Brief intervention for smoking cessation
The Ask, Advise, Help structure for supporting smoking cessation is a brief intervention that can be provided by a wide range of health professionals working in a variety of settings. The brief intervention can be delivered in a short time, reducing one of the key barriers to health professionals providing smoking cessation advice.62,63,64 This three-step model, developed by Quit Victoria, offers patients best practice smoking cessation treatment by linking into multi-session behavioural interventions (eg Quitline) and encouraging the use of pharmacotherapy, as indicated. Three-step approaches for supporting smoking cessation have been used for some time in the UK,65 Canada66,67 and New Zealand.68
The three-step brief intervention model (Figure 1.3) can be summarised as follows:
- Ask and record smoking status
- Advise all people who smoke to quit and on the most effective methods
- Help by offering to arrange referral, encourage use of behavioural intervention and use of evidence-based smoking cessation pharmacotherapy
Options for behavioural support include the Quitline (13 78 48) or a tobacco treatment specialist.
Recommendation 1 – All patients who smoke should be offered brief advice to quit smoking.
Strong recommendation, high certainty
Reproduced with permission from Quit Victoria, 2019.
Comprehensive intervention for smoking cessation
Comprehensive support for quitting within the clinical service can be provided using the 5As structure:
- Ask
- Assess
- Advise
- Assist
- Arrange follow-up
The 5As approach (Figure 1.4) is applicable when health professionals are providing assistance personally or with help from other staff within the clinical service. It involves:
- identifying all patients who smoke
- assessing nicotine dependence and barriers to quitting
- advising them to quit
- offering quitting assistance
- arranging follow-up.
The approach is adopted in full or as a modified form in the majority of international smoking cessation guidelines.69 Where possible, health professionals should maintain long-term and ongoing relationships with people who smoke in order to foster the person’s motivation and confidence to attempt smoking cessation.
Ask all patients about smoking
Ask
Ask about and document the smoking status of all patients
Health professionals should ask all patients whether they smoke tobacco and their smoking status should be recorded. Implementing recording systems that document tobacco use almost doubles the rate at which clinicians intervene with patients who smoke, and results in higher rates of smoking cessation.21 For those patients known to smoke, health professionals should try to continue a conversation about their smoking at each visit, even if it is just an offer to discuss options and importance of action at a subsequent visit. It is important for health professionals to be non-judgemental when asking about smoking.
Recommendation 2 – A system for identifying all people who smoke and documenting tobacco use should be used in every practice or healthcare service.
Strong recommendation, high certainty
Assess nicotine dependence and barriers to quitting
Assess
Assess nicotine dependence
How many minutes to first cigarette after waking? (Smoking within 30 minutes indicates nicotine dependence)
Assess and address barriers to quitting
Assess nicotine dependence
The majority of people who smoke are nicotine dependent, and smoking can be conceptualised as a chronic medical illness requiring ongoing care for these people.70 As nicotine dependence is under-recognised by clinicians, routine assessment of nicotine dependence can help predict whether a person who smokes is likely to experience nicotine withdrawal on stopping smoking,71,72 and the intensity and type of support that may be required to assist quitting.
A quick assessment of nicotine dependence can be made by asking the person who smokes:73
- ‘How soon after waking do you have your first cigarette?’
- ‘Have you had cravings for a cigarette, or urges to smoke and withdrawal symptoms (refer to ‘Nicotine withdrawal symptoms’ for examples) when you have tried to quit?’
Smoking within 30 minutes of waking, smoking more than 10 cigarettes per day (although some nicotine-dependent people may not smoke daily) and a history of withdrawal symptoms in previous attempts to quit are all indicators of nicotine dependence.
Time to first cigarette is the most reliable single indicator of nicotine dependence. Since cigarettes per day became a measure of dependence, a combination of public health and clinical interventions have changed smoking habits in developed countries, making it a less robust indicator. As the number of cigarettes per day declines in countries with strong anti-smoking policies, and the fact that those who smoke underestimate their own consumption level, time to first cigarette has been widely accepted as a more reliable marker of dependence in most people who smoke.64
Assess and address barriers to quitting
It is important for health professionals to be aware of the potential difficulties patients face when attempting to quit smoking, and identify and address any mistaken beliefs and attitudes about quitting at the time of the quit attempt (Table 1.2).74,75 Support could include providing treatment for withdrawal symptoms or mental health issues, or recommending physical activity and a healthy diet to minimise weight gain. It is also important to recognise the broader influence of social determinates on health behaviours and people’s capacity to make health choices.
Nicotine withdrawal symptoms
Nicotine withdrawal symptoms commonly include craving for nicotine and onset of other symptoms. The Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5) defines nicotine withdrawal as occurring:
'after abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four or more of the following signs or symptoms:
- irritability, frustration, anger
- anxiety
- difficulty in concentration
- increased appetite
- restlessness
- depressed mood
- insomnia.'79
To meet the DSM-5 definition:
'these symptoms need to cause clinically significant distress or impairment in social, occupational or other important areas of functioning, and not be attributable to another medical condition or better explained by another mental disorder, including intoxication or withdrawal from another substance.'79
Other nicotine withdrawal symptoms may include:80
- craving for sweet or sugary foods
- constipation
- coughing
- dizziness
- dreaming/nightmares
- nausea
- mouth ulcers
- sore throat.
It is important to inform the person beginning a first or subsequent quit attempt that they may experience nicotine withdrawal symptoms when quitting.
Usually, nicotine withdrawal symptoms begin within 24 hours of the last cigarette and are strongest in the first week (but for some people only in the first 2–3 days). For most people, withdrawal symptoms decline steadily and can disappear after approximately 2–4 weeks.80 Symptoms can occur for other reasons, so caution should be exercised in attributing them to nicotine withdrawal.
Nicotine withdrawal symptoms can be reframed as recovery symptoms. Pharmacotherapies will reduce or completely prevent withdrawal symptoms.81
Urges to smoke and cravings for nicotine are elements of withdrawal, and are strong predictors of relapse.81 Providing strategies to manage withdrawal is an essential aspect of the healthcare professional’s role:
- Quitline services offer a number of patient calls, especially in the first few weeks,
to help and encourage those who smoke in a quit attempt to stay on track.
- Smoking cessation pharmacotherapies can prevent or reduce the severity
of withdrawal symptoms.81,89
- There is evidence that exercise can help reduce acute cravings and nicotine withdrawal for some people.82
Advise all patients who smoke to quit
Advise
In a way that is clear but non-confrontational, advise all patients who smoke to quit
‘The best thing you can do for your health is to quit smoking’
Health professionals should advise patients who smoke to quit and, where possible, personalise the advice and the benefits of quitting. Establishing rapport and asking permission to discuss smoking minimises any risk of harming the patient–healthcare professional relationship. In fact, asking patients who smoke if they would like help to quit can be appreciated and can strengthen the relationship.83 Patients express greater visit satisfaction when smoking cessation is addressed.59,84
Brief, repeated, positive reminders to quit by a range of health professionals can increase success rates.21
Recommendation 3 – Offer brief cessation advice in routine consultations and appointments, whenever possible.
Strong recommendation, high certainty
Assist those who smoke to quit
Assist
- Offer smoking cessation assistance and, if the person is willing to accept the offer, affirm and encourage them
- Agree on a quit plan, including agreeing on a quit day, strategies for managing smoking triggers and barriers to success, and mobilising social support
- Recommend pharmacotherapy if nicotine dependent (refer to the pharmacotherapy treatment algorithm in Chapter 2)
- If the patient is not ready or unsure, use motivational approach, explore barriers and review at future visits
The decision on what assistance to provide those who smoke and those who recently quit depends on:
- willingness to quit
- needs
- preferences
- suitability of available support
- capacity of the health professional and their service.
Assistance could include advice and support, referral, or a combination of these options. When capacity within the clinical service to provide behavioural support is limited, referral to Quitline can be useful in addition to providing support from within the practice, including advice on pharmacotherapy.
For people willing to make a quit attempt:
- help the person develop a quit plan, including
- agreeing on a quit day
- providing strategies for managing smoking triggers and barriers to success
- mobilising social support
- recommend pharmacotherapy if the patient is dependent on nicotine (refer to the pharmacotherapy treatment algorithm in Chapter 2); consider strategies such as pre-cessation nicotine replacement, combination therapy
- discuss the importance of follow-up and behavioural support.
If the person is not ready to quit or unsure about quitting, use motivational approaches, explore barriers and review at future visits. For further details on smoking cessation strategies, refer to Chapter 2, ‘Pharmacotherapy for smoking cessation’, and Chapter 3, ‘Behavioural and advice-based support for smoking cessation’.
Motivational interviewing
Assistance from health professionals may include motivational interviewing, which is an evidence-based counselling technique based on a therapeutic partnership that acknowledges and explores a person’s ambivalence about their smoking behaviour. Motivational interviewing requires more time than brief interventions. It allows the person who is trying to quit to clarify what goals are important to them and to organise their reasons in a way that supports actions. Motivational interviewing values patient autonomy and mutual respect, and uses open-ended questions, affirmations, reflection and summarising.85,86,87
For motivational interviewing strategies, refer to Chapter 3, ‘Clinical interventions for tobacco use and dependence’ and Table B1, page 58 in Treating tobacco use and dependence: 2008 update ).88
Arrange follow-up
Arrange
For patients making a quit attempt, arrange follow-up contact starting within a week of the quit day
- Congratulate and encourage
- Review progress and problems
- Encourage continued use of pharmacotherapy
- Monitor and manage medication side effects
Follow-up visits to discuss progress and provide support have been shown to increase the likelihood of successful long-term abstinence.89 Additional follow-up leads to further increases in smoking cessation rates when compared with no follow-up.89
Encouragement can help maintain motivation, as can affirming the person’s decision to quit and reinforcing the benefits (health, social, financial) of quitting and being someone who does not smoke. It is important to review progress and identify and seek to address problems. Examine any slips so that more effective coping strategies can be planned. Explain that slips are valuable learning experiences, not failures, and encourage them to keep trying. Neuropsychiatric symptoms (eg anxiety, agitation, poor sleep, low mood) can be features of nicotine withdrawal; it is important to identify these symptoms and offer support.89 Behavioural disturbances and suicidal thoughts can also occasionally occur.89
Many people who are trying to quit will discontinue the use of smoking cessation pharmacotherapy prematurely, or may need dosage adjustment. Hence, reviewing the use of medication is important:
- Is the patient taking the medication?
- Are they using it correctly?
- Are they experiencing any side effects?
If NRT is used and there are withdrawal symptoms, a larger dose or combination NRT may be required.89
Discuss relapse prevention by offering support and help to identify and manage high-risk situations (eg drinking alcohol, emotional stress, social situations with others who smoke). Encourage the patient to enlist the support of family and friends. Encourage use of support services:
- Quitline – 13 78 48
- Online programs
- SMS-based support – QuitTxT
Relapse in the first weeks after quitting is common and often related to nicotine withdrawal.89 There is a later peak in relapse after discontinuation of smoking cessation medication.90 Relapse can also be triggered by alcohol, stress and social situations. About 50% of those who quit smoking and who are still abstinent at 12 months will subsequently relapse.91 There is as yet no behavioural intervention, including behavioural support or skills training, that has been proven to prevent relapse.92,93 Advice, behavioural counselling and pharmacotherapy are recommended to treat symptoms of withdrawal, stress and weight gain.94 Health professionals should offer ongoing support to all people who have made a quit attempt and need further help to remain smoke free.
Recommendation 4 – Offer follow-up to all people who are attempting to quit smoking.
Strong recommendation, high certainty