Time to enhance "5 A's" of smoking cessation?

The Public Health Service's Tobacco Cessation Guideline is slated to begin revision before the end of the year.

The "five A's" are the guideline's basic mnemonic, which encourages physicians to ask about tobacco use, advise patients to quit, assess their willingness to do so, and assist and arrange follow up. Experts in tobacco cessation in the primary care setting are wondering now whether these prompts should be changed, whether new "A's" should be added or if some need to be deleted.

"The five A's were and still are a wonderful tool to promote discussing tobacco, and [they] have tremendous value," said Susan Swartz, MD, MPH, medical director of the Center for Tobacco Independence at Maine Medical Center in Portland. "It could probably become better. Let's move to the next generation of five A's."

The A's were last updated in the 2000 guideline when the original four listed in the 1996 version were expanded to include a reminder to assess. This addition was an attempt to clarify the need for doctors to determine how ready patients were to stop. It also reflected the increasingly collaborative nature of tobacco cessation.

"The whole relationship between patients and physicians has evolved enormously," said Michael Fiore, MD, MPH, chair of the panel that devised the guideline and director of the University of Wisconsin Medical School's Center for Tobacco Research and Intervention. "It's of critical importance to ensure that patients have full participation in the plan."

Additionally, some experts have begun to question the order of the A's -- whether, for instance, the assessment should occur before the advice is offered.

"Giving advice to people who don't want to quit just puts up another barrier. Preaching to patients doesn't work," said Charles Bentz, MD, medical director of Smoking Cessation and Prevention at Providence Health System in Portland, Ore.

Others argue, though, that, while a patient's position on quitting might impact the intervention's frequency and intensity, it should not affect whether it happens. Many anti-smoking advocates feel that physicians should always take a position that quitting is imperative.

"We have a duty to say that smoking is bad, and patients expect it." said Kristina Kline, MD, clinical assistant professor of family practice at the University of Oklahoma College of Medicine. "And you can tell by the reaction if people are ready."

Cooperation necessary

The question of patient buy-in also could be addressed. To this end, some experts would like "agree" to replace "advise," or at least be added to the list to underscore the co-operation between doctor and patient that is involved.

"We need to discourage lecturing and encourage compassion and empathy," Dr. Swartz said. "It's not about telling people what to do."

But primary care physicians expressed concern that another "A" might make this tool too unwieldy, and most believe the need for patient agreement is implied.

"It goes along with assist. At that stage, we come up with a list of what we are going to do, and it's important to have agreement," Dr. Kline said. "The five A's are pretty easy to remember. If we start adding things, then it may get washed out."

Another suggestion is to truncate the list to ask, advise and refer to a local quit line or other resource. Some people say this approach may be more appealing for physicians who, because of the nature of their practices, are not able to be heavily involved in helping their patients quit.

"The five A's are an honorable set of principles, but even those who know them find them hard to follow," said Steven A. Schroeder, MD, director of the Smoking Cessation Leadership Center at the University of California, San Francisco. "Physicians who cannot do the full five A's should ask, advise and then refer patients to a telephone quit line or to a system within their own practice setting."

Some physicians countered that too often patients don't follow up on referrals to quit lines or for more specialized help. Many also suspect that some physicians already could be practicing the shortened version with or without official direction.

"Physicians who are not that interested in getting involved don't need to be told to refer," said Carolyn Lopez, MD, chair of the Dept. of Family and Community Medicine at Cook County's (Ill.) John H. Stroger Jr. Hospital. "They are already doing that."

Although there is significant disagreement about what the five A's should become, experts do agree that the biggest problem is that not enough physicians are using them in their practices, and ways need to be found to increase physician involvement in this kind of behavior change.

"It's not a question of which comes first when we know that 50% of physicians don't do anything," said Thomas Bodenheimer, MD, professor of family and community medicine at UCSF. "It should be used. If doctors can't do it, someone else in the practice should."

Experts also stressed the importance of evidence.

"If we're going to tweak the five A's, there should be a good reason to do so," said AMA Trustee Ronald M. Davis, MD, who has long worked on smoking issues.

The AMA has policies encouraging doctors to ask at every visit if their patients smoke and carry out a brief intervention for those who do. The Association also went one step further at its Annual Meeting in Chicago last month and adopted policy calling for the involvement of health care professionals at all points of contact in the medical system. This involvement includes not just physicians caring for their own patients but also pediatricians intervening with parents who smoke and interventions from other health care professionals, such as advanced-practice nurses, physician assistants and dentists.