Tobacco dependence is a chronic condition that typically requires repeated cessation treatment and ongoing care.11,61 A minority of smokers achieve long-term abstinence on the first attempt to quit, while the majority cycle through multiple attempts with relapse and remission before achieving long-term or permanent abstinence. Multiple attempts over a period of years are not unusual – the average 40-year-old smoker will have made around 20 unsuccessful quit attempts, most without any external help.63
It is important to take every opportunity to identify all patients who smoke, document their smoking status, explore barriers to cessation and offer treatment, which may involve counselling by a health professional, referral to more intensive support and pharmacotherapy.
The most common method used by most people who have stopped smoking is unassisted cessation (either stopping abruptly or cutting down on their own),62 although now more than half of all smokers making quit attempts are using some form of help, mainly medications.63 If people who smoke want to try to quit unassisted this choice should be respected but they should be informed that additional help is available should they want it, and that using it will increase their chance of success.64 This is especially important for smokers who have tried multiple times without long-term success. Many smokers need encouragement, assistance and guidance to quit successfully. Smokers who are more nicotine-dependent are more likely to both need and seek treatment.65
Ask, assess, advise, assist and arrange follow-up
The 5As approach (five components of effective tobacco cessation counselling) originally proposed by the US Clinical Practice Guideline,11 provides health professionals with an evidence-based framework for structuring smoking cessation by identifying all smokers and offering support to help them quit.7,8 The approach is adopted in guidelines from The Netherlands and WHO,12,13 and adopted in modified forms in other international guidelines.14,52 In the United Kingdom an approach of ‘very brief advice’ is being suggested with the steps Ask, Advise and Act (UK National Centre for Smoking Cessation and Training).66
The 5As structure allows health professionals to provide the appropriate support for each smoker’s level of interest in quitting (Figure 1). 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. It is important for health professionals to ask all patients/clients if they use tobacco, assess their willingness to make a quit attempt, advise on the importance of quitting and offer assistance in the form of help from the health professional or referral.
1. Ask all patients about smoking
Health professionals should ask all their patients/clients whether they smoke and their smoking status should be recorded. Implementing recording systems that document tobacco use almost doubles the rate at which clinicians intervene with smokers and results in higher rates of smoking cessation.11 For known smokers, try to continue a conversation about their smoking at each visit, even if it is just an offer to discuss if they are ready to quit.
Instituting a system designed to identify and document tobacco use almost doubles the rate of health professional intervention and results in higher rates of cessation. Level II
A system for identifying all smokers and documenting tobacco use should be used in every practice or healthcare service. Strength A
2. Assess readiness to quit
Assessment of readiness to quit
Prochaska and DiClemente’s Stages of Change Model67 acknowledges that the smoker’s readiness to change is an important issue in cessation and advice can be tailored on the basis of the patient/client’s readiness to quit.7
The role of the Stages of Change Model in assisting smoking cessation
- The model serves as a reminder that people at all stages can be offered assistance.
- Smokers do not necessarily progress in an ordered fashion through each of the stages of change before attempting to quit, but the model can help clinicians tailor advice in a way that is most applicable to the smoker at that encounter.
- Smokers are in different stages of readiness when the clinician sees them at different times, so readiness needs to be re-evaluated at every opportunity. The extent of the assessment will depend on the clinical context.
- Stages of change can be influenced by the nature of the communication and the relationship between health professional and smoker.68
Though there is a lack of evidence for greater effectiveness of stage-based approaches,69 this model provides a useful framework to help clinicians identify smokers and provide tailored support for a smoker’s level of interest in quitting in a way that is time efficient and likely to be well received.10,70
Willingness to make a quit attempt can change rapidly with changing life circumstances and there is evidence that quit attempts made with minimal planning can be successful.71,72 Thus, there is benefit in encouraging all smokers to consider quitting whenever the opportunity arises.11
Factors consistently associated with higher abstinence rates are high motivation, readiness to quit, moderate to high self-efficacy and supportive social networks. Level III
Assessment of readiness to quit is a valuable step in planning treatment. Strength C
Assessment of nicotine dependence
The majority of smokers are nicotine-dependent and for these people smoking can be conceptualised as a chronic medical illness requiring ongoing care.73 Dependence can happen quickly and, in some cases, even after a few cigarettes. As nicotine addiction is under-recognised by clinicians, routine assessment of nicotine dependence can help predict whether a smoker is likely to experience nicotine withdrawal upon stopping smoking,74,75 and the intensity and type of support that may be required to assist quitting.
Nicotine withdrawal symptoms commonly include craving, as well as onset of other symptoms.76The American Psychiatric Association publication DSM-5 defines tobacco withdrawal as 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
- difficulty in concentration
- increased appetite
- depressed mood
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, with the signs or symptoms not attributable to another medical condition and not better explained by another mental disorder, including intoxication or withdrawal from another substance.
Other withdrawal symptoms include craving for sweet or sugary foods, constipation, coughing, dizziness, dreaming/nightmares, nausea and sore throat. All of these symptoms can occur for other reasons so caution should be exercised in attributing them to physiological withdrawal.76
Characteristics of smokers with nicotine dependence include smoking soon after waking, smoking when ill, difficulty stopping smoking, finding the first cigarette of the day the most difficult to give up, and smoking more in the morning than in the afternoon.74,77,78
A quick assessment of nicotine dependence can be made by asking the smoker:
- ‘How soon after waking do you have your first cigarette?’
- ‘How many cigarettes do you smoke each day?’
- ‘Have you had cravings for a cigarette, or urges to smoke and withdrawal symptoms when you have tried to quit?’79
Smoking within 30 minutes of waking, smoking more than 10 cigarettes per day (although some dependent smokers may not be daily smokers) and a history of withdrawal symptoms in previous attempts to quit are all indicators of nicotine dependence. Time to first cigarette has been shown to be the most reliable indicator of nicotine dependence.
3. Advise all smokers to quit
Brief, repeated, consistent, positive reminders to quit and reinforcing recent quit efforts by a number of health professionals can increase success rates. When the practice is routinely applied to a large proportion of clients who smoke, a larger impact on population smoking rates can be achieved.11 Establishing rapport and asking permission minimises any risk of harming the patient–health professional relationship. In fact, asking if smokers would like to have help to quit can be appreciated and can strengthen the relationship.80 Where possible, it helps to personalise the advice and the benefits of quitting. Patients express greater visit satisfaction when smoking cessation is addressed.60,81 One useful approach to raising the topic is to acknowledge that the smoker is aware of the risks, and ask if he or she is ready to discuss options.
Brief smoking cessation advice from health professionals delivered opportunistically during routine consultations has a modest effect size but substantial potential public health benefit. Level I
Offer brief cessation advice in routine consultations and appointments whenever possible (at least annually). Strength A
The decision on whether and what assistance to provide to smokers and recent quitters depends on their needs, preferences and suitability of available support, and the capacity of the health professional and their service. A package of assistance can be put together which may involve the health professional and their service, referral, or a combination of these options. When necessary, clients should be referred to a health professional with a smoking cessation practice, or to a tobacco treatment specialist where medication can be prescribed where indicated.
Assistance from the health professional may involve motivational interviewing. This is an evidence-based counselling technique based on a therapeutic partnership that acknowledges and explores a client’s ambivalence about a behaviour – in a way that allows them to clarify what goals are important to them and to organise their reasons in a way that supports actions. Motivational interviewing is a counselling philosophy that values patient autonomy and mutual respect and the use of open-ended questions, affirmations, reflection and summarising.82,84 This type of counselling requires more time than brief interventions.
Barriers to quitting
It is important for health professionals to be aware of the potential difficulties smokers face when attempting to quit and, where possible, to address the barriers at the time of the quit attempt (Table 4). This could include providing treatment for withdrawal symptoms or mental health issues, or recommending physical activity and a healthy diet to minimise weight gain. Situations likely to discourage quit attempts or lead to unsuccessful attempts at quitting include:17,52
- high dependence on nicotine and heavy smoking (more than 20 cigarettes per day, short time to first cigarette)
- lack of knowledge of the benefits of quitting or belief that action is not necessary
- enjoyment of nicotine or smoking behaviour
- psychological or emotional concerns (stress, depression, anxiety, psychiatric disorders)
- fear of weight gain
- fear that quit attempt will be unsuccessful
- substance use (alcohol and other drugs)
- living with other smokers
- circumstances that result in the smoker giving quitting a low priority, such as poverty and social isolation.
Table 4. Barriers to quitting
I can quit at any time/I’m not addicted
Ask about previous quit attempts and success rates
Use of cessation assistance is a sign of weakness/help is not necessary
Reframe assistance. Explain that nicotine dependence is a powerful addiction
Highlight unassisted quit rate is 3–5%
Too addicted/too hard to quit
Ask about previous quit attempts
Explore pharmacotherapy used and offer options, eg. combination therapy
Too late to quit/I might not benefit so why bother?
Benefits accrue at all ages, and are greater if earlier: at age 30 years, similar life expectancy to non-smoker. Provide evidence/feedback, eg. spirometry, lung age, absolute risk score
My health has not been affected by smoking/you have to die of something/I know a heavy smoker who has lived a long time
Provide evidence/feedback, eg. spirometry, lung age, cardiovascular absolute risk score
Reframe, eg. chronic obstructive pulmonary disease (COPD) = smoker’s lung
Not enough willpower/no point in trying unless you want to/to quit successfully you really have to want to, then you will just do it
Explore motivation and confidence. Explore and encourage use of effective strategies, eg. Quitline, pharmacotherapy
Smokers should be reassured that it may take many attempts at quitting before successfully stopping, but that this should not stop them attempting to quit. It has been estimated that a 40-year-old smoker who started in their teens will have made as many as 20 quit attempts.58 The average smoker makes at least one failed attempt per year; some make a lot more and some people rarely try. They can learn something from each attempt to help overcome tobacco dependence.
5. Arrange follow-up
Follow-up visits to discuss progress and to provide support have been shown to increase the likelihood of successful long-term abstinence.45,88
Relapse prevention includes awareness of coping strategies for smoking cues and high-risk situations such as stress, negative emotional states, alcohol and other social cues to smoke. It is important to frame each lapse (eg. a single smoke or full relapse to smoking) as a learning experience and encourage the smoker to try again with support in the future.
All interventions by a health professional or by a team of health professionals should be recorded so that progress in quitting can be monitored and adjustments made where and when necessary to current medications, cessation pharmacotherapy and intensive counselling.
Follow-up is effective in increasing quit rates. Level I
All smokers attempting to quit should be offered follow-up. Strength A