Brief Interventions

 

What are Brief Interventions?

• Brief Interventions are practices aimed at investigating a potential problem in a short interaction and motivating an individual to begin to do something about it. ²
• Brief interventions for tobacco use focus on enhancing tobacco users’ motivation to change and connecting them with evidence-based resources to help make the next quit attempt a success.
• The 5 A’s method for brief interventions has substantial research support for its utility in helping tobacco users across a variety of settings and can be incorporated with motivational strategies in a step-by-step process.
• Some providers and settings prefer to use abbreviated forms of the 5 A’s model, such as Ask, Advise, Connect (AAC), which focuses on referring patients to national tobacco quitlines for assistance. MDQuit recommends Ask, Advise, Assess, Connect (A3C).
• Brief interventions are the second step in a more involved process called SBIRT.  This stands for Screening, Brief Intervention, and Referral to Treatment.  The brief intervention can be informed by a screening and assessment process and can be a critical step to supporting the patient in getting the more specialized treatment they need to successfully make a quit attempt for their tobacco use.

 

The 5A’s

The 5 A’s approach is a brief, goal-directed way to more effectively address tobacco use with patients with the goal of meeting tobacco users’ needs in terms of readiness to quit. Altogether, the 5 A’s may take 1 to 5 minutes, depending on a provider’s clinical setting and roles. The 5 A’s do not need to be applied in a rigid manner, and an entire office/clinical staff may be involved to support tobacco users.

1. Ask: About tobacco use every time

This is essential for identifying the patient’s tobacco use, and some settings include inquiring about tobacco use as part of vital signs like blood pressure. Ask patients about their current and past smoking patterns.

2. Advise : Urge tobacco users to quit

Advising the patient to quit should be done in a clear, strong, and personalized manner. Urge every tobacco user to quit. Expect ambivalence. Be willing to listen non-judgmentally to his/her concerns about quitting tobacco use.

3. Assess: Determine willingness to make a quit attempt

Assess how ready the patient currently is to quit tobacco use. Readiness rulers (i.e., “On a scale of 1 to 10, where 10 is very ready, how ready are you to quit smoking?”) and Stages of Change assessments are useful in addressing the extent to which a person is ready to change, which can change from visit to visit.

 

Table 1. Stages of Change from the Transtheoretical Model of Intentional Behavior Change

Precontemplation	Current smokers who are NOT planning on quitting within the next 6 months.
Contemplation	Current smokers who are considering quitting within the next 6 months and have not made an attempt in the last year.
Preparation	Current smokers who have made quit attempts in the last year and are planning to quit within the next 30 days.
Action	Individuals who are not currently smoking and stopped within the past 6 months (recently quit).
Maintenance	Individuals who are not currently smoking and stopped smoking for longer than 6 months but less than 5 years (former smokers).

 

4. Assist: Provide help to move the individual toward a successful quit attempt

Former Tobacco Users (Action or Maintenance)
For those who have successfully quit using tobacco, you can Assist by affirming their success to support self-efficacy, and discussing any challenges to staying quit and methods to prevent relapse.

Current Tobacco Users with High Readiness to Quit (Preparation or Action)
You can Assist by helping him/her develop a personalized quit plan with a quit date and offer an array of effective treatment options:

• Medications and Nicotine Replacement Therapy (when medically advisable - consider pregnancy, other medications, allergies, etc.)
• Free telephone counseling through the Maryland Quitline with an easy referral through our Fax to Assist program
• Your local health department's cessation services programs
• Individual or group smoking cessation programs

Current Tobacco Users with Low Readiness to Quit (Precontemplation or Contemplation)
You can Assist by enhancing willingness or motivation and ability or confidence through these methods:

• Offer personalized, relevant feedback about the importance of quitting
• Explore the individuals’ perceived pros and cons of smoking and quitting
• Discuss the 5 R’s of quitting tobacco use as follows

 

Table 2. The 5 R's

Relevance	Help the individual identify why quitting tobacco is relevant to him/her.
Risk	Encourage the individual to verbalize possible negative outcomes of tobacco use.
Rewards	Help the individual identify the possible benefits of quitting tobacco use.
Roadblocks	Help the individual to identify possible obstacles to quitting, including those from his/her past quit attempts.
Repetition	It might take more than just one brief intervention before a tobacco user becomes ready to quit. Use the 5 A’s or AC3 at every visit!

 

5. Arrange: Follow-up contact

Follow-up is most helpful to do it within the first weeks of a quit date and can be either in person or via telephone. During this call encourage the individual to remain quit. Discuss any obstacles and how to overcome them. Congratulate success for those who have been able to quit. For those who continue to use tobacco, repeated use of the 5 A’s and 5 R’s is important for supporting motivational changes over time to move toward Action for quitting tobacco.

Fax to Assist Training

For more detailed training on use of the 5 A’s for tobacco, MDQuit’s FREE Fax to Assist certification program offers four brief modules that help you understand the 5 A’s and Stages of Change and how to effectively refer patients to Maryland’s FREE tobacco Quitline.

 

The A3C's

 Similar to the 5A’s, the intent of Ask, Advise, Assess, Connect (A3C) is a simpler, goal-directed brief intervention to effectively address tobacco use with patients or clients who are smokers. The goal is to meet tobacco users’ needs in terms of readiness to quit and, if ready, to connect patients directly to a tobacco quitline for assistance. 

 

1. Ask:  It is essential to ask patients every time at every visit. It will show patients that smoking cessation is a priority. It will also allow providers to track your patient’s changes in use so you can adjust your approach accordingly. 

 

2. Advise:  By making advice personal, the provider offers the client/patient a chance to really think about how their tobacco use is either affecting them physically or interpersonally.  Additionally, smokers will typically respond to this advice in a way indicative of how they truly feel about their tobacco use assisting with the assessment in the next step.

 

3. Assess: Assess how ready the patient currently is to change their tobacco use whether they want to cut down their use or cut it out entirely. Change can be assessed using a readiness ruler as shown below or by using the Stages of Change model. By addressing the extent to which a person is ready to change, which can change from visit to visit, providers can better tailor their approach to helping their patients.

 

“On a scale of 1 to 10, with 10 being very ready, how ready are you to quit smoking?”

 

If a smoker picks a low number, you can ask why they didn’t pick something even lower (evokes change talk).  If they picked the middle of the road, you can ask about what it would take to get higher or still why they didn’t pick something lower.  Higher responses indicate they may simply need encouragement and additional support! That is the function of the next step.

4. Connect: Connect patients who are ready to quit directly to tobacco cessation treatment and support. When a smoker indicates they are ready for taking some steps, he or she can be connected with the quitline proactively through fax to assist or an electronic health record referral.  Visit smokingstopshere.com to connect patients to the quitline or go online to become a Fax-to-Assist provider at the mdquit.org website, or link them with other resources in your community. Directly connecting is a much preferred and efficacious way to capitalize on current motivation and get significant additional help to quit smoking. 

Brief Interventions and Motivational Enhancement

• Brief interventions which include motivational enhancement strategies acknowledge that quitting smoking involves a process of change and includes assessing and responding to patient readiness, abilities, and confidence to change.

• Motivational enhancement strategies used by clinicians help tobacco users feel supported and understood, not judged, and can be especially effective for engaging the process of change to help tobacco-users move toward quitting. According to developers of Motivational Interviewing, William Miller and Stephen Rollnick, “It is the patient who should be voicing the arguments for change” (p. 8). ¹

• Motivational enhancement techniques include:
  • Non-judgmental, reflective listening
  • Expressing genuine empathy
  • Exploring ambivalence about both the pros and cons of change
  • Avoiding argumentation/confrontation
  • Supporting self-efficacy or confidence to change

• Brief interventions including motivational enhancement strategies help tobacco users:
  • Make informed, autonomous choices to change
  • Overcome barriers to quitting
  • Have greater confidence about a future quit attempt

• Learning motivational enhancement techniques requires time and practice. To learn more, we recommend the Rollnick et al. (2008) and CSAT (2003) references below. 

 

How Effective Are Brief Interventions for Tobacco?

Brief interventions including the 5 A’s are effective in many ways:

• “Minimal intervention lasting less than three minutes increases overall tobacco abstinent rates.”⁵
• Evidence shows that treatments like brief clinical interventions including clinician advice and follow-up are not only clinically effective but highly cost effective, as well.⁴
• Clinical settings that fully implement all of the 5 A’s show better results than those with partial or inconsistent use of the 5 A’s .⁴

Physicians play an important role in tobacco cessation:

• A study shows that at least 82% of patients want their physician to discuss smoking cessation often or at every visit. ³
• Evidence shows that abstinence rates increase when a physician advises the smoker to quit smoking. ⁴
• A 1996 review of several studies shows that individuals who received no advice had an abstinence rate of 7.9 %, whereas individuals who received physician advice to quit had an abstinence rate of 10.2 % .⁴

Brief interventions can be effectively tailored for special populations and settings:

• “Studies have shown that dentists and dental hygienists can be effective in assessing and advising smokeless/spit tobacco users to quit” (p. 82).^4,6
• In a study conducted to demonstrate effectiveness of the 5 A’s for tobacco cessation during inpatient hospital visits, the intervention helped patients avoid relapse in the early days after cessation and discharge.⁷  However, additional follow-up phone calls using an interactive voice response system post-discharge did not have additive value in supporting long term cessation in this medical population. More research is needed to identify whether there are populations for whom follow-up assistance (e.g., addressing barriers to change and making referrals to more intensive tobacco treatment) may be useful in supporting continued cessation.
• A study conducted to test the effectiveness of brief interventions in individuals with severe mental illness (SMI) found that there was increased abstinence and reduced number of cigarettes smoked when the 5A’s were implemented for a period of twelve months, but no significant difference was observed when the 5A’s were implemented for a period of six months.⁸ These findings indicate that with special populations like those with SMI, repeat follow-up and engagement with tobacco users over time may be necessary to support change.