Smoking Cessation Counselling – OSCE Guide

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Background

Smoking is a significant risk factor for multiple conditions including cardiovascular disease, stroke and lung cancer.

Smoking negatively impacts overall health and increases the burden on the healthcare system, costing the UK government 2.6 billion pounds in 2015 due to premature death, hospital admissions and loss of productivity.¹ Although the number has been gradually decreasing over the last decade, approximately 15% of adults in the UK smoked cigarettes in 2018.²

Smoking cessation counselling is frequently delivered in a general practice setting as primary care physicians have the unique opportunity to harness long-term patient-doctor relationships.³

However, time restraints may lead to ineffective counselling sessions. This article focuses on how to counsel patients who are considering stopping smoking using the 5A’s approach: ask, assess, advise, assist and arrange, which is currently recommended by NICE.⁴ Studies have shown that implementing all of the 5A’s is associated with a higher quit rate compared to consultations that only involve general, non-targeted advice to quit smoking.⁵ 

We have also included an alternative approach using the ‘UNITED’ structure which can be used for motivational interviewing.

Ultimately, a structured and patient-centred approach is key to ensuring the patient feels listened to and understood. This will allow you to reassure the patient and use shared decision-making.

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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explore the reason for the patient’s visit.

Ideas, concerns and expectations (ICE)

Explore the patient’s current ideas, concerns and expectations in regards to smoking:

• “How do you feel about smoking?”
• “Is there anything that worries you about smoking or giving up?”
• “What are you hoping to get from the visit today?”

Emphasise that the purpose of this consultation is not to be confrontational but to explore the patient’s views on smoking and motivations to change their behaviour.

Establishing ICE creates common ground between you and the patient, this will help you to tailor your advice and make sure the patient feels listened to.

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Smoking history

It’s important to take a comprehensive smoking history before counselling a patient about smoking cessation. In an OSCE, you may be provided with these details in the brief and asked to move straight on to counselling.

Explore the patient’s smoking history:

• How long has the patient been smoking?
• How much does the patient smoke? (pack-years = [number of years smoked] x [average number of packs smoked per day]; one pack is equal to 20 cigarettes)
• What type of tobacco/nicotine does the patient use?
• In what situations does the patient smoke?
• How does smoking make the patient feel?
• How does smoking affect the patient’s life and interpersonal relationships?
• How does the patient finance their smoking habit?
• How much would the patient save if they quit smoking?
• Has the patient previously tried to quit? If so, what resulted in the patient relapsing?
• Does the patient experience any withdrawal symptoms? (e.g. craving, irritability, dizziness, low mood, fatigue, insomnia)

Past medical history

Explore the patient’s past medical history for information relevant to smoking:

• Pre-existing lung disease (e.g. chronic obstructive pulmonary disease, asthma, pulmonary fibrosis)
• Cardiovascular disease and cardiovascular risk factors (e.g. coronary artery disease, hypertension, diabetes, hyperlipidaemia)
• Previous hospital admissions and surgery

Medications

Check if the patient is currently or was previously prescribed any nicotine replacement (if so, ask the patient about its effectiveness).

Family history

Explore the patient’s family history for evidence of malignancy (this may suggest an increased baseline risk for the patient).

Social history

Explore the patient’s social history:

• Quantify the patient’s weekly alcohol intake.
• Ask about recreational drug use.
• Explore psychosocial aspects of the patient’s health including stressors at home and work – do these factors affect their smoking habit?
• Ask about the patient’s employment: does this have a relationship with their smoking?

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The 5 A’s approach

Ask

Ask about and record the patient’s smoking status.

Advise

Commend the patient for coming in to speak to you about smoking cessation and advise the patient on the risks of smoking and long-term effects on their own health (e.g. risk factor for cardiovascular disease, lung cancer, stroke, peripheral vascular disease).

Reassure the patient that the healthcare team will provide support throughout the process.

Even if the patient is not ready to quit, it is still important to advise them to quit (reducing frequency/quantity can be used as an alternative but complete cessation is still advised).¹⁰

Assess

Assess the patient’s understanding of the consequences of smoking in relation to their own health condition(s).

Explore the patient’s views on smoking cessation and ask if they currently feel motivated to quit.

Attempt to quantify the patient’s level of motivation by asking them to describe their level of motivation on a scale from 1 to 10; with 1 being the least motivated and 10 being the most motivated.

Use the Stages of Change model to guide the assessment of behaviour modification. The stages of this model include:

• Pre-contemplation: no interest in changing behaviour
• Contemplation: an awareness of the negative aspects of smoking
• Preparation: an understanding of why they should quit smoking
• Action maintenance: an attempt to stop smoking
• Relapse: the attempt to quit was unsuccessful

Assist

Use the STAR approach:¹¹

• Set a quit date based on the patient’s willingness, motivation and agreement. This should usually be within 2-4 weeks (abrupt quitting is usually more effective than gradual quitting).
• Tell family and friends. Advise the patient to make family and friends aware that they are quitting to provide further accountability and support.
• Anticipate challenges that a patient will face and make plans on how to overcome them.
• Remove all tobacco products as well as recommending counselling programs and pharmacological therapies as indicated (see below).

Pharmacological therapies¹⁰

Nicotine replacement therapy:

• Used as first-line therapy and available in a variety of forms (e.g. patches, spray)
• Increases successful cessation by 1.5 times
• Caution in patients with cardiovascular disease or acute coronary syndrome

Bupropion:

• Increases successful cessation by 2 times
• Advise the patient to commence the medication for 1-2 weeks before the quit date and complete a 12-week course
• Contraindications: hypersensitivity reactions, seizure disorders and eating disorders

Varenicline:

• Works as a nicotine receptor partial agonist
• It is the most effective pharmacological therapy, increasing successful cessation by greater than 2 times
• Advise the patient to commence the medication 1 week before their quit date and complete a total course of 12 weeks
• Contraindications: hypersensitivity reactions

Non-pharmacological therapies

Non-pharmacological therapies involve a selection of behavioural counselling programs which can be tailored to patient preferences and beliefs.

Explain the different options available with the patient to decide which they feel would be most effective.

Some patients may benefit from more than one method.

Brief intervention:¹²

• A brief form of face-to-face behavioural therapy
• These short discussions have been shown to increase overall abstinence rates

Individual counselling:

• Formal counselling sessions consisting of multiple visits by a trained therapist

Group counselling:

• Formal counselling in a group setting
• The presence of other people trying to quit can provide mutual support

Telephone counselling:

• A proactive approach involving a counsellor calling the patient at a pre-arranged time

Arrange

Arrange a follow-up appointment within 1-2 weeks to assess the patient’s progress.

The highest rates of relapses are within the first three months of cessation.

In the event of a relapse, reassure the patient that this is not a setback but merely a natural part of the behavioural modification process.

Patients will often need multiple attempts to achieve permanent cessation.

During each follow-up visit:

• Assess the level of motivation
• Congratulate and encourage the patient to remain abstinent
• Monitor progress and response to therapies
• Identify current and upcoming challenges
• Remain supportive and help to develop plans to overcome challenges

Current recommendations for the frequency of follow-up visits:¹⁰

• Within 1-2 weeks after the patient’s quit date and then at 4 weeks
• At 3 months and 1 year to follow-up on new side effects, smoking status and relapse

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The UNITED approach

Understanding

Try to gain an understanding of the patient’s smoking history. Include a brief general medical history to get a better idea of the patient’s health and lifestyle:

• “I would like to understand a bit more about your smoking and how it is affecting you. Could I ask you a few questions?”

At this point, it is also useful to briefly gauge what the patient’s understanding is of how their smoking impacts their health. This is a good starting point from which you can give information later on:

• “What is your understanding about how your smoking is impacting your health?”

Non-negotiable issues

It is important to establish early on if there are any specific topics that the patient doesn’t want to discuss. If clinicians repeatedly visit these topics it can make the patient feel uncomfortable and want to disengage from the consultation.

The best approach is to ask about these topics openly and upfront to make sure that everyone is on the same page:

• “Are there any topics or types of support that you absolutely don’t want to discuss today?”

Identify common ground

This part of the consultation is all about understanding the patient’s thoughts and feelings about smoking. This will give you a good understanding about what motivates the patient, and will therefore give you common ground to work from.

This is the stage of the consultation where you should cover the patients ideas, concerns and expectations (ICE):

• “How do you feel about smoking?”
• “Is there anything that worries you about smoking or giving up?”
• “What are you hoping to get from the visit today?”

Using the answers to these questions as a baseline, you should then explain the risks of smoking using relevant links to the patient’s ideas, concerns and expectations. This makes the explanation more relatable for the patient and helps to illustrate your points:

• “You mentioned you were concerned that your father had a stroke which may have been related to smoking. Unfortunately, smoking is associated with an increased risk of stroke amongst other conditions such as heart disease and lung cancer.”

As always, you should use a ‘chunk and check’ style approach to giving an explanation; in this case, giving an explanation of the risks of smoking.

Identifying common ground will also give you areas to focus on for the rest of the consultation when you come to discuss possible interventions.

Tensions remaining

It’s usually a good idea to check in with the patient after explaining the risks of smoking. There may be new tensions/questions that have arisen:

• “Now that I have explained some of the risks, I would really like to help you quit smoking so that we can make these risks as low as possible. Do you have any reservations about me giving you some advice?”
• “Are there any questions you would like to ask before we continue?”

Explore possible solutions

Based on all of the information you have now collected about the patient, you are now in a good position to give the patient tailored smoking cessation advice.

You could consider:

• Pharmacological therapies (e.g nicotine replacement therapy, either rapid-acting or long-acting).
• Non-pharmacological therapies (e.g. telephone counselling appointments)

Different therapies will be effective for different patients depending on their health and other factors which influence their smoking behaviours.

Decide together

Once you have explored possible options, take the opportunity for some shared decision-making with your patient. Commit to at least one option.

After the best option has been chosen, encourage them to use the STAR approach:¹¹

• Set a quit date based on the patient’s willingness, motivation and agreement. This should usually be within 2-4 weeks (abrupt quitting is usually more effective than gradual quitting).
• Tell family and friends. Advise the patient to make family and friends aware that they are quitting to provide further accountability and support.
• Anticipate challenges that a patient will face and make plans on how to overcome them.
• Remove all tobacco products as well as recommending counselling programs and pharmacological therapies as indicated (see below).

Ensure that you have a plan in place to follow up with the patient after they have begun their smoking cessation journey; usually 1-2 weeks after the first appointment.

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Closing the consultation

Ask the patient if they have any questions or concerns that have not been addressed.

Check the patient’s understanding at regular intervals using “teach-back” by asking phrases like “Can you repeat back to me just to make sure I have mentioned the important points regarding…..?”

Direct the patient to further information using websites and leaflets:

• NHS SmokeFree National Campaign
• 10 Health Benefits of Stopping Smoking
• Take Steps NOW to Stop Smoking

Make sure the patient is aware that this is entirely their choice and offer them time to think about their decision.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

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Reviewer

Dr Tony Foley

Consultant General Practitioner

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Editor

Hannah Thomas

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References

1. Public Health England: Cost of smoking to the NHS in England. Published in 2015. [LINK]
2. Office for National Statistics. Adult smoking habits in the UK. Published in 2018. [LINK]
3. Rosenberg G, Crawford C, Bullock S, Petty R, Vohra J. Smoking Cessation in Primary Care: A cross-sectional survey of primary care health practitioners in the UK and the use of Very Brief Advice. Published in 2019. [LINK]
4. Myers K, McRobbie H, West O, Hajek P. National Institute for Health and Clinical Excellence. Review 3: Barriers & facilitators for smoking cessation interventions in acute & maternity services. Published in 2012. [LINK]
5. Quinn V, Hollis J, Smith K, Rigotti N, Solberg L, Hu W et al. Effectiveness of the 5-As Tobacco Cessation Treatments in Nine HMOs. Published in 2008. [LINK]
6. WHO, Dependence syndrome. Published in 2020. [LINK]
7. Health Service Executive. Brief Interventions for Smoking Cessation. Published in 2014. [LINK]
8. Agency for Healthcare Research and Quality, Rockville, MD. Patients Not Ready To Make A Quit Attempt Now (The “5 R’s”). Published in 2012[LINK]
9. Tobacco-Free RNAO. Stages of Change. Published in 2011. [LINK]
10. UpToDate, Overview of Smoking Cessation Management in Adults. Published in 2019. [LINK]
11. Lowry B, Caragianis A. Master the NAC. Published in 2016. [LINK]
12. UpToDate, Behavioral Approaches to Smoking Cessation. Published in 2020. [LINK]

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