The 5 A’s method for smoking cessation has been proven to be the best practice for helping women of childbearing age reach the goal of cessation. This method of brief intervention 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. However, there are multiple behavioral health interventions that can be used with clients, depending upon where they are in the quit process.

Health care providers and programmatic staff have several tools available to them, such as the 5As, 5Rs, and Motivational Interviewing. These can be used to offer encouragement and assistance to clients to modify their behavior. These types of interventions are uniquely appropriate for women who are of childbearing age who are either considering or are already pregnant.

For more information on using behavioral health interventions for tobacco cessation and to access additional resources, Providers are encouraged to download the Provider Toolkit.

The 5 A’s method for smoking cessation has been proven to be the best practice for helping women of childbearing age reach the goal of cessation. Providers using the 5 A’s counseling intervention will progress through a series of 5 topics with their clients: Ask, Advise, Assess, Assist, and Arrange. This intervention is designed to be brief, 5 minutes or less, and is encouraged to be used by any trained health care professional working with tobacco users.
It is important to ask every client if they use tobacco, provide advice to quit, assesses their willingness to make a quit attempt, and provide resources to aid in the quit process. This method is not meant to be forced and progression through the 5As should be contingent upon where the client is in the quit process. For more information about using the 5As with your clients, see below or refer to the Provider toolkit.

Ask: Ask every client about their current and past tobacco use and if they or their family is exposed to second hand smoke. Help the client quantify their tobacco usage by documenting the number of cigarettes the client smokes on a daily basis. Continue to the Advice stage if the client is a current or former smoker or if the client or their children are exposed to secondhand smoke.

Advise: For current smokers and clients who are exposed or whose families are exposed to secondhand smoke, provide advice on at least one Advise topic. Provide the client with the Willing to Quit, Recently Quit, or Not Ready to Quit resources.

Advise Topics

1. Strong advice to quit
In a clear, strong, and personalized manner, urge the client to quit smoking.
2. Benefits of quitting
Provide the client with information on the benefits of quitting, including improved health, money savings, easier breathing, and a longer life expectancy. Additional benefits of quitting are available in the Consumer Resources.
3. Harms of smoking
Provide the client with information on the harms of smoking including increased risk for heart disease, cancer, and stroke. Additional benefits of quitting are available in the Consumer Resources.
4. Difficulty of quitting
Discuss the difficulties of quitting smoking with the client. Brainstorm ways to combat mood changes, cravings, weight gain, and being around other smokers. Strategies for combatting these topics are available on page 10 of the Willing to Quit resource.
5. Risks of second hand smoke exposure
Provide the client with information on the harms of secondhand smoke, including health risks for adults, children, and unborn babies. Additional information on the harms of secondhand smoke exposure are available on the Secondhand Smoke Exposure page of this website and on page 13 of the Willing to Quit resource.

Continue to the Assess stage if the client is a current or former smoker.

Assess: Assess all current and former smokers for their Stage of Change. For clients who are willing to quit, set a quit date with them. Provide the Former Smoker, Recently Quit, or Willing to Quit resources to the client, according to their stage of change.
 
 
 
Stages of Change
Stage Description Toolkit Resources
Pre-contemplation Current smokers who are NOT planning on quitting within the next 6 months. See page 11
Contemplation Current smokers who are considering quitting within the next 6 months and who have not made an attempt in the last year. See page 7
Preparation Current smokers who have made quit attempts in the last year and/or are planning to quit within the next 30 days. See page 7
Action Individuals who are not currently smoking and who stopped smoking within the past 6 months (recently quit). See page 14
Maintenance Individuals who are not currently smoking and who stopped smoking longer than 6 months but less than 5 years ago (former smokers). See page 14
 
 

Continue to the Assist and Arrange stages for clients who are in the Contemplation, Preparation, or Action Stage. If the client is in the Maintenance stage but expresses a desire to begin smoking again, continue to the Assist and Arrange stages.

Assist: For clients who are willing to quit, provide assistance in at least one Assist area.

Assist Areas

1. Follow-up from last visit
Ask the client about their progress on quitting since their last visit. Arrange for a follow-up call or appointment to check in with the client about their quit process. Identify potential triggers and review problem-solving skills for those triggers.
2. Review problem-solving skills
Review problem-solving skills with the client like exercising, deep breathing, drinking water, and walking away from smokers when they feel like smoking.
3. Provide self-help materials
According to the client’s Stage of Change, provide them with one of the Consumer Resources or other self-help material.
4. Provide social support
Affirm the client’s decision to quit smoking. Tell the client that about half of all of the people who ever smoked have now quit. Communicate your belief in their ability to quit. Invite the client to talk about their success. Additional social support topics are available on page 10 of the Provider Toolkit.
5. Identify local social support
Identify friends and family the client can use for social support, including people who will encourage the client to quit, help them in the quit process, or be a “quit buddy” with them.


Arrange: For clients who are willing to quit, provide a referral to a Certified Tobacco Treatment Specialist program, the Quit Line at 1-800-934-4840, or another tobacco cessation program. Schedule a follow-up appointment or phone call with the client.

Providers are encouraged to download the Provider Toolkit for a detailed description of how to progress through the 5 A’s with clients in all levels of the quit process.


The 5 R’s is effective in increasing a client’s motivation to quit tobacco use. Using the 5 R’s strategy gives clients the opportunity to express their motivation for quitting in their own words and providers the opportunity to tailor their responses to meet the specific needs of the client.
 

Relevance

Encourage the woman to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it relates to a woman’s risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important factors (e.g., prior quitting experience and personal barriers to cessation).

For more information about using the 5 R’s with the 5 A’s method, please download the Provider Toolkit.

Risk

Ask the woman to identify potential negative consequences of smoking and suggest and highlight those that seem most relevant to her. Emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks.
 
 

Examples of risks for a woman can include:

Short-term risks:

Shortness of breath, worsening of asthma or bronchitis

Increased risk of respiratory infections

Infertility

Long-term risks:

Heart disease and stroke

Lung and other cancers

Examples of risks for a baby can include:

Dying while in the womb (miscarriage or stillbirth)

Being born prematurely

Having low birth weight

Having birth defects such as cleft lip or cleft palate

Second hand smoke exposure increasing

 

Rewards

Ask the woman to identify potential benefits of quitting and suggest and highlight those that seem most relevant to her.
 

Examples of rewards are:

  • Having healthier babies and children
  • Home, car, clothing, and breath smelling better
  • Saving money
  • Improved appearance, including reduced wrinkling/aging of skin and whiter teeth

Roadblocks

Ask the woman to identify barriers to quitting and provide problem-solving counseling or referral to tobacco cessation services to address barriers.
 

Barriers to quitting may include:

  • Withdrawal symptoms
  • Excessive weight gain
  • Lack of support
  • Depression
  • Being around other tobacco users
  • Fondness for smoking

Repetition

Repeat the motivational intervention every time an unmotivated woman has a visit with the program/clinic. Tell women who smoke and have failed in previous quit attempts that most people make repeated quit attempts before they are successful and that you will continue to discuss their smoking with them.
Motivational Interviewing (MI) is a client-centered method for enhancing motivation for change by exploring and resolving feelings about quitting tobacco use. MI is designed to help clients identify and address their barriers to the quit process and move through the stages of change. The method of counseling is client driven and should be approach as a collaborative versus prescriptive treatment. Trained healthcare or behavioral health specialists employing this methodology should adhere to the following steps:

1. Express Empathy (understand where the client is coming from)
2. Identify Ambivalence (inconsistency)
3. Avoid Argumentation (diffuse defensiveness)
4. Roll with Resistance (address struggle and conflict…don't deflect)
5. Support Self-Efficacy (believe in the client’s ability to change)

MI should be used to build the client’s confidence in their ability to quit and promote opportunities for them to reach their goals. Scare tactics have proven ineffective with this population, and can lead to more stress for the client and steer them away from confiding about their barriers to the quit process. Health care providers and programmatic staff can use MI to identify small goals and build on those goals overtime as clients begin to believe in their own ability to change and quit tobacco use permanently. See page 12 of the provider toolkit to identify more MI training tips, or listen to the presentation here.