use to the impact of tobacco use on children and others in the household.
 

Patients' motivation to quit smoking should be assessed at every visit. 

Patients not yet willing to quit should receive a motivational intervention. Readiness rulers (PDF) (i.e., “On a scale of 1 to 10, where 10 is very ready, how ready are you to quit smoking?”) and Stages of Change assessments are useful in addressing the extent to which a person is ready to change, which can change from visit to visit. Behavior change can be conceptualized into five progressive stages: precontemplation, contemplation, preparation, action, and maintenance.

Although tailoring interventions to a patient's stage of change may not be necessary, these stages emphasize that not all patients are equally motivated to quit smoking. Motivation is malleable, and patients can be assisted toward behavior change through clinician intervention.

Stages of Change from the Transtheoretical Model of Intentional Behavior Change
  • Precontemplation: Current smokers who are NOT planning on quitting in the next 6 months.
  • Contemplation: Current smokers who are considering quitting within the next 6 months and have not made an attempt in the last year.
  • Preparation: Current smokers who have made quit attempts in the last year and are planning to quit within the next 30 days.
  • Action: Individuals who are not currently smoking and stopped within the past 6 months (recently quit).
  • Maintenance: Individuals who are not currently smoking and stopped smoking for longer than 6 months but less than 5 years (former smoker).

Another useful tool that is also motivational is the CO monitor. Tobacco smoke contains a significant amount of carbon monoxide (CO). The breath CO monitor can be used as a validating, motivational, and educational tool. CO testing is a billable outpatient service and can contribute to the sustainability of face-to-face tobacco use treatment services.

Pharmacotherapy
Counseling Delivery Methods

Use one or more of these methods to support integrating tobacco dependence treatment within your practice: 

Assist your patients to quit.

Assisting patients to quit can take as little as three minutes. For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit. Use the fax referral form (English, Spanish) to connect patients with personalized quit coaching from QuitlineNC: Call 1-800-QUIT-NOW.

Together with the patient, develop a STAR quit plan:
  • Set a quit date -- ideally, the quit date should be within two weeks.
  • Tell family, friends, and co-workers about quitting and request understanding and support. 
  • Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms. 
  • Remove tobacco products from the environment. Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car).
Provide practical counseling
  • Total abstinence is essential. "Not even a single puff after the quit date." 
  • Anticipate triggers or challenges in upcoming attempt. Discuss challenges/triggers and how the patient will successfully overcome them. 
  • Since alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting. 
  • Quitting is more difficult when someone else in the household is smoking. Patients should encourage housemates to quit with them or not smoke in their presence.
Assisting Patients Not Ready to Quit

The "5Rs," Relevance, Risks, Rewards, Roadblocks, and Repetition, are designed to motivate tobacco users who are unwilling to quit at this time. There are several reasons why tobacco users may be unwilling to quit: misinformation, concern about the effects of quitting, or demoralization because of previous unsuccessful quit attempts. Therefore, after asking about tobacco use, advising the tobacco user to quit, and assessing the willingness to quit, it is important to provide the "5Rs" motivational intervention.

Tools to help assist patients quit tobacco use

STAR Quit Plan
STAR Quit Plan for Pregnant Women
Medications for Quitting (PDF)
Materials to reinforce the cessation message

Arrange follow up with patients.

Arranging can take as little as 1 minute and is an important component of the 5 As. To arrange and ensure consistent follow-up with patients who have set a quit date:

  • Follow-up 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. 

Keep in mind that nothing can replace the involvement of the health care provider giving personal follow-up in patients' quit attempts.

Actions during follow-up contact: 
  • Identify problems already encountered and anticipate future challenges. 
  • Offer patient materials to reinforce the cessation message. 
  • Assess medication use. 
  • Remind patients of the free QuitlineNC service (1-800-QUIT-NOW). 
  • For patients who are abstinent or have made some progress, congratulate success. 
  • If tobacco use has occurred, discuss triggers, and ask for commitment to total abstinence
     
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