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The A-R-T of tobacco use counseling with adolescents: A new office approach
Source: Patient Care
By: Michael G. Spigarelli, MD, PhD, Richard B. Heyman, MD
Originally published: December 1, 2005

MICHAEL G. SPIGARELLI, MD, PhD, Clinical Assistant Professor of Pediatrics and Internal Medicine, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

RICHARD B. HEYMAN, MD, Adjunct Professor of Clinical Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and Chair, American Academy of Pediatrics Section on Adolescent Health.

Every physician is well aware of the importance of preventing or stopping tobacco use among young patients and parents, yet the perceived obstacles to providing such counseling are daunting—so much so that many providers spend very little time on it.¹ Each clinician quickly finds that there is no ideal intervention—that perfect 1- or 2-line statement or question that fits easily into a busy office visit and is effective. To counter that trend, we offer a practical approach to counseling that provides the clinician with feedback that the process is working, and, ultimately, encourages continued prevention efforts. Our approach also nurtures the developing relationship between parent and child, which can form the basis for a tobacco-free life for that child.

Obstacles to counseling

A recent study comparing the smoking cessation counseling practices of family physicians and pediatricians provides insight into the perceived barriers to counseling among these clinicians.² The obstacle cited most often was concern that children would not provide accurate information because of the presence of parents at the interview (86%) or fear that parents would be told about the child's responses (74%). Sixty-one percent of respondents cited the time-consuming nature of counseling, and 55% of pediatricians believed that they lacked the appropriate skills.

TABLE 1. Billing codes for tobacco cessation counseling and treatment
These obstacles are surmountable. Engaging in some private conversation with all children older than 10 years (a good time to explore the risk and protective factors outlined in the so-called HEEADSSS schema)—and helping parent and child to understand the importance of fostering the physician-child relationship—greatly encourage honesty and confidentiality.³ Most health insurance companies provide reimbursement for tobacco-related counseling (see Table 1). Worried about your counseling skills? Resources are available that review, in detail, the process of smoking cessation (see "Internet resources").¹

5 As, 5 Rs—and 5 Ts

The most recent evidence-based approach to creating a comprehensive plan for counseling about tobacco use is summarized in the 2000 report Tobacco Use Cessation, developed by the United States Agency for Healthcare Research and Quality (AHRQ) for the CDC.⁴ The AHRQ report features 2 useful mnemonics:

The 5 As (ask, advise, assist, assess, and arrange) conceptualize the process of quitting
The 5 Rs (relevance, risks, rewards, roadblocks, and repetition) help personalize the approach.

TABLE 2. The 5 Ts
The practical application of the 5 As and 5 Rs is left to the individual practitioner to devise. To supply the missing "how-to" component, we propose adding a third mnemonic: the 5 Ts— terminate, tend, teach, tune in, and talk (see Table 2). Like the 5 As and 5 Rs, the 5 Ts are memory prompts designed to stimulate an ongoing conversation among you, the parent, and the child that encourages the parent and, later, the child to examine the role and impact of tobacco in their life. By keeping in mind these prompts, you can easily incorporate sound, developmentally appropriate messages into both routine and ill visits.

During the prenatal visit, encourage each mother to terminate all tobacco use and exposure for the sake of the pregnancy and the child's future health. When compared to infants of nonsmokers, infants born to women who smoke are more likely to be premature and underweight.⁵ Moreover, exposure to nicotine increases the number of nicotine receptors in the brain of the developing fetus, and studies suggest that such children have an increased propensity to develop attention problems and a variety of addictions, including nicotine.^6-7 Tobacco use during pregnancy may also harm the developing fetal lung and is linked to increased likelihood of asthma and reactive airway disease later in life.

Remind parents of children from birth to 4 or 5 years of age that it is their parental responsibility to tend to the process of keeping their child's environment free of tobacco. Encourage parents who smoke to stop, for their own health and that of their children. Parents who cannot or will not quit should never smoke in the presence of children. They should smoke only outside the home and car and cover clothing with a waterproof coat to minimize the amount of particulate matter that clings to clothes and is brought inside. Smoking away from children reduces not only the health risks of secondhand smoke but also the likelihood that the child will become a smoker. The most significant predictor of youth smoking is parental tobacco use; approximately 40% of children of smokers become smokers themselves.⁸

When children become increasingly exposed to outside influences—at about 5 years of age—parents must continually teach about the dangers of tobacco use and make clear their expectation that the child will never use tobacco. Printed materials (available online from AHRQ at http://www.ahrq.gov) can help parents to reinforce the message. Portrayal of tobacco use in the media or observation of people smoking can provide teaching moments. The parent can allude to the odor, nicotine staining of fingertips, and overall effect on the smoker's appearance and health. If an older friend or relative smokes, the parent might mention the effects that a lifetime of smoking has had on that person. Such discussion not only validates a negative response to tobacco use but also opens the lines of communication between parent and child on this and other "difficult" topics.

Older children and teenagers become acutely aware of the world around them—including pervasive protobacco messages in the media and peers who smoke and use smokeless tobacco—and they develop images of how they want to be perceived. Parents must tune in to these social influences and support the choice not to use tobacco. Frank and open discussion concerning tobacco use, especially by a favorite pop star or actor on television or in a movie, can help cut through some of the misleading and harmful images to which children are exposed. The tobacco industry has mastered the art of "image advertising"; explaining how such advertising works and that it is a form of manipulation may help a child to make good decisions about smoking and in many other areas too.

As the child develops the ability to think critically, ask him to consider whether he really thinks smoking will make him "cool," macho, independent, sexy, glamorous, or successful (images the tobacco industry seeks to convey) or whether it might damage health and relationships and cost both money and independence. Children can understand the concept of addiction, so references to friends and family who are addicted and unable to stop may be effective. Parents should state their expectations clearly and unambiguously—"I expect that you will never try one cigarette," not "you know smoking is bad for you." It is crucial that prevention begin early: 90% of adults who smoke started as children or teenagers.⁹

As the child moves into adolescence, even if parents perceive such discussions as difficult and fruitless they must continue to talk with their child about tobacco and encourage their child to talk with them. Such discussions help encourage the young person not to use tobacco or, if he does, to recognize it as a problem and seek help. Parent and teenager must work together on the issue of remaining tobacco-free in a partnership that has been forged over the preceding years by using the first 4 Ts.

Parents must continue to state the expectation that the teenager will not use tobacco; know where the adolescent is and who he or she is with; be aware of the smell or other signs of tobacco use among the teenager's friends and acquaintances; and enforce restrictions that encourage appropriate behavior.¹⁰ The adolescent must remain honest and open, even in the face of peer pressure and the drive for independence. He must learn to make good choices about where to go, with whom to associate, and develop strategies for saying No if pressured to engage in risky behaviors, including tobacco use. Lapses by either parent or child may occur, but with open communication based on trust, honesty, and love, an adolescent can feel confident in telling his parents the truth, and parents can be supportive and helpful even if the teenager makes a bad decision.

The 5 Ts fit well within office practice, providing quick and easy keywords to prompt the developmentally appropriate message and sow the seeds for follow-up conversations. Initially, your discussions will be with the parent(s) alone, but as the child grows, you can ask him whether his parents have raised the tobacco issue and what is his understanding of their expectations. Positive responses reinforce your perception that the effort is worthwhile; negative responses prompt persistence. Both can serve as motivators to continue counseling attempts.

Using the 5 As and 5 Rs

Tobacco use is best treated according to the chronic disease model: Health will improve over time, but relapses are to be expected and no one treatment method or single trial of a particular therapy will be successful and permanent for everyone. Most tobacco users have tried to quit, leading them to feel that they are not only addicts but failures.¹¹ Issues that must be addressed include feelings of stress, sadness, loneliness, and anger, all of which may make quitting harder. Many people begin to smoke specifically to deal with such uncomfortable feelings and fear that the feelings will return if they quit. Patients may also see the negative affect (anger, anxiety, irritability, guilt, fear, and hostility) that is associated with quitting as an impediment.¹²

Addiction has 3 interconnected attributes: mental dependence, physical dependence, and habituation. Mental dependence describes the emotional relief from stress associated with addiction, which many tobacco users cite as the most difficult aspect to overcome when anticipating a quitting attempt. Physical dependence—including craving, increased tolerance, and withdrawal—is the typically tough aspect of actually stopping tobacco use. Habituation comprises the "automatic" aspects of handling, inhaling, and relaxing as well as the social cues that play directly into the potential for relapse.

Quitting tobacco use is a process, and it is important to set reasonable, achievable expectations. As each successive goal is achieved it serves as a stepping-stone to the next goal: Success breeds success. The 5 As are reminders of major steps that have been identified on the pathway to successful intervention. These simple actions— ask, advise, assist, assess, and arrange —help organize the discussion of tobacco use in the office setting.

Ask After assuring the patient of confidentiality, ask directly if he or she uses or has ever used tobacco. If you have been using the 5 Ts all along, this step should be second nature. If you have never raised the subject of tobacco use with the patient, early adolescence (10 years of age at the latest) is a good time to start.

If the patient has not used tobacco, support that choice as both normal and healthy. Appropriate questions include

What might make you decide not to use tobacco products?
Do any of your friends smoke or use smokeless tobacco?
Have you tried, or thought about trying, any form of tobacco?
Have you ever thought about what you would do if someone offered you tobacco?

The same strategy works for youngsters who have either tried or currently use tobacco. Your goals are to help the patient understand that change is possible and to offer to support him when he is ready to begin that process. A "motivational interview" may help the patient to understand his actions and begin to make the sorts of choices that result in healthier decisions.¹³

Behavioral change, described in the Stages of Change model, occurs along a continuum, with a series of smaller mental changes preceding the actual change of behavior.¹⁴ Identifying where a patient is on the continuum can help determine what questions to ask and what to expect. It is unrealistic, for example, to ask an adolescent who smokes and has never considered quitting to set a quit date. Rather, you must lead him down the path, introducing the concept of quitting, reviewing the advantages of quitting, and encouraging him to consider an attempt.

TABLE 4. Answers to "Why do you smoke?"
Understanding specifically why a patient likes to smoke or wants to quit may help you formulate a treatment approach. Typical questions might include

Why do you smoke (see Table 4)?
What problems do you encounter because of your tobacco use?
What would make you want to quit?
Are any of your friends nonsmokers or nonusers of tobacco?
Have you thought of quitting or tried to quit?
What happened when you tried to quit?

You can further explore each question by asking if the adolescent has ever considered these issues before and whether he thinks it is possible that he will change his mind in the next 3 to 6 months.

Advise Youngsters who have never used tobacco should receive a congratulatory, supportive message. Encourage those who have contemplated smoking or are moving in that direction to reconsider the decision, and identify strategies to help reverse the trend. Asking why the patient is thinking about using tobacco and what he thinks the consequences of the decision may be can provide insight into his thought process and suggest how to successfully intervene. Advise patients who use tobacco to quit. One of the best methods for moving such patients through the stages of change is motivational interviewing. By asking questions sensitively, creating discrepancy, avoiding confrontation, and listening empathically, you may see some willingness on the patient's part to consider changing his behavior.

Even if the patient is not interested in quitting, encourage him to decrease his tobacco use, an objective which has value as an end in itself and a means to make quitting easier at a later time. Although the evidence linking the amount of damage caused by tobacco to the amount used is somewhat ambiguous, the theory of "harm reduction" suggests that any decrease in tobacco use is a healthy decision.

The best advice for quitting combines relevant information with a clear and honest presentation of the benefits of quitting compared to the drawbacks of continuing to use tobacco. This is where the 5 Rs— relevance, risks, rewards, roadblocks, and repetition —come in.

Relevance Advice to quit smoking is most effective if you gear the discussion to the patient's age, developmental stage, family situation, state of health, prior quitting experience, problems related to smoking, and goals and plans. Record your discussion of each of these areas in the patient's record so that you can address them as necessary at future visits. A change in one area often makes the difference between a patient who is precontemplative in the Stages of Change (no plan or desire to change) and one who is, at least, contemplating change.

Risks Discuss the short-term health consequences of tobacco use, such as increased risk of upper respiratory tract infection and sore throat, especially when a patient is ill. Remind patients with asthma and reactive airway disease of the role smoking plays in exacerbating these conditions. Long-term health consequences such as emphysema, cardiovascular disease, and lung cancer are not significant disincentives in the minds of most adolescents and young adults ("Only old people get that," "I won't be smoking when I'm older"). Social issues—such as stained and malodorous clothing, bad breath, dental problems, and cost—can be motivating, however.

Rewards Discussing the benefits of becoming (or remaining) tobacco free is as important as warning of the risks of tobacco. Point out that if the patient quits, he will not only feel better physically and emotionally, but food will taste better and the sense of smell will improve—as will stamina and athletic endurance. In addition, beating an addiction will eliminate a source of nagging by parents and others in his life. Moreover, the money he spends on tobacco will be available for other uses.

Roadblocks Physical symptoms of withdrawal (such as irritability, nervousness, and the ongoing desire to do something with hands or mouth) are often a major barrier to quitting, although you can reassure patients that pharmacotherapy can help. It is also important to discuss the fear of failure and lack of support that many patients feel, particularly those who have not succeeded at quitting.

Many smokers worry about weight gain if they quit; this issue should be addressed honestly and straightforwardly. You can note that the average weight gain after quitting is 6 to 8 lb, caused by reversal of the metabolic poisoning induced by tobacco use, an apparent craving for high-calorie foods, and substitution of one oral fixation for another. Suggest alternative oral gratifications such as chewing sugarless gum, sucking on sugarless candy, and snacking on vegetables. Although the potential weight gain is not desirable, it is far less harmful in both the short and long term than the effects of continued tobacco use.

Patients who began to use tobacco in an attempt to treat underlying depression or anxiety may experience recurrence of those symptoms. They need a promise of support and discussion of alternative therapeutic approaches, such as counseling or medication.

Repetition The final R is the most challenging for the health care practitioner: Repeat and highlight the appropriate tobacco cessation messages at every visit (both health maintenance and ill visits), and emphasize the role of tobacco use in the patient's current health situation. This charge is easy to forget in a busy office practice but is very important to the patient's ongoing health and well-being.

Assist Once the patient moves into the contemplation stage, the partnership between provider and patient becomes all the more important. Several steps can help the patient move from contemplation to the preparation stage.

Set a specific quit date. The patient should choose a date carefully, avoiding times of stress when triggers to smoke will be rampant or when the patient is not confident of success. Write the agreed-upon date in the chart and on something the patient can refer to, such as a prescription pad or personal calendar. Do not underestimate the power of a specific written directive from you as motivation to quit.

Overall preparation for quitting is at least as critical as the quit date. Review previous quit attempts and their outcomes with the patient for clues to potential triggers for relapse. Have the patient remove tobacco products from the home and destroy any extra or "emergency" cigarette packs. Friends and coworkers should be asked to provide ongoing encouragement and support (and to promise not to provide cigarettes); the more people supporting the quit attempt, the better the odds for success. The smoker should avoid turning to friends who smoke and therefore may be unable to provide a "no use" message. Look for underlying depression or anxiety and treat it in advance of the quit date if possible.

Stress plays a large role in foiling quit attempts. Methods of coping with the increased stress include avoiding people who smoke and situations in which many others will be smoking. For those situations in which avoidance is impossible, such as at home with other smokers or at work, other stress-modifying strategies such as music or an exercise program may be helpful. In much the same fashion as the quit date is established, specific calming interventions should be discussed, and the final decision should be the patient's. The effectiveness of the distraction technique should be reviewed at each subsequent visit to determine if it remains effective enough to ensure success.

The AHRQ guidelines state that "all clinicians should feel comfortable prescribing nicotine replacement therapy (NRT)" because "it is generally safe, and certainly is less hazardous than the dangers of nicotine addiction."² NRT is available OTC in patch, gum, and lozenge form; nasal spray and inhaler can be prescribed for those who cannot use the other preparations. Preliminary studies suggest that NRT is as safe and effective for adolescents as it is for adults, although the formal AHRQ report did not find enough evidence to make a formal recommendation. Support for the use of NRT can be drawn from the harm-reduction model: Nicotine by itself is much safer than the combination of nicotine and other chemicals that is ingested by using tobacco.

Studies in adults indicate a role for bupropion (Zyban) in promoting smoking cessation and reducing relapse rates. Adult data show that attempts at smoking cessation succeed 2.5 times more often among patients who take the medication than among those who do not, and preliminary studies suggest that using bupropion in combination with NRT is more effective than either therapy alone.^4,14,15 Although bupropion has not been fully studied in adolescents, it has been used to treat depression in teenagers for years. It should not be prescribed for patients with a history of seizure disorder or ongoing use of marijuana (which lowers the seizure threshold).

Appropriate candidates for smoking cessation should be referred to support programs to increase their changes of success. Cessation programs run by local hospitals, HMOs, and other health organizations are typically available; information can be obtained from the Web sites of the American Cancer Society, the American Lung Association, AHRQ, and the American Academy of Pediatrics. Support groups, such as NicAnon, can usually be found in the local phone book.

Assess Evaluate where each current tobacco user stands on the Stages of Change continuum with regard to making a quit attempt. Perform this assessment at every visit while encouraging the patient to move further along the path toward quitting. As part of the evaluation, revisit the preceding categories—that is, ask, advise, and assist until tobacco cessation is achieved. Record the assessment in the patient's chart in a prominent place to prompt follow-up at the next visit.

Arrange Schedule follow-up contact with the patient, in person or by phone, preferably within one week after the established quit date, to discuss the status of the quit attempt and address any difficulties that may have arisen. It is at this time that patients who were reluctant to try NRT or other pharmacotherapy often begin to feel the need for medication. The follow-up call or visit can be rewarding for you and the patient because it demonstrates the commitment to health that has begun with the patient's transition from the preparation stage to the action stage of change. Your conversation will help determine the frequency of additional follow-up—sooner for patients who have had a great deal of difficulty or started medication recently, later for those who have not experienced substantial difficulty.

As the patient moves into the action stage of change, you should anticipate and prepare for a relapse. Preventing relapse depends on ongoing communication between you and the patient. The conversation should include congratulations on the success of the attempt, encouragement of continued abstinence, and consideration of the benefits of quitting. It should also encompass the problems encountered while quitting and anticipated challenges to staying abstinent. Typical issues include weight gain, stress, and ongoing association with others who use tobacco.

This is also the time to consider longer-term follow-up, typically in about 3 to 6 months, but sooner if the patient has been started on medication. During this critical period, the patient progresses from the action stage of change to the maintenance stage. He needs reinforcement and encouragement, even if relapse has occurred. If the quit attempt has remained successful, discuss ongoing health maintenance and improvement. If a relapse has occurred, mention whatever success the patient has achieved and discuss the strategy and timing of the next attempt.

This article was contributed by Drs Spigarelli and Heyman and edited by Julia M. Russell.

Drs Spigarelli and Heyman disclose that they have no financial relationship with any manufacturer in this area of medicine.

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