Smoking Cessation Counselling – OSCE Guide


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 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

  • Introduce yourself
  • 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)

  • Emphasise confidentiality
  • 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
  • See Geeky Medics Guide on ICE here

The Middle: 5 A’s Approach

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:

Dependence Syndrome

  • 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

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?
  • Any withdrawal symptoms? (e.g. craving, irritability, dizziness, low mood, fatigue, insomnia)

Past Medical History

  • Ask about existing lung diseases (e.g. COPD/asthma/pulmonary fibrosis)
  • Ask about cardiovascular diseases and risk factors (e.g. hypertension, diabetes, hyperlipidemia)
  • Previous hospitalization and surgery

Medications/Allergies

  • Ask if the patient is currently or previously on any nicotine replacement (if so, assess its’ effectiveness)

Family History

  • Ask about family history of smoking and cancer (e.g. lung cancer, head and neck cancer)

Social History

  • Ask about other lifestyle habits (e.g. alcohol, recreational drug use)
  • Explore psychosocial aspects of the patient’s health including stressors at home/work/school

Assess

  • Assess the patient’s understanding of the consequences of smoking in relation to their own health condition(s)
  • What are the patient’s views on smoking cessation?
  • Does the patient want to quit now?
  • How motivated is the patient to quit? (*it may be useful to ask patients to present their level of motivation on a scale from 1 to 10; 1 being the least motivated, 10 being the most)
  • Use the “Stages of Change” model to guide assessment on behaviour modification (Figure 1)

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

  • No interest to change
  • Mostly sees smoking as a positive aspect of their lives
  • Action for Healthcare Providers:
    • 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

  • Aware of the negative aspects of smoking
  • Positives of behaviour still outweigh negatives
  • Action for Healthcare Providers:
    • Same as “Pre-contemplation” but focus on reinforcing their reasons for change and acknowledge ambivalent feelings.
    • Assist the patient by revisiting this issue at a future date.9

Preparation

  • Understands why they should quit smoking
  • Desires and plans to make a change
  • Action 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

  • Makes the attempt to stop smoking
  • Action for Healthcare Providers:
    • Ask about how the patient is keeping with the plan and if experiencing any side effects of pharmacological therapies.
    • Assess their feelings and temptations.
    • Advice on relapse prevention with further benefits from non-pharmacological therapies.
    • Assist by focusing on successes, continuing with encouragement and support.9

Maintenance

  • Continues with behavioural change
  • No relapse but needs ongoing support and encouragement
  • Action for Healthcare Providers:
    • Same as Action but do not forget to congratulate!9

Relapse

  • Attempt to quit was unsuccessful
  • Common for patients to return to one of the previous stages
  • Action 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

Advise

  • Should apply to all stages of change
  • Be clear, strong and personalized
  • Commend the patient for coming in today to speak to you about it
  • 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 them 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 advised10)

Assist

Use the STAR approach:11

  • S = Set a quit date (based on the patient’s willingness, motivation and agreement, usually within 2-4 weeks, abrupt quitting more effective than gradual)
  • T = Tell family and friends (encourage to create a strong support system)
  • A = Anticipate challenges/obstacles patient will face and how to overcome them
  • R = Remove all tobacco products, recommend counselling programs and pharmacological therapies as indicated

Pharmacological Therapies

Nicotine replacement therapy:

  • 1st line therapy
  • Gums/patches/spray etc
  • Increases cessation by 1.5 times 10
  • Caution in patients with cardiovascular disease or acute coronary syndrome

Bupropion:

  • Increase cessation by 2 times 10
  • Take 1-2 weeks before quit date for a total course of 12 weeks
  • Contraindications: hypersensitivity reactions, seizure disorders, eating disorders

Varenicline:

  • Nicotine receptor partial agonist
  • Most effective, increase cessation by greater than 2 times 10
  • Take 1 week before quit date for a total course of 12 weeks
  • Contraindications: hypersensitivity reactions

Non-Pharmacological Therapies

  • Selection of behavioural counselling programs will depend on patient preference, beliefs and accessibility
  • Give different options and discuss with the patient to determine which will be most engaging and acceptable to them
  • Some patients may benefit from more than one method

Brief intervention:

  • Face-to-Face brief behavioural therapy recommended to all smokers
  • Short discussions in the office can effectively increase overall abstinence rates12

Individual counselling:

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

Group counselling:

  • Advantage of having other people who share the same desire to quit creates mutual support

Telephone counselling:

  • Proactive approach (Counselor calls patient that pre-arranged time)

Arrange

  • Arrange a follow-up appointment within 1-2 weeks
  • Highest rates of relapses within the first 3 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

Smoking Cessation Counselling: The End

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 time to think about their decision
  • Thank the patient for their time

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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