NICE recommends the 5A’s approach:

 Ask

Assess

Advise

Assist

Arrange

This approach has been demonstrated to achieve a higher quit rate when implemented in smoking cessation counselling.

Introduction

🚬 Greet the patient and introduce yourself 👋

🚬 Confirm patient details ✍

🚬 Discuss why the patient is there

🚬 Assess the patient’s understanding about the risks of smoking (ICE: Ideas, Concerns, Expectations)

History

Investigate the smoking history of the patient:

🚬 e.g. how long they have been smoking, how much they smoke per day, what they smoke, their feelings about smoking and the impact quitting may have both emotionally and financially etc.

🚬 Explore the medical history of the patient: Looking at pathology related to smoking e.g. lung/cardiovascular disease

🚬 Assess any medication currently or previously prescribed: e.g. nicotine replacements

🚬 Examine the family history of the patient: e.g. malignancy may put the patient at increased risk

🚬 Look at the social history of the patient: e.g. alcohol abuse/recreational drug use

5A’s Approach

NICE recommends the 5A’s approach:

🚬 Ask: the patient about their tobacco use status ❓

🚬 Assess: the patient’s knowledge and motivation

1. Check understanding about the consequences of smoking
2. Identify current motivation to quit
3. Quantify from 1 (low) to 10 (high), the level of motivation to quit
4. Use the stages of change model as a guide

🚬 Advise: the patient to quit smoking ✖

1. Explain the risk caused by smoking
2. Reassure the patient that they will be supported throughout the process 

🚬 Assist: the patient in quitting, using the STAR method  

🚬 Set a date on which the patient will quit (within 2-4 weeks) 📅

🚬 Tell friends and family for additional support 👫

🚬 Anticipate any challenged the patient may face and prepare them for overcoming these

🚬 Remove tobacco products

🚬 Recommend counselling and pharmacological programmes they may find beneficial

🚬 Arrange: follow up appointments (Within 1-2 weeks after the quit date, then after 4 weeks, 3 months and 1 year to monitor the progress/ relapse, to provide continued monitoring and support

🚬 This approach has been demonstrated to achieve a higher quit rate when implemented in smoking cessation counselling

Pharmacological therapies

Varenicline:

🚬 Partial agonist of the nicotine receptor

🚬 12-week medication course commenced a week before quit date

🚬 Success in quitting >2x more likely

🚬 Contraindication: hypersensitivity

Bupropion:

🚬 12-week medication course commenced 1 or 2 weeks prior to quit date

🚬 Success in quitting 2x more likely

🚬 Contraindication: eating disorders/hypersensitivity/ seizure disorders

Nicotine replacement therapy:

🚬 Patches/sprays/alternative forms

🚬 First line therapy

🚬 Success in quitting 1.5x more likely

🚬 Beware: cardiovascular disease/ acute coronary syndrome

Non-pharmacological therapies

🚬 Telephone counselling: calls with a trained counsellor at pre-arranged times

🚬 Individual counselling: multiple meetings with a trained therapist

🚬 Group counselling: multiple meetings with a trained therapist with other individuals going through the same process for support

🚬 Brief intervention: short behavioural therapy sessions

Completion

1. Identify any remaining queries ❓ the patient has
2. Double check the patient has understood what you have been telling them
3. Provide additional informative resources for the patient
4. Ensure the patient has made the decision to quit independently
5. Thank the patient 

Stages of change model

🚬 This model describes the different stages people go through when undergoing behavioural change to enable you, as a clinician, to support them appropriately

Pre-contemplation:

🚬 No interest in changing their behaviour (quitting smoking)

🚬 You should implement the 5 R’s:

• Relevance: find relevant reasons for the patient to quit 
• Risks: discuss the risks of smoking
• Rewards: discuss the positives of smoking
• Roadblocks: highlight what is preventing the patient from quitting
• Repetition: repeat the steps involved and make sure they understand it is common to have to try to quit multiple times before succeeding

Contemplation:

🚬 Recognition of the negative aspects of smoking but a feeling that these are outweighed by the positives

🚬 Implement the 5R’s, focussing on reinforcing why quitting is important, and revisit their feeling at a later meeting 

Preparation:

🚬 Planning to quit as they recognise the negative aspects of smoking

🚬 Identify any potential difficulties they may face and consider how they will be avoided

🚬 Create an action plan

Action:

🚬 Attempts to stop smoking

🚬 Implement the 4 A’s:

1. Ask: about side effects and how they are finding the plan
2. Assess: how the patient is feeling
3. Advise: them on how to reduce the change of relapsing using non-pharmacological therapy
4. Assist: continue to support them and highlight their success thus far

Maintenance:

🚬 Patient has still not smoked but you must support them to prevent relapse

🚬 Congratulate the patient and continue to support them

Relapse:

🚬 The patient tried to quit but is now smoking again

🚬 This can happen at any stage

🚬 Do not judge the patient, and implement the 2R’s:

1. Reassure: the patient this is common and not a setback
2. Reassess: establish which stage the patient is now at 

Summary:

1. Greet the patient and discuss why they are there
2. Investigate the patient's smoking history
3. Use the 5As approach (Ask, Assess, Advise, Assist, Arrange)
4. Consider Pharmacological therapies (Varenicline, Bupropion and Nicotine replacement therapy)
5. Consider Non-pharmacological therapies (Telephone/individual/group counselling, and brief intervention)
6. Complete the consultation by answering any questions and provide informative resources
7. Use the Stages of Change model (pre-contemplation, contemplation, preparation, action, maintenance, relapse)