Smoking Cessation Counselling – OSCE Guide

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Background

Numerous studies have shown that smoking is a 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 Though 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 often frequently delivered in a general practice setting as primary care physicians have the unique opportunity to harness longterm patient-doctor relationships, whereby follow-up appointments and progress check-ins can be facilitated.3 However, time restraints may lead to ineffective counselling sessions, ultimately undermining the true value of general practitioners in their assistance of smoking cessation. 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 Therefore, it is important to have a structured format when discussing smoking habits with patients during a consultation.


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.

Check the patient’s understanding of smoking and its associated health risks.

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?”

Emphasize 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.


Smoking history

It’s important to take a comprehensive smoking history prior to 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 hospitalization 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.

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 assessment on 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

See the end of the guide for a summary of the Stages of Change model.

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 therapies

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 10
  • Caution in patients with cardiovascular disease or acute coronary syndrome

Bupropion:

  • Increases successful cessation by 2 times 10
  • 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 10
  • 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 preference 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:

  • A brief form of face-to-face behavioural therapy
  • These short discussions have been shown to increase overall abstinence rates 12

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 set-back 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:

  • Within 1-2 weeks after the patient’s quit date and then at 4 weeks10
  • At 3 months and 1 year to follow-up on new side effects, smoking status and relapse10

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:

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.


Stages of change model

In 1983, Prochaska and DiClemente developed a model that described the different stages a person goes through in order to facilitate a behavioural change. 7 This model helps healthcare professionals better understand what patients are thinking and feeling about their behavioural change. By identifying which stage your patient is at, you will be able to communicate at the same level without “pushing” someone over their limits.

Stages of Change Model
Figure 1. Stages of Change Model (adapted from Health Service Executive (HSE)- Brief Intervention for Smoking Cessation- National Training Programme 2nd Edition )7

Pre-contemplation

In the pre-contemplation stage, the patient has no interest in changing and mostly sees smoking as a positive aspect of their lives.

Healthcare workers should try to implement the 5R’s of motivational intervention:

  • Relevance: Ask and assist patients in searching for reasons to quit that are relevant to them.
  • Risks: Discuss the negative aspects of smoking.
  • Rewards: Discuss the positive aspects of smoking.
  • Roadblocks: Encourage patients to identify the barriers to quitting.
  • Repetition: Repeat the motivational process and allow patients to understand that it commonly takes repeated attempts to be successful.8

Contemplation

In the contemplation stage, the patient recognises the negative aspects of smoking, however, ultimately they feel the positives of smoking outweigh these.

Actions for healthcare providers:

  • Same as “Pre-contemplation” but with a focus on reinforcing their reasons for change and acknowledging their ambivalent feelings.
  • Assist the patient by revisiting this issue at a future date.9

Preparation

In the preparation stage, the patient understands why they should quit smoking and plans to make a change.

Actions for healthcare providers:

  • Same as “Contemplation” but prepare for change by identifying barriers and consider solutions to overcome anticipated obstacles.
  • Assist the patient by setting up an action plan together.9

Action

In the action stage, the patient makes an attempt to stop smoking.

Actions for healthcare providers:

  • Ask about side effects of pharmacological therapies and how the patient is generally managing to follow the plan.
  • Assess the patient’s feelings and temptations.
  • Advise on relapse prevention with further benefits from non-pharmacological therapies.
  • Assist by focusing on successes, continuing with encouragement and support.9

Maintenance

In the maintenance stage, the patient continues to not smoke but requires ongoing support and encouragement to prevent relapse.

Actions for healthcare providers:

  • Same as the action stage but do not forget to congratulate the patient! 9

Relapse

In the relapse stage, the patient begins to smoke again and often returns to one of the earlier stages of change.

Actions for healthcare providers:

  • Remain non-judgemental.
  • Reassure the patient that relapses are not a setback, but part of the process of change.
  • Reassess the patient’s stage of change.9

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]

Reviewer

Dr Tony Foley

Consultant General Practitioner


Editor

Hannah Thomas


 

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