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 too, 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 easily 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 their consultation.
Smoking Cessation Counselling: The Start
Opening the Consultation
Confirm the patient’s details (name, date of birth)
Explore the reason for their visit
Check the patient’s understanding of smoking and its’ associated health risks
Patient’s Ideas, Concerns and Expectations (ICE)
Explore the patient’s initial ideas, concerns and expectations (e.g. How do you feel about smoking? What are your expectations of this visit today? Is there anything you are worried about?)
Explore concerns in an honest and non-judgmental manner
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
Recurrently check-in with the patient’s ICE throughout the consultation
Ask the patient about features of their smoking history, along with other aspects of the traditional medical history. It is important to be non-judgmental and empathetic. In discussions with the patient, keep the following features of dependence syndrome in your mind:
ICD-10 definition: “A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value” 6
Exact diagnostic guidelines can be found here but it is not always black and white when it comes to diagnosing patients with dependence syndrome
Below are some common questions that should be asked in a typical smoking cessation counselling session.
History of Presenting Complaint
How long have you been smoking for?
How much do you smoke? Pack-Years =(# of Years Smoked) X (Average # of Packs Smoked Per Day); 1 Pack = 20 Cigarettes
What type of tobacco/nicotine do you use?
In what situations do you smoke?
How does smoking make you feel?
How does smoking affect your life and interpersonal relationships?
How do you finance your smoking habits?
How much would you save if you quit smoking?
Have you tried to quit? If so, what made you relapse?
Make sure the patient is aware that this is entirely their choice and offer time to think about their decision
Thank the patient for their time
Public Health England: Cost of smoking to the NHS in England. Published in 2015. [LINK]
Office for National Statistics. Adult smoking habits in the UK. Published in 2018. [LINK]
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]
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]
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]
WHO, Dependence syndrome. Published in 2020. [LINK]
Health Service Executive. Brief Interventions for Smoking Cessation. Published in 2014. [LINK]
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]
Tobacco Free RNAO. Stages of Change. Published in 2011. [LINK]
UpToDate, Overview of Smoking Cessation Management in Adults. Published in 2019. [LINK]
Lowry B, Caragianis A. Master the NAC. Published in 2016. [LINK]
UpToDate, Behavioral Approaches to Smoking Cessation. Published in 2020. [LINK]