The Five A's Model for Facilitating Smoking Cessation
Ask about tobacco use during every office visit: Ask: "Do you use tobacco products?"
Advise all smokers to quit:
Clear: "I think it is important for you to quit smoking now. Cutting down or changing to light cigarettes is not enough."
Strong: "As your physician, I need to tell you that smoking cessation is one of the most important
decisions you can make for your health."
Another example: "Quitting smoking is the single most important thing you can do for your health."
Personalize: "And you've given your":
- High blood pressure
- Your son with asthma
- Your high choleterol
- Your chronic cough
- Your diabetes
- The high cost of cigarettes
- And so on - try to find a way to personalize the need to quit
Assess the patient's willingness to quit: "On a scale from 0 to 10, with 0 being 'not at all motivated' and
10 being 'extremely motivated,' how motivated are you to quit smoking?"
Use the patient's level of motivation to determine the next step:
- If the patient is willing to make a quit attempt, offer medication, brief counseling,
and self-help resources and schedule a follow-up visit.
- If the patient is unwilling to quit, identify why the patient is not motivated.
Explore what he or she likes and does not like about smoking and the potential advantages and disadvantages of quitting.
Identify the patient's core values (e.g., health, being a role model for children) and how smoking affects these values.
Assist the patient in his or her attempt to quit.
- Help the patient make a quit plan
- Set a quit date, ideally within two weeks of the office visit.
- Request encouragement and support from family and friends.
- Anticipate triggers and cues to smoking and identify alternative coping strategies.
- Help the patient change his or her environment:
- throw away cigarettes, matches, lighters, and ashtray
- launder clothing
- vacuum home and car
- go to the dentist to get teeth cleaned
- start an exercise program
- Avoid smoking in places where the patient spends a lot of time (e.g., home, work, car).
- Avoid other smokers and drinking alcohol.
- Provide basic information about smoking and cessation (e.g., addictive nature of smoking,
importance of complete abstinence, possible withdrawal symptoms).
- Recommend pharmacotherapy, unless contraindications exist (avoid nicotine replacement in pregnancy,
or in the setting of a recent [1 month] MI, unstable angina or serious arrhythmias), and behavior therapy for smoking cessation.
Arrange follow-up contact. Follow-up should occur within the first week after the quit date. A second follow-up contact is recommended within the first month. Further follow-up visits should be scheduled as needed.
During a follow-up visit, success should be congratulated. If the patient has relapsed, review the circumstances and elicit a new commitment to quit. Consider referral for more intensive treatment. Follow-up contact can be by telephone, e-mail, or in person.
- Bupropion (Zyban): Usual dose 150 mg qd x 3 days, then bid for 7-12 weeks. Costs about $5/day in 2006. Insomnia, dry mouth, HA, nausea, anxiety, and tremor are side effects. Do not use in patients with history of seizure, head trauma, bulimia, anorexia nervosa or those taking MOAI.
- Nicotine gum: OTC; dose of 2 mg q 1-2 hours for those smoking < 15 cigarettes per day, and 4 mg q 1-2 hours for those smoking > 15 cigarettes per day. Costs about $10/day for 16 pieces per day. Category D in pregnancy. Do not use in unstable cardiac patients. No food or drink 15 minutes before use. Dyspepsia, jaw pain and mouth soreness are potential side effects.
- Nicotine inhaler: May use 6 to 16 cartidges per day (each is 10 mg, delivering about 4 mg of nicotine); taper after 6-12 weeks. Costs about $10 per day. Pregnancy category D. Do not use in unstable cardiac patients. May cause mouth and throat irritation.
- Nicotine lozenges: OTC; dose of 1 lozenge every 1-2 hours during the first 6 weeks, tapered to q 2-4 hours for weeks 7-9 and q 4-8 hours for weeks 10-12. Those who smoke their first cigarette < 30 minutes after awakening should start with 4 mg lozenge, while others start with 2 mg lozenge. Costs about $9 per day for 16 lozenges. Pregnancy category D. Do not use in unstable cardiac patients. May cause mouth soreness and dyspepsia.
- Nicotine patch: OTC; use 21 mg if smoking > 10 cigarettes per day, and 14 mg for those smoking < 10 cigarettes per day. Step down to 14 mg (or 7 mg) patch in 6-8 weeks, and then to 7 mg in after another 2-4 weeks (for 2-4 weeks). Costs about $4 per day. Pregnancy category D. Do not use in unstable cardiac patients. Side effects include skin irritation and insomnia (if worn at night).
- Nicotine nasal spray: Dose 1-2 doses (0.5 mg) in each nostril every hour for 3-6 months, then taper over 4-6 weeks. Costs $16 per day. Pregnancy category D. Do not use in unstable cardiac patients. May cause nose and eye irritation. This is the most addictive form of nicotine replacement.