To Quit or not to Quit

Tobacco smoking continues to be the main preventable cause of morbidity and mortality in Australia. Active tobacco smoking is associated with diseases such as lung cancer, coronary heart disease, cerebrovascular accidents, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), emphysema, and a large number of other cancers. Unfortunately, despite all of the health benefits associated with smoking cessation, this remains a very difficult process for most people.

Primary health care visits present a significant opportunity to promote smoking cessation. Nurses, doctors and pharmacists are all well placed to be involved in this process due to their interaction with smokers who visit for routine checkups, treatments, and specific guidance on health issues.

The evidence-based 5A framework, developed by the U.S. Public Health Service, is a useful tool to assist with the quitting process. This framework breaks the process into five stages: ask, advise, assess, assist, and arrange. The value of the framework has been recognised by the Australian Department of Health and is now recommended by the Royal Australian College of General Practitioners.

The 5As: Evidence-Based Smoking Cessation

Smoking cessation should be considered a process rather than a single discrete event. Smokers tend to cycle through the stages of being ready, quitting, and relapsing three to four times before long-term success is achieved. The 5A framework is a useful tool to identify the stage of readiness a particular smoker may be in. This framework is easy to use and remember, and can be successfully implemented into a busy practice.

1. Ask (1 minute)

Do you smoke? Have you ever smoked? When did you quit?

This is a vital step of the framework that is often overlooked by healthcare professionals. It is estimated that around one-third of smokers are not identified by their doctor. Failing to identify patients who smoke represents a significant missed opportunity for encouraging smoking cessation.

It is recommended that all patients are asked about their smoking status to reach the maximum number of smokers during routine consultations. The patient’s answer should be documented accordingly so that the conversation may be continued at repeat visits.

2. Assess (2 minutes)

The assessment stage is an important step to maximise the efficiency of the process. Smokers should be assessed on their willingness to quit, any barriers that may stand in their way, and their level of nicotine dependence.

Nicotine dependence may be assessed by asking the patient how many cigarettes are smoked each day and the time between waking and the first cigarette of the day. An accurate assessment of a patient’s willingness to quit and their level of nicotine addiction will enable healthcare professionals to tailor their support to the individual.

3. Advise (1 minute)

Advise patients of the health effects and benefits of smoking cessation. This message should be delivered in a clear and non-confrontational way in order to preserve patient rapport.

4. Assist (3 minutes)

Upon identification of a patient who is willing to quit, strategies can be put in place to support the quit attempt.

Problem-solving methods and skills can be discussed to improve the patient’s chances of success.

The patient should be encouraged to pick a quit date. Timing of the quit date is important to maximise a patient’s success rate. It is recommended that the quit date is not set too far in the future and does not coincide with celebrations that may act as a smoking trigger. Support, in the form of a referral to Quitline (phone 137 848) and provision of printed information, is beneficial.

Setting a quit date encourages commitment and also enables discussion of pharmacotherapy options, such as nicotine replacement therapy (NRT). In patients who have a high level of nicotine dependence and have been unsuccessful in previous quitting attempts, the use of combination NRT may be beneficial. This involves the use of patches for basal nicotine withdrawal symptoms and short-acting formulations such as gum, lozenges and inhalers, for breakthrough cravings.

Part of this stage of the process is also to assist patients in addressing barriers to quitting. Some commonly reported fears that may act as barriers are stress, weight gain, negative emotions, lack of support, and fear of failure.

5. Arrange (1 minute)

Follow-up appointments to discuss progress and provide support increase the chances of successful long-term abstinence. Initial follow-up should be arranged to occur within one week of the quit day. An additional follow-up appointment should be scheduled one month later to congratulate and affirm the decision, review pharmacotherapy, advise about relapses and their prevention, and to review progress.

If the patient has relapsed or no quit attempt has occurred, explore the reasons and reframe the attempt as a learning experience. Further follow-up can be tailored to the needs of the patient.

Summary

A person who attempts to quit smoking unassisted has only a 3% to 6% chance of success. The most successful strategy involves a combination of counseling, support, pharmacotherapy, and follow-up. Use of first–line pharmacotherapy doubles the likelihood of a successful quit attempt. Pharmacotherapy may include nicotine replacement therapy or non-nicotine options, such as bupropion or varenicline. The strategy chosen for a quit attempt must be tailored to the individual and their preferences. Regardless of which option is selected, the value of counseling and support services shouldn’t be overlooked.

Implementation of effective smoking cessation strategies has enormous benefits for public health. Quitting smoking reduces the risk of heart disease, after 15 years the risk of stroke is reduced to that of a non-smoker, and the risk of developing lung cancer is reduced by 90% if quitting occurs before the age of 30. Patients may also notice a rapid improvement in their well-being and exercise tolerance. The benefit for patients with chronic diseases, such as COPD, is significant. Quitting smoking has long been recognised as the single most effective intervention to slow the rate of lung decline in patients suffering from COPD. An additional benefit of lower smoking rates is the lower incidence of passive smoking-related illness.

Over the past 40 years, the Australian government has implemented a range of strategies to curb the incidence of smoking. These have ranged from education campaigns, tighter restrictions on smoking in public spaces, tax increases, and advertising restrictions. Well-funded ‘Quit’ campaigns resulted in significant reductions in smoking rates during the 1980s. Smoking rates continued to decline, albeit at a slower rate, in the decades that followed.

The smoking rate amongst Australian adults has fallen by almost 50% since 1980. The 5A framework provides an evidence-based approach to enable further reductions to be made. The success of this system lies in the ability of physicians to accurately identify patients who are willing and ready to quit. Education of healthcare professionals on the use of this tool may provide further benefits to patients.