Basics: 2As & R Clinical Intervention

Artwork by Nancy Z. © 2010 American Aca0emy of Pediatrics (AAP) Children's Art Contest. Support for the 2010 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

Objectives• Understand and be able to implement the 2 As and an R

intervention in clinical pracitce

• Make recommendations for cessation to patients and family members

Principles of Tobacco Dependence Treatment

• Nicotine is addictive

• Tobacco dependence is a chronic condition

• Effective treatments exist

• Every person who uses tobacco should be offered treatment

Why Physicians?• Tobacco use and smoke exposure result in adverse

health outcomes for both adults and children

• 70% of smokers see a primary care physician annually– Only 17.3% of adults report being asked about secondhand

smoke exposure by their physician– 27.2% of parents report being asked about secondhand

smoke exposure by children’s physician– 63% of physicians assess patients’ willingness to quit– 13% of physicians refer to appropriate treatment– 17% of physicians arrange a follow-up visit to address

smoking issues

Cessation is the Goal

• Eliminate the #1 cause of preventable morbidity and mortality

• Eliminate tobacco smoke exposure of all household members

• Decrease economic impact– Average cost per pack across US > $5.75

• Decrease teen smoking rates• Eliminate smoking in future pregnancies

Smokers Want to Quit

• 70% of tobacco users report wanting to quit• Most have made at least one quit attempt• Tobacco users cite health expert advice as important

• Regardless of type of provider! THIS MEANS YOU!

Artwork by Aishani S. © 2013 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2013 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

But… few adults are “Ready to Quit” in the next 30 days

• You can help these patients and/or family members as well!– Promoting awareness of the risks of smoking to the patient and

family member, and the importance of quitting for complete protection creates tension…

– You can recommend cessation medications and referral to state quitline services

So What To Do?• Ask the RIGHT questions.

• SUPPORT patients and family members in what they are already doing to protect their health and their family’s health, and HELP them move them toward greater protection.– Start from where THEY are, and not from where you want

them to be…– We have more to offer than just telling them to quit.– Help parents get the information to the smokers.

The 5 As

Assess readiness to quit

Ask about tobacco use and secondhand smoke exposure

Advise to quit

Assist in quit attempt

Arrange follow-up

The 5 As

AssessAssess

AskAsk

AdviseAdvise

AssistAssist

ArrangeArrange

AskAsk

AdviseAdvise

ReferRefer

“2As & R”

Ask patients and family members about tobacco use and

rules about smoking in the home and car

Every year, ask patients and families:

“Does any member of the household use tobacco?”

Step One: Ask

Step One: Ask

If the patient or family member you’re speaking with usestobacco.. ask if they are:

– Interested in quitting?– Would they like a medication to help

them quit?– Want to be enrolled in the free

quitline?

Step One: Ask

If the patient or family members you’re speaking with uses tobacco but says NO, ask if they are:

– Interested in help to maintain a completely smoke free home and car?

– Would they like medication to help them avoid smoking or to reduce smoking?

• Use the responses on Step One to guide how you assist with addressing tobacco use.

• Ways to approach:• “Quitting smoking is the best thing you can do to help protect

your health and the health of your family.”• “I can help you.”

• Assess interest in quitting• Set a quit date in the next 30 days• Prescribe or recommend medication for assisting quit• Enroll in Quitline

• Document services delivered to enhance complexity of visit to level 4

Step Two: Assist

Refer families who use tobacco to outside help

• Use your state’s “fax to quit” quitline enrollment form

• Arrange follow-up with tobacco users

• Record in the patient’s medical record

Step Three: Refer

But How?• Include all the parts that make the practice run

• Staff, clinical and administrative

• Records, paper and electronic

• Rooms, hallways, waiting rooms

• Resources in the community and beyond

Be Thoughtful In Your Implementation

• Understand the current system

• Research the areas most in need of change in your practice

• Start with the end in mind…how do you want your system to function?

Team Involvement Is CRITICAL

• Involve your staff early!

• First meet with key staff, then invite participation by staff at all levels

• Be sure to include:• Front desk

• Nursing and clinical staff

• Administration

Get Input

• Brainstorm about implementation and barriers

• Invite ideas on logistics of asking and advising

• Consider developing implementation plans, using quality improvement processes

www.aap.org/richmondcenter

Need more information?

American Academy of PediatricsJulius B. Richmond Center of Excellence

Audience-Specific Resources State-Specific Resources

Cessation InformationCoding & Payment InformationTobacco Control E-mail Lists

Clinical Practice Change Resources

American Lung Associationwww.lung.org/cessationta