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Smoking Cessation: It’s all about the Questions – 5A’s and 5R’s

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Consent precedes action, and this is no different for smoking cessation. Asking the right questions as a healthcare professional can prepare the patient mentally for the challenge ahead. And for this, we have the 5As framework. 

The 5 As the framework of Smoking Cessation

ASK Identify smokers and document smoking status at every visit, which serves as a reminder to address cessation
ADVICE Unambiguous support for smoking cessation should be clear, strong, and personalized. 
ASSESS Willingness to quit and barriers to quitting should be discussed, with smoking history and current level of nicotine use. Also, obtain their timeline for quitting and if any previous attempts were done.
ASSIST Help anticipate difficulties e.g. withdrawals, mood changes/depression, and weight gain and prepare a support system (e.g. involving their family, cessation clinics, quit-line contacts).  
ARRANGE Set clear goals, with exact dates, as abstinence by the quit date is highly predictive of long-term success. 

But pertaining to this framework, what I would like to personally highlight is that oftentimes, after our patient has mentioned that they would like to quit and have begun on their journey, we tend to stop asking this set of questions. Something like a checklist that we mark done, and move on from. Even for patients who have successfully quit smoking, it would be nice to occasionally ask again, encourage and praise their efforts routinely thereafter. This is also taking into consideration that a quarter of patients who successfully quit, do have the tendency to relapse (read Part One of this four-part series covering the Evidence for Smoking Cessation).

However, what I believe most of us are less familiar with are the 5 Rs to motivate patients to quit smoking. In a nutshell, we must remember that smoking cessation is a 2-way conversation that will only be as effectively personalised if we listen more to our patients instead of us talking through our lists, or presenting our points of view. Ask open-ended questions. 

The 5 R’s for Motivating Patients to Quit Smoking 

RELEVANCE Encourage the patient to identify reasons to stop smoking that are personally relevant.

  • Get to know them, their interests, their priorities in life, their current and perceived struggles, and their fears. 
  • It might be difficult when you have a line of patients waiting for you but try, to the best of our ability, to pick up the small details and spare a minute or two, just to listen. This will help greatly in your credibility and in building their trust in you – that you do care for them and they aren’t just another number on the screen. 
  • Also, this helps us in smoking cessation in a way that is relevant for them and the current situation they’re in e.g. bringing in their current health status, family or social situation
RISKS  Educate the patient on the harmful effects of continued smoking to both the patient and to others, incorporating aspects of personal and family history where possible. 

  • Ask open-ended questions to prompt their reflection e.g. what do you know about the risks of smoking, and substantiate it with relevant statistics or general information e.g. apart from the lungs, it increases cancer of the throat and mouth as well
  • If you see their spouse, you may also mention the deleterious effects of second-hand smoke, what more on their children or grandchildren. 
REWARDS Ask the patient to identify the benefits of smoking cessation e.g. improved health, financial savings, decreased cigarette odour, less anxiety on long-haul flights, positive influence on children etc. 
ROADBLOCKS Explore the anticipated barriers that the patient may encounter, and come up with possible solutions together: 

  • Other smokers in the home or workplace make it a social activity [HABIT]
    • If they might be tempted by family or friends who smoke around them, recommend an alternative activity that they can occupy themselves with; or even better, rope in the family! 
    • Or if they are used to having smoke breaks after a meal – recommend coffee? 
  • History of failed quit attempts or severe withdrawal symptoms [ADDICTION]
    • Prepare them for withdrawals (e.g. irritability, anxiety, flu-like symptoms, restlessness peak within the first week and lasts 2-4 weeks) and discuss how NRTs can gradually decrease nicotine dependence, alleviating withdrawals.
  • Stresses, low mood, psychiatric comorbidity [MIND]
    • Monitor the mood of smokers during quit attempts and screen for depression in those who have repeatedly been unable to quit. Smokers are more likely than non-smokers to have a depressive episode, and smokers with depression are less likely to quit successfully; cessation may also trigger depression in those with a history. 
  • Weight Gain  
    • Though usually fewer than 4.5kg for the majority, can be as much as 13.5kg for 10% of quitters. Smoking cessation is linked to a decrease in metabolism, or it may also be an exchange of one addiction for another – eating. 
    • NRTs may delay weight gain while in use and it may be easier to monitor and adjust food intake/exercise once immediate cravings are not as prominent. It is important to watch out for this “adverse effect” as studies have shown that mortality is increased with post-cessation weight gain! 
  • Also, It is important to anticipate relapse, and counselling must be done about relapse prevention and re-engagement  – where they can seek help 
REPEAT Repetition is key. Include aspects of the five Rs in each clinical contact with unmotivated smokers. 

 

To round it off, I’d like to share a quote that you can keep at the back of your head to inspire your patients or keep them going. 

“The best time to quit smoking was the day you started; the second best time to quit is today.”

 

References: 

Larzelere, MM et al. (2012) Promoting Smoking Cessation. American Academy of Family Physicians.

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