Using the Public Health Services Guidelines (PHS) for Smoking Cessation

[Scott Crespy]

The Public Health Services (PHS) Guidelines for Smoking Cessation outlines the recommended steps that healthcare providers take with their patients who have a current or recent history of smoking.

On December 9th, 2004, Dr. Charles Stimler discussed this topic with Medical Residents at Brookdale Hospital. Below is a brief multi-media RealPlayer recording of the counseling components from that presentation.

http://jeny.ipro.org/files/crespy/80PHSStimCounImage.jpg (rtsp://webstage.ipro.org/smoking-cessation/stimler-phs/realphsstimcounselingv1.smil) Charles E. Stimler, M.D., M.P.H. Smoking Cessation Counseling Basics and use of the (rtsp://webstage.ipro.org/smoking-cessation/stimler-phs/realphsstimcounselingv1.smil)Public Health Services (PHS) Guidelines for Physicians (rtsp://webstage.ipro.org/smoking-cessation/stimler-phs/realphsstimcounselingv1.smil) (21 minutes). Topics include: Transtheoretical Stages of Change, the 5As and the 5Rs. Free RealPlayer - Downloading Instructions (http://jeny.ipro.org/showthread.php?p=303#post303).

I think that this presentation offers an excellent introduction to the use of the PHS's 5As and 5Rs. I know that many of you have already incorporated these into your practice and have developed ways to enhance their effectiveness. Please share your questions, thoughts, and experiences with others by posting a reply to this message. Thank you!

Scott Crespy, PhD
IPRO Smoking Cessation Project Manager

[Scott Crespy]

The following is a summary of the "Clinical Considerations" in the "Recommendations Statement" for "Counseling to Prevent Tobacco Use and Tobacco-Caused Disease (http://www.ahrq.gov/clinic/3rduspstf/tobacccoun/tobcounrs.htm#ref4)" by the U.S. Preventive Services Task Force (USPSTF; hyperlinks added for reader convenience).

The 5As (http://www.surgeongeneral.gov/tobacco/5steps.pdf) (Five Major Steps to Intervention (http://www.surgeongeneral.gov/tobacco/5steps.pdf)) counseling framework can be used as an approach to engage patients in smoking cessation discussions:

Ask about tobacco use.
Advise to quit through clear personalized messages.
Assess willingness to quit.
Assist to quit.
Arrange follow-up and support.
Other helpful aspects of counseling include:

Provide problem-solving guidance for smokers to:
- develop a plan to quit
- overcome common barriers to quitting
- build social support
Common complementary practices include:
- motivational interviewing (http://www.motivationalinterviewing.org/)
- 5 R's (http://www.surgeongeneral.gov/tobacco/5rs.pdf) (relevance, risks, rewards, roadblocks, repetition)
- assessing Readiness-to-Change
- intensive counseling and/or referrals for quitters needing extra help.
Telephone "quit-lines"
Scott Crespy, PhD
IPRO Smoking Cessation Project Manager

[Scott Crespy]

The Center for Tobacco Research and Intervention at the University of Wisconsin Medical School (UW-CTRI) (http://www.ctri.wisc.edu/main_dept/guide/guide_main.html) has been centrally involved in assisting the development of national guidelines for clinicians and others to assist tobacco users to quit

Smoking Cessation-A Clinical Practice Guideline (1996)
Treating Tobacco Use and Dependence (2000) (http://www.surgeongeneral.gov/tobacco/)
They have a Web-site with excellent smoking cessation resources at: http://www.ctri.wisc.edu/main_dept/guide/guide_main.html

Here are just a few of the clinician training materials available on this site:

http://jeny.ipro.org/files/crespy/50GuidelineTrainingManualCover.jpg Training Manual: Practical Strategies to Help your Patient Quit
Manual Cover (http://www.ctri.wisc.edu/main_dept/guide/Guideline%20Training%20Manual%20Cover.pdf) - pdf format document, Training Manual (http://www.ctri.wisc.edu/main_dept/guide/Guideline%20Training%20Manual.pdf) - pdf format document
http://jeny.ipro.org/files/crespy/UWvideoimage.jpg (http://www.ctri.wisc.edu/main_dept/guide/tobacco.mpg) Training Video (http://www.ctri.wisc.edu/main_dept/guide/tobacco.mpg) - mpg - This is a very fine 19-minute training video which presents very useful information, two training senarios: a willing and an unwilling patient, and describes the use of the 5As and some motivational suggestions as well. IMPORTANT: This is a large file and will take you a minimum of 12 minutes to download.
http://jeny.ipro.org/files/crespy/50GuidelineHospitalInfoCover.jpg Training Manual: Practical Strategies to Help your Patient Quit - Hospital Program
Manual Cover (http://www.ctri.wisc.edu/main_dept/guide/Guideline%20Hospital%20Info%20Cover.pdf) - pdf file document, Training Manual (http://www.ctri.wisc.edu/main_dept/guide/Guideline%20Hospital%20Info.pdf) - pdf file document
As the need increases to improve performance on the smoking cessation advise/counseling clinical indicator, hospitals are searching to find excellent training materials. I think that this discussion can begin to assist with sharing already existing materials. Please post on this discussion board your experience with these materials and also share the training materials that you use with us as well. Thanks.
Scott Crespy

[Scott Crespy]

The American Medical Student Association (AMSA) is an independent association of physicians-in-training in the United States. They are very active in promoting health and "Tobacco Use" is one of their key priority issues. They have a broad array of both educational and activist resources on their Action Against Tobacco (http://www.amsa.org/cph/tobacco.cfm) Web page.

Developed for the Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine and Dentistry, the American Medical Student Association/Foundation put together an excellent provider educational resource:

http://jeny.ipro.org/files/crespy/50healthdialoguesimage.jpg (http://www.amsa.org/pdf/TobaccoUse.pdf) Health Dialogues - Tobacco Use: A Tool to Help You and Your Patients Change Unhealthy Behaviors (http://www.amsa.org/pdf/TobaccoUse.pdf)

In this Manual, they recommend combining three Behavioral Change Models:

Stages of Change (Transtheoretical Model)
Motivational Interviewing
Health Belief Model
with the 5As.

Incorporating Behavioral Change Models such as Motivational Interviewing appears to provide clinicians with strategies that enhance the effectiveness of their smoking cessation interventions.

Are you currently incorporating aspects of Behavioral Change Models in the smoking cessation advise/counseling that you provide? Are you interested in do this? Please share your thoughts and experiences with us by replying to this post. Also, you may want to visit our Applying Motivational Interviewing Techniques (http://jeny.ipro.org/showthread.php?t=105) discussion.

Help make these JENY discussions as active and vibrant as possible, please post a reply today! Thanks.

Scott Crespy

[Scott Crespy]

The Public Health Services (PHS) Clinical Guidelines offers a useful outline for conducting smoking cessation counseling. Motivational Interviewing provides clinicians with a set of tools, which appears to nicely complement and extend the clinical guidelines. Please join us in developing a series of clinical tools that work towards a useful integration of these approaches at: http://jeny.ipro.org/showthread.php?p=720#post720 and an audio discussing these tools are available at: http://jeny.ipro.org/showthread.php?threadid=105

Thanks.

Scott Crespy, PhD
IPRO Smoking Cessation Project Manager

[roselyn]

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[Scott Thomas]

The Public Health Service’s 5A’s (ask, advise, assess, assist, arrange) highlight the elements that are important for a health care setting are important to get in place to help tobacco users quit. But, “get in place” is far different than what usually happens with the 5A’s. Oftentimes, providers are taught the 5A’s all at once and right at the start of a campaign to implement new cessation services. Which goes against most everything we know about how to get buy-in and produce behavior change. One day the providers aren’t even asking about tobacco use and the next day we want them to be office-based cessation counselors (because they have so much time on their hands).

I was at Kaiser Permanente in Northern California when we significantly increased the advice to quit rate, the number of patients participating in cessation activities, and the amount of medications prescribed. We did this without really emphasizing the 5A’s. We used the Public Health guidelines that include the 5A’s. But, we did so only for the evidence to help build the different components (documenting advice to quit, etc.). We got most of the 5A’s in place, but not by terrifying the providers with it at the outset (exaggeration).

There is no doubt that some people out there are effectively training providers using the 5A’s. And I admit to doing it on numerous occasions. However, I’m still doubtful about the way it often becomes the centerpiece of trainings. Does it really build intention and confidence in providers to work with tobacco users? I guess I believe that the 5A’s can often be built better without using the 5A’s.

Scott Thomas, PhD