Helping the Quit Process: Using the 5 A’s Source: Clinical Practice Guideline: Treating Tobacco Use and Dependence (2008). US Dept. of Health and Human Services Website: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf

Helping the Quit Process We can help with the process of quitting smoking by targeting the way in which we do two things: Interact with the individual Ask questions

Why is it so hard to quit? Smoking has physiological, emotional, social and behavioral components, all of which must be addressed. No one picks up his or her first cigarette hoping to destroy their health – they pick it up for emotional and social reasons, and continue to smoke for these same reasons. These issues are usually ignored in smoking cessation.

Why It’s So Hard to Quit – Craving Comes From Brain Chemistry1 *Note to facilitator: Build Slide (6) When you smoke a cigarette: Nicotine is sent to your brain in a few seconds1 Nicotine starts a series of biochemical reactions in your brain that ultimately cause the release of dopamine. Dopamine gives you a feeling of pleasure and calm2 The level of dopamine drops between cigarettes, and you start to feel jumpy1 Your brain craves the nicotine so that more dopamine will be released to make you feel calm again1 And the cycle goes on of craving, smoking, calming, and craving References: Schroeder SA. What to do with a patient who smokes. JAMA. 2005;294(4):482-487. Reuter M, Netter P, Rogausch A, et al. The role of cortisol suppression on craving for and satisfaction from nicotine in high and low impulsive subjects. Hum Psychopharmacol Clin Exp. 2002;17(5): 213-224.

Helping the Quit Process If we recognize the perspective of the person who is addicted to nicotine, it becomes easier to relate and interact. The types of questions we ask will allow us to have a more productive conversation.

The 5 A’s Brief Intervention: The 5 A’s Ask about current tobacco use Advise them to quit Assess willingness to make a quit attempt Assist the person with quitting Arrange for follow up

The 5 A’s Ask about tobacco use Identify and document tobacco use status for every person at every visit. Advise to quit. In a clear, strong and personalized manner urge every tobacco user to quit. Assess willingness to make quit attempt. Is the tobacco user willing to make a quit attempt at this time? Assist in quit attempt. For the individual willing to make a quit attempt, refer to tobacco cessation counseling and physician Arrange At the next follow up contact, inquire about their smoking use status, encourage if in the quit process, assess and refer if still smoking. For Home Visitors Assist will consist of the Home Visitor assisting the patient find resources to quite to include using a list of the providers and contact information provided on the resource directory provided in their handouts. For Arrange: Home Visitors will be trained to ask clients at their follow up visits about

The 5 A’s ASK Action Step: Implement an office-wide system that ensures that, for every person, at every visit, tobacco use status is queried and documented. Strategy: Include tobacco use as a part of the assessment process.

The 5As How to ASK: Are you a current or former smoker? Tell me about your smoking history. Tell me more about your smoking. Interject role play here

The 5 A’s ADVISE Action: In a clear, strong and personalized manner, urge every tobacco user to quit. Clear Advice: “I think it is important for you to quit smoking now and I can help you.” “Cutting down while you are ill is not enough.” Interject role play here

The 5 A's ADVISE Strong Advice: “As a healthcare professional, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. Your healthcare professional and I will help you.” Personalized Advice: Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children in the household. Role play

The 5 A's ASSESS Action: Ask every tobacco user if he or she is willing to make a quit attempt a this time. Strategy: If the individual is willing to make a quit attempt at this time, provide assistance. If the individual will participate in an intensive treatment, deliver such a treatment or refer to intensive intervention.

The 5 A's ASSESS, cont. If the individual clearly states he or she is unwilling to make a quit attempt at this time, provide a motivational intervention. If the individual is a member of a special population consider providing additional information. Role play using brief cessation intervention survey as a tool

Stages of Change Model Precontemplation Relapse Contemplation Preparation Action Maintenance

Brief Cessation Intervention Survey Name:_________________ Address:_______________ Phone:_________________ 1. During the past 12 months have you stopped using tobacco for one day or longer because you are trying to quit? Yes No 2. Are you seriously considering quitting tobacco use within the next 6 months? 3. Do you intend to quit using tobacco within the next 30 days? Yes No 4. Are you interested in enrolling in a tobacco cessation program that would assist you in quitting and provide nicotine replacement therapy to quit? 5. Would you be interested in talking to a Tobacco Treatment Specialist about quitting? 6. If you are interested in enrolling in a tobacco cessation program what times are best for you to attend? (Please give specific days and times) Structured survey helps track client’s stage of readiness to quit. To use as a along with open ended questions. Match patients response with program that can meet the needs and time demands of client. To include transportation issues. Provide linkages, use referral forms available from providers to programs. (TWC sample referral form attached)

The 5 A's ASSIST Action: Help the individual find resources to quit. Strategy: Review resources of tobacco cessation programs and health providers who can assist in quit process. Advise the individual to tell support persons about quitting and request understanding and support. Provide contact information, referral and linkages to cessation services.

The 5 A's ASSIST, cont. Action: Provide practical counseling: problem solving/skills training. Strategy: Abstinence: Total abstinence is essential. “Not even a single puff after the quit date.” Past quit experience: Identify what helped and what hurt in previous quit attempts. Anticipate triggers or challenges in upcoming attempt: Discuss challenges/triggers and how patient will successfully overcome them. Other smokers in the household: Quitting is more difficult when there is another smoker in the household. The person quitting should encourage housemates to quit with them or not smoke in their presence.

The 5 A's ASSIST, cont. Action: Provide intratreatment social support. Strategy: Provide a supportive environment while encouraging the person in his or her quit attempt. “We will be here to assist you throughout the quit process.” Note: Going tobacco-free for the whole agency creates the most supportive environment and removes the social and behavioral triggers.

The 5 A's ASSIST, cont. Action: Help individual obtain extra-treatment social support. Strategy: Help individual develop social support for his or her quit attempt in his or her environments outside of treatment. “Ask your spouse/partner, friends, and coworkers to support you in your quit attempt.”

The 5 A's ASSIST, cont. Action: Recommend the approved providers and tobacco cessation programs and services. Strategy: Explain how these resources increase smoking cessation success and deal with relapse and withdrawal symptoms. Action: Provide supplementary materials. Strategy: Pamphlets, videos, etc. Show Home Visitor(Gretchen) reviewing resource directory with client. Go to www.smokefree.gov, healthohioans

Online Resources http://healthyohioprogram.org/healthylife/tobc2/tobintro.aspx http://healthyohioprogram.org/healthylife/tobc2/Cessation/quit.aspx - 1-800-QuitNow* *Only provides services to pregnant women and low income. Program to discontinue in 2012

Online Resouces Continued http://women.smokefree.gov/ http://www.smokefree.gov/resources.aspx

Local Providers See Tobacco Coalition list: programs by geographical location See list of healthcare providers and tobacco cessation programs Review list of local programs for prescription assistance programs. Pharma assistance programs Inform of Pfizer, Glaxo-Smith Kline, AstraZeneca web sites for information on eligibility for their prescription assistance programs. Match with tobacco programs that offer assistance with prescription assistance programs (see directory) Have them ask their healthcare provider and tobacco cessation counselor which medication would work best for them and inquire about prescription assistance if their insurance does not cover or can not pay out of pocket

The 5 A's ARRANGE Action: Schedule follow-up contact, either in person or via telephone. Strategy: Timing: At your next home visit ask the individual about their smoking status, encourage if they are in quit process, assess and refer if still smoking.

Thinking Ahead You may need to repeat this process several times before the individual finally quits. This process is also helpful when dealing with someone who has relapsed.