11/13/24, 8\:20 PM Guide | Smoking cessation

Smoking cessation

Table of contents
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Background

Smoking is a signilung 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
Although 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 frequently delivered in a general practice setting as primary care physicians have the unique
opportunity to harness long-term patient-doctor relationships.
3
However, time restraints may lead to ine
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
We have also included an alternative approach using the ‘UNITED’ structure which can be used for motivational interviewing.
Ultimately, a structured and patient-centred approach is key to ensuring the patient feels listened to and understood. This will
allow you to reassure the patient and use shared decision-making.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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Explore the reason for the patient's visit.
Ideas, concerns and expectations (ICE)
Explore the patient’s current ideas, concerns and expectations in regards to smoking\:
" H o w d o y o u f e e l a b o u t s m o k i n g ?"
" I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t s m o k i n g o r g i v i n g u p ?"
" W h a t a r e y o u h o p i n g t o g e t f r o m t h e v i s i t t o d a y ?"
Emphasise 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.
Establishing ICE creates common ground between you and the patient, this will help you to tailor your advice and make sure
the patient feels listened to.

Smoking history

It's important to take a comprehensive smoking history before 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 a
How does the patient
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 )
Cardiovascular disease and cardiovascular risk factors (e.g. coronary artery disease, hypertension, diabetes, hyperlipidaemia)
Previous hospital admissions and surgery
Medications
e
Check if the patient is currently or was previously prescribed any nicotine replacement (if so, ask the patient about its
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 - do these factors a
smoking habit?
Ask about the patient’s employment\: does this have a relationship with their smoking?

The 5 A's approach

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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 e
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 the assessment of behaviour modi
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

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 e
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
10
Nicotine replacement therapy\:
Used as
Increases successful cessation by 1.5 times
Caution in patients with cardiovascular disease or acute coronary syndrome
Bupropion\:
Increases successful cessation by 2 times
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 e
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
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Non-pharmacological therapies involve a selection of behavioural counselling programs which can be tailored to patient
preferences and beliefs.
Explain the di
Some patients may bene
Brief intervention\:
12
A brief form of face-to-face behavioural therapy
These short discussions have been shown to increase overall abstinence rates
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
In the event of a relapse, reassure the patient that this is not a setback but merely a natural part of the behavioural
modi
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\:
10
Within 1-2 weeks after the patient’s quit date and then at 4 weeks
At 3 months and 1 year to follow-up on new side e

The UNITED approach

Understanding

Try to gain an understanding of the patient’s smoking history. Include a brief general medical history to get a better idea of the
patient’s health and lifestyle\:
“ I w o u l d l i k e t o u n d e r s t a n d a b i t m o r e a b o u t y o u r s m o k i n g a n d h o w i t i s a
At this point, it is also useful to brie
is a good starting point from which you can give information later on\:
“ W h a t i s y o u r u n d e r s t a n d i n g a b o u t h o w y o u r s m o k i n g i s i m p a c t i n g y o u r h e a l t h ?”

Non-negotiable issues

It is important to establish early on if there are any speci
repeatedly visit these topics it can make the patient feel uncomfortable and want to disengage from the consultation.
The best approach is to ask about these topics openly and upfront to make sure that everyone is on the same page\:
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“ A r e t h e r e a n y t o p i c s o r t y p e s o f s u p p o r t t h a t y o u a b s o l u t e l y d o n’ t w a n t t o d i s c u s s t o d a y ?”

Identify common ground

This part of the consultation is all about understanding the patient’s thoughts and feelings about smoking. This will give you
a good understanding about what motivates the patient, and will therefore give you common ground to work from.
This is the stage of the consultation where you should cover the patients ideas, concerns and expectations (ICE)\:
“ H o w d o y o u f e e l a b o u t s m o k i n g ?”
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t s m o k i n g o r gi v i n g u p ?”
“ W h a t a r e y o u h o p i n g t o g e t f r o m t h e v i s i t t o d a y ?”
Using the answers to these questions as a baseline, you should then explain the risks of smoking using relevant links to the
patient’s ideas, concerns and expectations. This makes the explanation more relatable for the patient and helps to illustrate
your points\:
“ Y o u m e n t i o n e d y o u w e r e c o n c e r n e d t h a t y o u r f a t h e r h a d a s t r o k e w h i c h m a y h a v e b e e n r e l a t e d t o s m o k i n g . U n f o r t u n a t e l y ,
s m o k i n g i s a s s o c i a t e d w i t h a n i n c r e a s e d r i s k o f s t r o k e a m o n gs t o t h e r c o n d i t i o n s s u c h a s h e a r t d i s e a s e a n d l u n g c a n c e r .
”
As always, you should use a ‘chunk and check’ style approach to giving an explanation; in this case, giving an explanation of
the risks of smoking.
Identifying common ground will also give you areas to focus on for the rest of the consultation when you come to discuss
possible interventions.

Tensions remaining

It’s usually a good idea to check in with the patient after explaining the risks of smoking. There may be new
tensions/questions that have arisen\:
“ N o w t h a t I h a v e e x p l a i n e d s o m e o f t h e r i s k s , I w o u l d r e a l l y l i k e t o h e l p y o u q u i t s m o k i n g s o t h a t w e c a n m a k e t h e s e r i s k s a s
l o w a s p o s s i b l e . D o y o u h a v e a n y r e s e r v a t i o n s a b o u t m e g i v i n g y o u s o m e a d v i c e ?”
“ A r e t h e r e a n y q u e s t i o n s y o u w o u l d l i k e t o a s k b e f o r e w e c o n t i n u e ?”

Explore possible solutions

Based on all of the information you have now collected about the patient, you are now in a good position to give the patient
tailored smoking cessation advice.
You could consider\:
Pharmacological therapies (e.g nicotine replacement therapy, either rapid-acting or long-acting).
Non-pharmacological therapies (e.g. telephone counselling appointments)
Di
smoking behaviours.

Decide together

at least one option.
Once you have explored possible options, take the opportunity for some shared decision-making with your patient. Commit to
After the best option has been chosen, encourage them to 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 e
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).
Ensure that you have a plan in place to follow up with the patient after they have begun their smoking cessation journey;
usually 1-2 weeks after the
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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 “C a n y o u r e p e a t b a c k t o m e
j u s t t o m a k e s u r e I h a v e m e n t i o n e d t h e i m p o r t a n t p o i n t s r e ga r d i n g…..?”
Direct the patient to further information using websites and lea
NHS SmokeFree National Campaign
10 Health Bene
Take Steps NOW to Stop Smoking
Make sure the patient is aware that this is entirely their choice and o
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Tony Foley
Consultant General Practitioner

References

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2. O[LINK]
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Published in 2012[LINK]
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10. 12. UpToDate, O v e r v i e w o f S m o k i n g C e s s a t i o n M a n a g e m e n t i n A d u l t s . 11. Lowry B, Caragianis A. M a s t e r t h e N A C . Published in 2016. [LINK]
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Source\: geekymedics.com
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