Tell a Colleague

Public Health Service Guideline In Action

Clinical Opportunities and Teachable Moments
Lori Pbert, PhD
Associate Professor of Medicine
University of Massachusetts Medical School

Physicians in the clinical practice setting are in a unique position to identify tobacco users and to provide effective intervention.

• First, as a physician you provide accessible and continuous care to your patients. Your long-term relationship with your patients offers many clinical opportunities and teachable moments to deliver intervention and provide crucial follow-up within the course of routine care.
• Second, you are a credible source of health-related information and assistance.
• Lastly, there is strong evidence from many clinical trials that brief smoking cessation counseling delivered by physicians, dentists, and other clinicians increases smoking cessation rates in their adult patients.

This evidence led to the development of the clinical practice guideline for treating nicotine dependence, produced by the U.S. Public Health Service in 2000 (see Related Resources below).

The current guideline recommends that clinicians deliver the 5A intervention: Ask about tobacco use at every visit, Advise all tobacco users to stop, Assess their willingness to make a quit attempt, Assist the patient in quitting, and Arrange follow-up contact to support their efforts.

The literature review conducted to develop the guideline concluded that physician advice to quit improved adult cessation rates, and the addition of brief counseling (less than three minutes) was even more effective. Both behavioral counseling (including telephone-based services) and pharmacotherapy (nicotine gum, patch, nasal spray and inhaler, or the antidepressant bupropion known as Zyban® or Wellbutrin SR®) were found to be effective, with a combination of counseling and pharmacotherapy producing the best results.

Because tobacco users state that a physician's advice to quit is a strong motivator to make repeated quit attempts and to maintain abstinence from tobacco use, the impact you can have on your patients' tobacco use cannot be overestimated.

5A Tobacco Intervention

Here's how QuitWorks-NH supports your efforts to integrate the 5A intervention as a standard of care in your practice:

ASK About Tobacco Use at Every Visit
Implement an office system that ensures that, for every patient at every visit, tobacco-use status is queried and documented. The QuitWorks-NH Office Practice Materials provide ideas and tools for this.

ADVISE All Tobacco Users to Quit
"I strongly advise you to quit smoking, and I can help you."

Ask every tobacco user if s/he is willing to make a quit attempt at this time:

• If willing to quit, provide assistance.
• If unwilling to quit, provide motivational intervention.

QuitWorks-NH provides a take-home pamphlet, "Think About It".

Provide brief counseling:

• Recommend use of pharmacotherapy (patch, gum, nasal spray, inhaler, bupropion-SR, varenicline) unless contraindicated.
• QuitWorks-NH provides clinicians with FDA recommendations for pharmacotherapy dosing.*
• Enroll patient for QuitWorks-NH services through the Try-To-STOP TOBACCO Resource Center. QuitWorks-NH provides a universal referral form and a QuitWorks-NH "Welcome Guide" enrollment pamphlet.
• Fax consent signed by patient to 1-866-560-9113. QuitWorks-NH receives referrals via toll-free fax.

ARRANGE Follow-Up
At subsequent visit, review quit status. Congratulate success; encourage maintenance. QuitWorks-NH provides a status report and a six-month follow-up report for every patient you refer.

If tobacco use has occurred:

• Ask for recommitment to total abstinence.
• Review circumstances that caused lapse.
• Use lapse as a learning experience.
• Assess pharmacotherapy use and problems.
• If willing to try again, re-enroll patient for QuitWorks-NH services.

*Inclusion of an adult dosage chart is strictly for the convenience of the prescribing provider. Please consult the Physicians' Desk Reference for complete product information and contraindications. The chart does not indicate or authorize insurance benefit coverage for any of these medications. For insurance benefit information, the patient will need to contact his/her insurer directly. The cost or provision of these medications is not included as any part of the Try-To-STOP TOBACCO Resource Center of New Hampshire or QuitWorks-NH program.

A Brief "5A's" Intervention in Action

Watch a 5-minute video entitled "Basic Skills for Working with Smokers: The Brief 5A Intervention".

Systematic Identification of Smokers

Adopting office systems to identify smokers and to prompt providers to intervene increases the delivery of tobacco treatment by clinicians. Based on a meta-analysis of studies evaluating the efficacy of office systems to identify smokers at each clinical encounter, the use of a screening system to identify smoking status was found to increase cessation rates. The QuitWorks-NH Office Practice Materials provide tools needed to implement office-wide systems to ensure that, for every patient at every clinic visit, tobacco-use status is queried and documented.

Behavioral Counseling and Pharmacotherapy

Behavioral counseling (including telephone-based services) and pharmacotherapy (nicotine gum, patch, nasal spray, lozenge and inhaler), the antidepressant bupropion (Zyban® or Wellbutrin SR®), or the nicotine receptor agonist varenicline (Chantix™) were found to be effective. A combination of counseling and pharmacotherapy produced the best results. Physician or clinician advice based on health issues provides a strong incentive for smokers to quit. QuitWorks-NH reinforces and enhances clinician efforts and supports successful quit attempts.

Telephone Counseling Works

The Public Health Service Clinical Practice Guideline recommends telephone counseling, as treatments involving person-to-person contact (individual, group, or telephone counseling) are consistently effective.