Addressing Specific Needs

Research into the etiology of tobacco dependence shows a diverse set of underlying mechanisms specific to each individual. Though researchers are still working to integrate patient characteristics into individualized clinical regimens, it is not too early to start adopting this strategy in an effort to produce effective results.

Start by considering the details of your patient’s quit status. Below are brief strategies from A clinical practice guideline for treating tobacco use and dependence for engaging patients who are willing to quit, unwilling to quit and recently quit.

Tobacco Users Willing to Quit

Utilize the 5 A’s model to assist your patient in taking the first steps toward cessation. For further guidance on how to promote cessation maintenance, see Individuals Who Have Recently Quit (below).

Ask (about tobacco use)
- Gather information regarding tobacco use for every patient for every visit.
Advise to Quit
Assess willingness to make a quit attempt
- Is the client willing to make a quit attempt currently?
Assist in the quit attempt
- Offer medication and either provide or refer for further counseling.
Arrange follow-up
- Schedule a follow-up appointment within a week of quit date.

Tobacco Users Unwilling to Quit

Resistance to quitting is a part of every ex-smoker’s past. As a supporter, it is important to help the individual understand that quitting is possible. To help empower your patients, consider the 5 R’s (below) to help guide your efforts.

Relevance – Discuss the importance of quitting.

Risks – Ask your client to identify risks and highlight those that are particularly relevant to the patient.

Rewards – Ask client to identify rewards, highlight the most relevant components.

Roadblocks – Ask client to identify potential barriers to quitting, mention any that he/she might miss, offer solutions (counseling, NRT, medication, etc.).

Repetition – Repeat motivational intervention each time unwilling client visits clinic. Reassure that any potential relapses are common for individuals seeking cessation.

As you utilize the 5 R’s strategy, consider integrating the following motivational interviewing techniques:

Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy

For expanded information on Motivational Interviewing, refer to page 75 of A clinical practice guideline for treating tobacco use and dependence from

Individuals Who Have Recently Quit

Ask how abstinence is going. Take any relevant data on client’s experience and assess the individual’s relapse potential.

Most relapse occurs within first 2 weeks and likelihood decreases overtime.
Ask about how long it’s been since client quit.
Assess level of urge to smoke.
Provide assistance as necessary.

Help your patient plan for the challenges associated with cessation can be key in helping a patient stay quit. Below are ways to address some common barriers to being tobacco free.

Lack of support for cessation
- Help client find support resources such as quit lines, or in-person therapy options)
Negative mood or depression
- Refer client to counseling or evidence-based support settings.
- If necessary, offer support and prescribe medication.
Strong or prolonged withdrawal symptoms.
- Consider adjusting medication.
Weight-gain
- Consider Harm-reduction model (some weight gain is better than smoking persistence).
- Promote physical activity and balanced diet.
- Consider continuing medication where weight gain is controlled.
- Offer nutritional counseling or refer to specialist.
Smoking lapses
- Reassure that this often requires multiple quit-attempts.
- Suggest re-commitment to abstinence.
- Provide or refer for intensive counseling.