Do Not Smoke

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For Who?		By Whom?^b	How Often?
Empowerment
All	Educate all on harms of tobacco smoking, including cigarette, e-cigarette, waterpipe, and second-hand smoke¹	Primary Healthcare Providers	Opportunistically
Smokers who are planning for pregnancy, or are pregnant	Provide messages of the significant maternal and perinatal risks associated with tobacco use² + Offer referral to a cessation service	Primary Healthcare Providers	Opportunistically and At each antenatal visit
Assessment
All smokers	Assess (Table 1.): (1) Smoking habit³	Trained Healthcare Professionals	Opportunistically
	(2) Readiness to quit³
Management
Non-pregnant smokers who are *Not Ready* to quit	Motivate to make a quit attempt by (1) Brief Interventions¹ 5R’s intervention (Table 2.) (Relevance, Risk, Rewards, Roadblocks, and Repetition)	Trained Healthcare Professionals	At every visit
	OR (2) Motivational Interviewing
Smokers who are *Ready* to quit	Offer counselling (Table 1.):	Trained Healthcare Professionals	At every visit
	+ pharmacotherapy such as: Nicotine replacement therapy^@ (“NRT”, including patch, gum and lozenge), or Varenicline^{^4}	^@Pharmacists ^Doctors
	+ Offer referral to a cessation service

1. Empowerment

a. For Who: All

Recommended Care Components^a:

                                            Educate all on harms of tobacco smoking, including cigarette, e-cigarette, waterpipe, and second-hand smoke1
                                        

By Whom^b: Primary Healthcare Providers

How Often: Opportunistically

b. For Who: Smokers who are planning for pregnancy, or are pregnant

Recommended Care Components^a:

                                            Provide messages of the significant maternal and perinatal risks associated with tobacco use2

                                        + Offer referral to a cessation service

By Whom^b: Primary Healthcare Providers

How Often: Opportunistically and At each antenatal visit

2. Assessment

a. For Who: All smokers

Recommended Care Components^a:

Assess (Table 1.):
(1) Smoking habit³

Assess (Table 1.):
(2) Readiness to quit³

By Whom^b: Trained Healthcare Professionals

How Often: Opportunistically

3. Management

a. For Who: Non-pregnant smokers who are Not Ready to quit

Recommended Care Components^a:

Motivate to make a quit attempt by
(1) Brief Interventions¹

5R’s intervention (Table 2.)
(Relevance, Risk, Rewards, Roadblocks, and Repetition)

                                            OR

                                            (2)	Motivational Interviewing

By Whom^b: Trained Healthcare Professionals

How Often: At every visit

b. For Who: Smokers who are Ready to quit

Recommended Care Components^a:

Offer counselling (Table 1.):

+ pharmacotherapy such as:

Nicotine replacement therapy^@ (“NRT”, including patch, gum and lozenge), or
Varenicline^{^4}

+ Offer referral to a cessation service

By Whom^b: Trained Healthcare Professionals / ^@Pharmacists / ^Doctors

How Often: At every visit

5R = Relevance, Risk, Rewards, Roadblocks, and Repetition; NRT = Nicotine Replacement Therapy

^a	Grade of recommendation according to colour code: Recommended (Strong) Conditionally recommended Practice points Generally not recommended Not recommended (Strong)

Primary Healthcare Providers – All providers of health services in primary healthcare settings
Primary Healthcare Professionals – Includes doctors, dentists, chinese medicine practitioners, nurses, pharmacists, physiotherapist, occupational therapist, dietitians
“Trained” Healthcare Professionals – Additional post-qualification training required to deliver the respective care component(s)

Table 1. 5A’s Model⁵

The 5A’s model (Ask, Advise, Assess, Assist, and Arrange) can be applied to assess smokers’ readiness to quit, and assist smokers who are ready to quit.

Ask	Ask ALL patients at each consultation about their smoking status, daily consumption and years of smoking, and record the information accordingly Include smoking status of the patient as one of the vital signs and record such information prominently
Advise	Convince the patient to quit smoking with a clear, personalised and strong manner, e.g. “Quitting smoking is the most important thing you can do to protect your health”, “Quitting smoking can delay the progression of COPD”
Assess	Assess each patient’s desire and readiness to quit Would you like to quit smoking? Do you think you have a chance of quitting successfully? If answer to either question is YES, can move on to the next step “Assist” If answer to both question is NO, or if patient is unsure if they want to quit smoking, can deliver 5R’s intervention
Assist	Work out with the patient on the smoking cessation plan, e.g. set a quit day and encourage the patient to tell family members, colleagues and friends to enlist their support and encouragement Provide appropriate techniques on problem solving and give advice for successful quitting Recommend the use of pharmacotherapy for smoking cessation and assist in making referral Provide relevant smoking cessation information such as pamphlets or quit-line card
Arrange	Work out with the patient on follow-up schedule and approaches such as interviews and telephone calls Recognise the efforts of those who have successfully remained tobacco-free, and remind those who are still unable to kick the habit to regard occasional “slips” as an alert If a relapse occurs, encourage the client to repeat quit attempt and review cause of relapse

COPD = Chronic Obstructive Pulmonary Disease

Table 2. 5R’s Model⁵

The 5R’s intervention (Relevance, Risk, Rewards, Roadblocks, and Repetition) can be delivered to those who are not ready to quit tobacco.

Relevance	Get the patient to understand why his/ her quitting is relevant to him/ her personally and to the people around
Risk	Guide the patient to identify potential negative consequences of tobacco use that are relevant to him/ her
Rewards	Get the patient to understand the personally relevant benefits brought about by smoking cessation
Roadblocks	Guide the patient to assess various barriers to quitting, e.g. experience of withdrawal symptoms or fear of repeated failure, and provide counselling accordingly
Repetition	Make good use of every contact opportunity by repeating motivational intervention

Further Readings Reference Materials for Healthcare Professionals Education and Self-Help Materials for the General Public References