Receipt of Evidence-based Brief Cessation Interventions by Health Professionals and use of Cessation Assisted Treatments Among Current Adult Cigarette-only Smokers: National Adult Tobacco Survey, 2009–2010

Judy Kruger; Alissa O'Halloran; Abby C. Rosenthal; Stephen D. Babb; Michael C. Fiore


BMC Public Health. 2016;16(141) 

In This Article


Current cigarette-only smokers who reported receiving the full 5 A's intervention (Ask, Advise, Assess, Assist, Arrange) were approximately 15 times as likely to report using the combination of counseling and medication (optimal treatment recommended by the USPHS Clinical Practice Guideline) as those who received one or none of the 5 A's. Additionally, we found that smokers who received any three or four components of the 5 A's were more likely to use cessation treatment compared to smokers who received one or none of the 5 A's. Among current cigarette-only smokers who received all 5 A's, 29.0 % reported using a combination of counseling and medication compared with 8.2 % who received four of the 5 A's. These findings suggest that delivery of all five elements of the 5 A's intervention is associated with greater use of cessation treatments. Moreover, findings suggest that any four or three of 5A's could also significantly promote cessation treatments compared to one or none of 5A's. The ABC pathway (Ask, Brief advice, Cessation) from New Zealand incorporates the 5 A's into three steps and emphasizes the important role health professionals play in offering tobacco users guidance to access cessation support.[13] However the importance of delivering all 5 A's is relevant, given data suggesting that a large proportion of health professionals now deliver the first 2 A's (Ask, Advise) but that a much lower percentage deliver the final two A's (Assist, Arrange).[6,14–17] This may be because 'Assisting' with cessation and 'Arranging' follow-up are often time consuming, may not be reimbursed, and require effective communication skills to tailor the intervention to patients' needs.[18–20] Our findings highlight the potential benefits to smokers when health professionals adopt the full complement of recommended evidence-based cessation treatments.[3]

In this large sample of current cigarette-only smokers who reported seeing a health professional within the last year, a marginal number reported being 'Assessed' for their willingness to quit or 'Assisted' by offer of cessation treatments, such as a telephone quitline. However, the finding that a minority of current smokers recalled having received the 'Assist' and 'Arrange' component of the 5 A's is consistent with previous studies on patient use of tobacco dependence treatments,[15,16,21] and suggests the need for continued efforts to expand health professionals' implementation of brief advice and cessation support. The 'Assess' step is key to determining the best approach to take for 'Assist' and what should be done about 'Arrange'. To enhance cessation, at each office visit after advising the smoker to quit, health professionals should 'Assess' each smoker's willingness to make a quit attempt and tailor the 'Assist' and 'Arrange' components to address the smoker's readiness to quit.[3] Given that providers who are proactive in 'Assisting' patients to use evidence-based tobacco cessation treatments have a significant impact on long-term quit rates,[22] health professionals may be most effective in helping their patients quit smoking by providing assistance and arranging follow-up for smokers to maximize quit attempts, treatment use, and quit rates.[23,24] This study also noted that patient participation in any of the 'Assist' strategies (counseling, medication, combination of counseling and medication) was higher in those aged 35 or older than those aged 18–24. The finding that older patients are more likely to use cessation assisted treatment could be related to health professionals spending more time with this population in efforts to improve patient adherence to treatment; but may also be due to the fact that older patients often have a variety of chronic health conditions and demonstrate a greater interest in quitting.[19] Further delivery of tobacco education including media campaigns such as the CDC Tips from Former Smokers campaign can motivate youth tobacco users to try to quit and to seek information on quitting.[25] Population-based strategies including providing telephone cessation counseling[25] can motivate tobacco users to quit while simultaneously making evidence-based cessation treatments readily available particularly to those who are vulnerable to social and environmental influences of cigarette use.[26] Since most cigarette smokers are receptive to their physicians' advice and willing to discuss quitting smoking,[3] our findings suggest that opportunities exist for health professionals to improve delivery of tobacco cessation assistance, including counseling and provision of medications, to increase patient use of these strategies.

The Institute of Medicine found that helping tobacco users to quit is essential to reduce tobacco use.[27] Our finding that 38.6 % of NATS current cigarette smokers reported receiving 'Assistance' to quit highlights the opportunity for health professionals to expand delivery of the 'Assist' brief intervention step.[17] We also found that less than 25 % of respondents reported receipt of any specific 'Assisted' strategy (cessation medication, cessation materials, counseling, counseling and medication, set a quit date) from a health professional. A number of factors are responsible for the lack of consistent delivery of brief cessation interventions, including time constraints, lack of expertise, lack of financial incentives, fear of alienating patients, and skepticism about smokers being able to quit.[28] The 2008 USPHS Guidelines cite a number of health system barriers that may impede clinicians' assessment and treatment of smokers, including inadequate institutional support for routine assessment and treatment of tobacco use, a lack of insurance coverage for tobacco use treatment, or inadequate payment for treatment.[3] Health system changes that integrate cessation interventions into routine clinical care have been found to increase the likelihood that health professionals consistently screen patients for tobacco use and intervene with patients who use tobacco, thereby making evidence-based tobacco dependence treatment the standard of care and increasing cessation.[3,5,29]

We found that use of the both counseling and medication treatment components, which is the optimal approach recommended by the USPHS Clinical Practice Guideline[3] to help smokers quit, was considerably higher among current smokers who recalled having received such counseling and medication during a medical encounter. Because tobacco dependence is a chronic condition that often requires multiple cessation attempts, primary care providers must repeatedly address cessation with their patients who use tobacco. The U.S. Preventive Services Task Force (USPSTF) is an independent, volunteer panel of national experts on prevention and evidence-based medicine. Their role is to make recommendations based on the body of peer-reviewed evidence about clinical preventive services and indicate the quality of the evidence using one of five letter grades (A, B, C, D, or I).[4] The USPSTF assigns a letter grade A or B to recommend a preventive service where there is high certainty that the net benefit is moderate to substantial. Medicare, and a number of state Medicaid programs have recently expanded coverage of cessation treatments.[30,31] In addition, several provisions in the 2010 Affordable Care Act expanded private and Medicaid cessation coverage. More specifically, the legislation requires all non-grandfathered private plans to cover with no cost sharing preventive services that receive an A or B rating from the USPSTF, which includes tobacco cessation interventions.[32] In May 2014, the United States Departments of Labor, Treasury, and Health and Human Services released a guidance document that provided specificity regarding the nature of Affordable Care Act tobacco cessation coverage – that it must include at least two quit attempts per year with coverage for both cessation counseling and medication.[33] Moreover, as of October 2010, the Affordable Care Act requires state traditional Medicaid programs to cover a comprehensive cessation benefit for pregnant women.[32] Effective January 2014, the legislation also bars states from excluding FDA-approved cessation medications from their coverage for all traditional Medicaid enrollees.[32] In sum, recent insurance policy changes may increase the capacity of clinicians to help their patients quit.[32]

Systems-level interventions can facilitate the delivery of all of the 5 A's and increase cessation.[5,29] Such interventions include the use of provider reminder systems, which prompt health professionals to assess smoking status during each medical visit and to intervene with patients who smoke.[3,26,34] Another example of a systems intervention is electronic health records, which can help health professionals monitor patients' smoking status and support delivery of evidence-based cessation interventions and referrals.[35] Strategic efforts to reconfigure policies and systems to increase delivery of cessation services in the health care setting may include the use non-physician staff to administer some of the 5 A's (e.g., Asking, Assisting, or Arranging).[5,23] Reimbursement of clinicians for making counseling and other cessation treatment a routine part of care may also support delivery of evidence-based cessation interventions.[3,24]

This study has several limitations. First, although the dataset was large and representative of the U.S. population, these data reflect patients' self-reported receipt and use of cessation interventions from a health professional, which may be subject to recall bias. Additional research that examines provider behavior through a monitoring system, electronic medical record, or direct observation of the medical encounter may be beneficial. Second, these data are cross-sectional, and thus, it was not possible to assess causal relationships between provider delivery of the 5 A's and patient use of cessation treatments. Third, questionnaire design did not allow estimates to be categorized by health professional type; therefore, we could not examine provision of tobacco cessation interventions by different health professions (i.e., doctor, dentist, nurse, or other health professional). Fourth, the study questions asked whether the 5 A behaviors had occurred in any visit in the past year, and it is not possible to determine the timeframe for cessation assisted treatment use, or how frequently multiple behaviors occurred in any given encounter. Fifth, the question order of the 5 A's was not asked in the typical traditional format and do not fully align with measures used elsewhere in the literature. While the NATS survey included all of the 5 A's, because of the skip pattern, it was not possible to determine if the question order of all of the 5A's impacted cessation treatment use. Moreover, misclassification bias could have occurred because those who were never asked an item due to the skip pattern or answered 'don't know' or refused were included in the denominator. Sixth, analyses do not include ever smokers who may have visited a health professional in the past 12 months but who quit more than 30 days before the survey was administered. Consequently, recall bias may exist as uptake of the 5 A's (receipt of cessation interventions among smokers interested in quitting) among then smokers with an ongoing quit attempt lasting 30 days or more was not measured.