Clinical review
ABC of smoking cessation

Cessation interventions in routine health care

BMJ 2004;328:631-633 (13 March)

Tim Coleman, senior lecturer in general practice
School of Community Health Sciences in the Division of Primary Care at
University Hospital, Queen's Medical Centre, Nottingham


Smoking cessation interventions are widely underused in primary and
secondary care despite being effective and easy to deliver (see earlier
articles in this series). Smoking causes much greater harm than, say,
hypertension (which is generally identified and managed entirely in primary
care by health professionals working to agreed routine, systematic, and
structured protocols), yet few primary healthcare teams manage smoking as
methodically as they approach hypertension.

Maximising the delivery of cessation interventions to smokers wanting to
quit can probably achieve more in terms of years of life saved and provide
better value for money (see later article in this series) than almost any
other simple medical intervention.

Smoking as a vital sign

The first step towards developing a systematic approach for the management
of smoking is to treat smoking as a "vital sign." To do this, health
professionals must regularly inquire about patients' smoking status and have
a methodical approach towards documenting and updating this in medical
records. This information needs to be recorded in a prominent place so that
it can be seen whenever medical records are accessed during consultations.
In paper records, a summary card can be used, and, in electronic records,
smoking status data should be lodged with other important summary
information on a patient's health. Recording information where it is easily
noticed prompts health professionals to raise the topic of smoking more
frequently with patients.

The minimum information to record is whether the patient smokes and the date
on which this was ascertained. It is also useful to record the average
number of cigarettes smoked each day, not least because those who smoke more
heavily are more likely to benefit from nicotine replacement therapy or
bupropion therapy. Recording whether the smoker is interested in or
motivated to try stopping smoking is also helpful: when health professionals
raise the topic of smoking in future consultations, they can then tailor
their messages to smokers' levels of motivation (see below).

Smokers' medical records should also be indexed so that they are readily
identifiable and easy to retrieve. Without easy access to smokers' medical
records, health professionals cannot effectively monitor their management of
smoking. The simplest method for indexing smokers' medical records is to tag
electronic records with one of the smoking status Read codes, but
non-computerised general practices could use a simple card index. Monitoring
longitudinal changes in patients' smoking behaviour and health
professionals' delivery of cessation interventions is most appropriate in
primary care because there is repeated contact between patients and primary
healthcare teams. Health professionals can therefore treat smoking as a
chronic disease, like asthma or diabetes.

The five "A"s approach

The five "A"s (ask, assess, advise, assist, arrange) summarise the role of
health professionals in managing smoking. Health professionals are urged to
ask all smokers about their smoking. Once smokers have been identified, it
is important to assess their interest in stopping smoking with an open
question such as "how do you feel about your smoking?" It is important to
ask sensitively as some smokers feel defensive when doctors raise the issue,
and this can make it difficult to ascertain patients' true views.

Managing smoking cessation needs to become a key part of routine practice
for all clinicians. This article discusses strategies for incorporating
effective antismoking interventions into routine clinical care

All smokers, irrespective of their motivation to stop, need to be advised
against smoking in a clear, personalised, and non-judgmental way. When
smokers are clearly interested in stopping, health professionals should
assist them to do so. Specific action will depend on the individual's
circumstances, but, where appropriate, smokers should be encouraged to set a
date for stopping completely, to plan for likely problems, and to enlist the
support of family and friends. Health professionals should discuss the use
of nicotine replacement therapy or bupropion with heavier smokers and
prescribe either treatment if this is appropriate (see earlier articles in
this series).

For smokers who want counselling and behavioural support, health
professionals should also arrange for this to be provided, if possible from
a specialist cessation service.

Implementing the approach
Success in integrating the five "A"s approach into routine clinical care
will vary. In primary care, for example, patients visit doctors for a wide
variety of reasons and general practitioners are, perhaps understandably,
reluctant to raise the issue of smoking in all consultations..

Conversely, cardiologists and respiratory physicians will probably ask about
smoking status in the vast majority of first consultations. Health
professionals, therefore, should be encouraged to raise the issue of smoking
with patients as often they believe is possible while recognising that
discussing smoking is sometimes better left for subsequent consultations.

One way is to ensure that inquiring about smoking status and updating
medical records is routine and systematic. If clinicians consider it
inappropriate to raise the issue of smoking at all consultations, they
should inquire and update records of smoking status at least annually. This
gives clinicians the opportunity to select consultations in which to discuss
smoking, taking into account patients' expectations of whether the issue
should be tackled.

Health professionals often cite pressure of time, among other things, as a
reason for not intervening against smoking more frequently. Smoking can be
one of several important health issues that need tackling in a single, short
consultation. The crucial difference between individual smokers is their
motivation to stop. Smokers vary greatly in their motivation and, to make
best use of limited time, health professionals should tailor their approach
to the motivational level of the individual smoker (see the chapter on
motivation earlier in this series). As only about a fifth of smokers who
attend general practitioners intend to try to stop smoking, it makes no
sense for general practitioners to give all smokers they meet detailed
information about how to stop. Non-motivated smokers need to be encouraged
to change their attitudes to smoking before being urged to take action to

Tailoring advice to motivation

Health professionals in both primary and secondary care can be encouraged to
advise and assist smokers in a manner appropriate to their motivation to

Primary care
"Help 2 Quit" (H2Q) is a smoking cessation service that encourages general
practitioners to use their routine consultations opportunistically to
intervene against smoking. They are encouraged to identify each smoker's
level of motivation for trying to quit as soon as possible after raising the
issue of smoking with them, and to use this as a base for subsequent
discussions on smoking. The primary objective of this method is to offer
support to those who are ready to quit and improve their chances of success.
H2Q uses a simplified version of the "stages of change" (see earlier
article) to tailor the intervention to the smoker. Although little empirical
evidence exists to support the use of this approach, it fits well with
clinical practice, including patients' expectations of how doctors should
respond to their smoking.

Where counselling and behavioural support is not available, health
professionals should consider providing follow up themselves or through
another member of their team; this may be particularly convenient for
smokers if pharmacotherapy for nicotine addiction is being prescribed and
they cannot attend a specialist service

General practitioners tend to prefer to discuss smoking when patients
present with smoking related problems, and they would generally avoid
discussing smoking at all with some patients (for example, bereaved

Secondary care
In the H2Q approach, general practitioners are urged to treat more motivated
and less motivated smokers differently: motivated smokers are given specific
advice about quitting that would be inappropriate for those not interested
in stopping. In Nottingham, midwives have developed a mechanism for
incorporating inquiry and intervention into their routine work. When
pregnant women attend their booking appointment for antenatal care, midwives
use an algorithm to ask a series of questions about smoking.

As 80% of pregnant women believe that stopping smoking is the most important
lifestyle change they can make to improve their babies' health, inquiring
about smoking at all booking appointments is unlikely to upset many pregnant
women. Midwives ask the women about smoking status, whether they live with
smokers (including partners), and finally whether they or other smokers they
live with are interested in quitting.

All smoking related data from manual records are entered into an electronic
database for monitoring purposes. Midwives then respond to women in an
appropriate way for their motivation level, and those who are interested in
receiving extra support in quitting are referred to the local cessation
service for behavioural counselling.

Monitoring management of smoking

All medical care systems sometimes experience some inertia or resistance to
change. The fact that effective smoking cessation interventions have not
been adopted into routine care despite their availability for over 20 years
shows that this is especially true in relation to smoking cessation.

It is therefore important to monitor and audit the implementation and
delivery of these services. This can be relatively simple when information
about smoking is recorded electronically. For example, most general practice
computer systems in the United Kingdom use Read codes, which allow
clinicians to record data on smoking status simply and accurately.

Recently, new Read codes describing the three categories of smokers'
motivation (and used by H2Q) have been approved, and these can now be used
by any general practice computer system to record individual smokers'
motivation to quit in medical records. Use of these Read codes and
information on patient management from medical records provides a means for
monitoring how primary care health professionals respond to smokers with
differing levels of motivation.

In the Help 2 Quit approach, general practitioners are urged to treat more
motivated and less motivated smokers differently: motivated smokers are
given specific advice about quitting that would be inappropriate for those
not interested in stopping

Further reading
� Butler CC, Pill R, Stott NC. Qualitative study of patients' perceptions of
doctors' advice to quit smoking: implications for opportunistic health
promotion. BMJ 1998;316: 1878-81.[Abstract/Free Full Text]

� Coleman T, Murphy E, Cheater FC. Factors influencing discussions about
smoking between general practitioners and patients who smoke: a qualitative
study. Br J Gen Pract 2000;50: 207-10.[ISI][Medline]

� Rollnick SR, Mason P, Butler C. Health behaviour change: a guide for
practitioners. London: Churchill Livingstone, 1999.

� West R, McNeill A, Raw M. Smoking cessation guidelines for health
professionals: an update. Thorax 2000;55: 987-99.[Abstract/Free Full Text]

The ABC of smoking cessation is edited by John Britton, professor of
epidemiology at the University of Nottingham in the division of epidemiology
and public health at City Hospital, Nottingham. The series will be published
as a book in the late spring.
The adapted figure showing the "Help 2 Quit" approach is published with
permission from K Lewis, and the flow chart for midwives with permission of
Nottingham City Hospital (NHS Trust).

Competing interests: TC has been paid for speaking at a conference by
GlaxoSmithKline, a drug company that manufactures treatments for nicotine
addiction; he has also done consultancy work on one occasion for Pharmacia.
See first article in this series (24 January 2004) for the series editor's
competing interests.[...]nt/full/328/7440/631