Maryland's Tobacco Resource Center - Linking Professionals to Best Practices

Brief Interventions & 5 A's

The way in which you talk with patients about their health can substantially influence their personal motivation for behavior change.  (Rollnick, Miller & Butler, 2008, p. 6)

 

What are Brief Interventions?

  • Brief Interventions are practices aimed at investigating a potential problem in a short interaction and motivating an individual to begin to do something about it. 2
  • Brief interventions for tobacco use focus on enhancing tobacco users’ motivation to change and connecting them with evidence-based resources to help make the next quit attempt a success.
  • The 5 A’s method for brief interventions has substantial research support for its utility in helping tobacco users across a variety of settings and can be incorporated with motivational strategies in a step-by-step process.
  • Brief interventions are the second step in a more involved process called SBIRT.  This stands for Screening, Brief Intervention, and Referral to Treatment.  The brief intervention can be informed by a screening and assessment process and can be a critical step to supporting the patient in getting the more specialized treatment they need to successfully make a quit attempt for their tobacco use.

 

The 5A’s

The 5 A’s approach is a brief, goal-directed way to more effectively address tobacco use with patients with the goal of meeting tobacco users’ needs in terms of readiness to quit. Altogether, the 5 A’s may take 1 to 5 minutes, depending on a provider’s clinical setting and roles. The 5 A’s do not need to be applied in a rigid manner, and an entire office/clinical staff may be involved to support tobacco users.

  1. Ask: About tobacco use every time

This is essential for identifying the patient’s tobacco use, and some settings include inquiring about tobacco use as part of vital signs like blood pressure. Ask patients about their current and past smoking patterns.

  1. Advise : Urge tobacco users to quit

Advising the patient to quit should be done in a clear, strong, and personalized manner. Urge every tobacco user to quit. Expect ambivalence. Be willing to listen non-judgmentally to his/her concerns about quitting tobacco use.

  1. Assess: Determine willingness to make a quit attempt

Assess how ready the patient currently is to quit tobacco use. Readiness rulers (i.e., “On a scale of 1 to 10, where 10 is very ready, how ready are you to quit smoking?”) and Stages of Change assessments are useful in addressing the extent to which a person is ready to change, which can change from visit to visit.

 

Table 1. Stages of Change from the Transtheoretical Model of Intentional Behavior Change

PrecontemplationCurrent smokers who are NOT planning on quitting within the next 6 months.
ContemplationCurrent smokers who are considering quitting within the next 6 months and have not made an attempt in the last year.
PreparationCurrent smokers who have made quit attempts in the last year and are planning to quit within the next 30 days.
ActionIndividuals who are not currently smoking and stopped within the past 6 months (recently quit).
MaintenanceIndividuals who are not currently smoking and stopped smoking for longer than 6 months but less than 5 years (former smokers).

 

  1. Assist: Provide help to move the individual toward a successful quit attempt

Former Tobacco Users (Action or Maintenance)
For those who have successfully quit using tobacco, you can Assist by affirming their success to support self-efficacy, and discussing any challenges to staying quit and methods to prevent relapse.

Current Tobacco Users with High Readiness to Quit (Preparation or Action)
You can Assist by helping him/her develop a personalized quit plan with a quit date and offer an array of effective treatment options:

Current Tobacco Users with Low Readiness to Quit (Precontemplation or Contemplation)
You can Assist by enhancing willingness or motivation and ability or confidence through these methods:

  • Offer personalized, relevant feedback about the importance of quitting
  • Explore the individuals’ perceived pros and cons of smoking and quitting
  • Discuss the 5 R’s of quitting tobacco use as follows

 

Table 2. The 5 R's

RelevanceHelp the individual identify why quitting tobacco is relevant to him/her.
RiskEncourage the individual to verbalize possible negative outcomes of tobacco use.
RewardsHelp the individual identify the possible benefits of quitting tobacco use.
RoadblocksHelp the individual to identify possible obstacles to quitting, including those from his/her past quit attempts.
RepetitionIt might take more than just one brief intervention before a tobacco user becomes ready to quit. Use the 5 A’s at every visit!

 

  1. Arrange: Follow-up contact

Follow-up is most helpful to do it within the first weeks of a quit date and can be either in person or via telephone. During this call encourage the individual to remain quit. Discuss any obstacles and how to overcome them. Congratulate success for those who have been able to quit. For those who continue to use tobacco, repeated use of the 5 A’s and 5 R’s is important for supporting motivational changes over time to move toward Action for quitting tobacco.

Some providers and settings prefer to use abbreviated forms of the 5 A’s model, such as Ask Advise Refer, which focuses on referring patients to national tobacco quitlines for assistance.

 

Fax to Assist Training

For more detailed training on use of the 5 A’s for tobacco, MDQuit’s FREE Fax to Assist certification program offers four brief modules that help you understand the 5 A’s and Stages of Change and how to effectively refer patients to Maryland’s FREE tobacco Quitline.

 

Brief Interventions and Motivational Enhancement

  • Brief interventions which include motivational enhancement strategies acknowledge that quitting smoking involves a process of change and includes assessing and responding to patient readiness, abilities, and confidence to change.
  • Motivational enhancement strategies used by clinicians help tobacco users feel supported and understood, not judged, and can be especially effective for engaging the process of change to help tobacco-users move toward quitting. According to developers of Motivational Interviewing, William Miller and Stephen Rollnick, “It is the patient who should be voicing the arguments for change” (p. 8). 1
  • Motivational enhancement techniques include:
    • Non-judgmental, reflective listening
    • Expressing genuine empathy
    • Exploring ambivalence about both the pros and cons of change
    • Avoiding argumentation/confrontation
    • Supporting self-efficacy or confidence to change
  • Brief interventions including motivational enhancement strategies help tobacco users:
    • Make informed, autonomous choices to change
    • Overcome barriers to quitting
    • Have greater confidence about a future quit attempt
  • Learning motivational enhancement techniques requires time and practice. To learn more, we recommend the Rollnick et al. (2008) and CSAT (2003) references below.  Another helpful, easy to use reference can be found at the Healthy Territory (Australia) website:  http://www.health.nt.gov.au/library

 

How Effective Are Brief Interventions for Tobacco?

Brief interventions including the 5 A’s are effective in many ways:

  • “Minimal intervention lasting less than three minutes increases overall tobacco abstinent rates.”5
  • Evidence shows that treatments like brief clinical interventions including clinician advice and follow-up are not only clinically effective but highly cost effective, as well.4
  • Clinical settings that fully implement all of the 5 A’s show better results than those with partial or inconsistent use of the 5 A’s .4

Physicians play an important role in tobacco cessation:

  • A study shows that at least 82% of patients want their physician to discuss smoking cessation often or at every visit. 3
  • Evidence shows that abstinence rates increase when a physician advises the smoker to quit smoking. 4
  • A 1996 review of several studies shows that individuals who received no advice had an abstinence rate of 7.9 %, whereas individuals who received physician advice to quit had an abstinence rate of 10.2 % .4

Brief interventions can be effectively tailored for special populations and settings:

  • “Studies have shown that dentists and dental hygienists can be effective in assessing and advising smokeless/spit tobacco users to quit” (p. 82).4,6
  • In a study conducted to demonstrate effectiveness of the 5 A’s for tobacco cessation during inpatient hospital visits, the intervention helped patients avoid relapse in the early days after cessation and discharge.However, additional follow-up phone calls using an interactive voice response system post-discharge did not have additive value in supporting long term cessation in this medical population. More research is needed to identify whether there are populations for whom follow-up assistance (e.g., addressing barriers to change and making referrals to more intensive tobacco treatment) may be useful in supporting continued cessation.
  • A study conducted to test the effectiveness of brief interventions in individuals with severe mental illness (SMI) found that there was increased abstinence and reduced number of cigarettes smoked when the 5A’s were implemented for a period of twelve months, but no significant difference was observed when the 5A’s were implemented for a period of six months.8 These findings indicate that with special populations like those with SMI, repeat follow-up and engagement with tobacco users over time may be necessary to support change.
References: 
  1.  Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press.
  1. Center for Substance Abuse Treatment. (2003). Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series 34. (DHHS Publication No. SMA 03-3810). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration
  1. Solberg, L.I., Maciosek, M.V., Edwards, N.M., et al. (2006). Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness. American Journal of Preventive Medicine, 31, 62-71.
     
  2. Fiore, M. C., Jaen, C. R., & Baker, T. B. (2008). A clinical practice guideline for treating tobacco use and dependence: 2008 update a U.S. public health service report. American Journal of Preventive Medicine, 35(2), 158-176. doi: 10.1016/j.amepre.2008.04.009
  1. Puschel, K., Thompson, B., Coronado, G., Huang, Y., Gonzalez, L., & Rivera, S. (2008). Effectiveness of a brief intervention based on the '5A' model for smoking cessation at the primary care level in Santiago, Chile. Health Promotion International, 23(3), 240-250. doi: 10.1093/heapro/dan010
  1. Carr, A.B., Ebbert, J.O. (2007). Interventions for tobacco cessation in the dental setting. A systematic review. Community Dental Health, 24, 70-4.
  1. Regan, S., Reyen, M., Lockhart, A. C., Richards, A. E., & Rigotti, N. A. (2011). An interactive voice response system to continue a hospital-based smoking cessation intervention after discharge. Nicotine & Tobacco Research, 13(4), 255-260. doi: 10.1093/ntr/ntq248
  1. Dixon, L. B., Medoff, D., Goldberg, R., Lucksted, A., Kreyenbuhl, J., DiClemente, C., et al. (2009). Is implementation of the 5 A's of smoking cessation at community mental health centers effective for reduction of smoking by patients with serious mental illness? The American Journal on Addictions, 18(5), 386-392. doi: 10.3109/10550490903077747