THE 5 As

From Treating Tobacco Use and Dependence Practice

Guideline by the U.S. Dept. of Health and Human
Services, Public Health Service (USPHS), 2000
THE 5 Rs MOTIVATIONAL TECHNIQUES
From the USPHS Tobacco Guideline, 2000



A HEALTHCARE
Relevance
Health of the smoker
Health of others (second-hand smoke
affects adults and children)
Costs of smoking
Social/environmental pressure
Personal commitment and control
Risks
2x greater risk of stroke
6x greater risk of oral cancer
10x greater risk of larynx cancer and COPD
12x greater risk of lung cancer and CAD
Rewards
IMMEDIATE = within minutes to several
weeks, B/P decreases, CO level decreases,
O2 level increases
IMMEDIATE = within months to 1 year,
respiratory congestion and infections
decrease; after 1 year, excess risk of CAD
reduced to half of a smoker
LONG-TERM = after 5 years, lung cancer
death rate decreases by almost half; after
5 years, risk of upper airway and
esophageal cancer is half of a
smoker; after 510 years, stroke risk is
reduced to that of a nonsmoker;
after 10 years, lung cancer death rate
similar to a nonsmoker; after 15 years,
risk of CAD is that of a nonsmoker
Roadblocks
Triggers to smoke
Concern for nicotine withdrawal
Concern for weight gain
Relapse
Repetition
The 5 As and 5 Rs must be repeated at
each healthcare setting visit
Incident of relapse is high (only 2% are
successful at 1 year quit date)
It takes multiple attempts (711) to quit
before becoming successful
Counseling and pharmacological
treatment increases success to 2025%
at 1 year quit date
PROVIDERS EVIDENCE-
BASED GUIDE



TO SUCCESSFUL
TOBACCO CESSATION
INTERVENTIONS


Offered by the
Nurses for Tobacco
Control Coalition





FOR MORE INFORMATION,
FAGERSTROM TEST FOR NICOTINE DEPENDENCE (ADULTS) Visit www.nurses4tobaccocontrol.org
1) How soon after you wake up do you
smoke your first cigarette?
Within 5 minutes = 3
630 minutes = 2
3160 minutes = 1
After 60 minutes = 0
2) Do you find it difficult to refrain from
smoking in the places where it is forbidden
(e.g., in church, at the library, in cinema)?
Yes = 1 No = 0
3) Which cigarette would you hate most to
give up?
The first one in the morning = 1
Any other = 0
4) How many cigarettes/day do you
smoke?
< 10 = 0 2130 = 2
1120 = 1 > 31 = 3
5) Do you smoke more frequently during
the first hours after waking than during
the rest of the day?
Yes = 1 No = 0
6) Do you smoke if you are so ill that you
are in bed most of the day?
Yes = 1 No = 0

TOTAL (higher scores indicate higher levels
of dependence, e.g. > 5)



HELP YOUR PATIENTS TAKE CONTROL
Refer to 1-800-QUIT NOW
ITS FAST, ITS EASY, IT WORKS
PHARMACOLOGIC PRODUCT GUIDE: FIRST-LINE RECOMMENDATIONS
Avg. wholesale price from
2006 Drug Topics Redbook
Modified from the Rx for Change: Clinician Assisted Tobacco Cessation Curriculum
The University of Virginia, University of Arkansas for Medical Sciences
and University of South Carolina Initiative For complete guide, visit
www.rxforchange.ucsf.edu
Nicotine Gum Nicotine Lozenge Nicotine Patch Nicotine Nicotine Buproprion SR Varenicline
PRODUCTS: PRODUCT: PRODUCTS:
Nasal Spray Oral Inhaler PRODUCT: PRODUCT:
Nicorette
1

2 mg, 4 mg; regular, mint, orange, fruit chill
Generic
2 mg, 4 mg
PRECAUTIONS:
pregnancy (Category D), recent (< 2 weeks) MI,
unstable angina, serious underlying
arrhythmias, TMJ disease, difficult to use with
dentures
DOSING:
25 cigarettes/day = 4 mg
< 25 cigarettes/day = 2 mg MAXIMUM
gum/day = 24 pieces Chew slowly 1
piece every 12 hours Park between
cheek and gum when taste/tingling
sensation appears (~15 chews)
Resume chewing when taste/tingling fades
Repeat steps until taste/tingling gone
(~30 minutes)
NO food/beverage 15 minutes prior or
during GUM use
Duration usually 12 weekstaper off as
appropriate
POSSIBLE ADVERSE EFFECTS:
mouth/jaw soreness, hiccups, dyspepsia,
if incorrect chewing = lightheadedness,
n/v, throat and mouth irritation
COST:
2 mg = $2.65$5.16 (9 pieces)
4 mg = $3.18$5.81 (9 pieces)
Most packages = 2 week supply
Commit
1

2 mg, 4 mg; regular, mint
PRECAUTIONS:
pregnancy (Category D), recent (< 2 weeks) MI,
unstable angina, serious underlying arrhythmias
DOSING:
1st cigarette = > 30 minutes after waking
= 2 mg
1st cigarette = 30 minutes after waking
= 4 mg
MAXIMUM lozenge/day = 20 lozenges
Dissolve slowly 1 piece every 12 hours
Dissolves completely ~30 minutes
Occasionally rotate lozenge to different areas
of the mouth
Do NOT chew or swallow the lozenge
NO food/beverage 15 minutes prior or
during lozenge use
Duration usually 12 weekstaper off
as appropriate
POSSIBLE ADVERSE EFFECTS:
hiccups, dyspepsia, if incorrect dissolving =
lightheadedness, n/v, throat and mouth
irritation
COST:
2 mg = $4.92 (9 pieces)
4 mg = $5.26 (9 pieces)
Most packages = 2 week supply
a) Nicoderm CQ Patch
1

7 mg, 14 mg, 21 mg (24 hour)
b) Generic Patch
formerly Habitrol
7 mg, 14 mg, 21 mg (16 hour)
PRECAUTIONS:
pregnancy (Category D), recent
(< 2 weeks) MI, unstable angina,
serious underlying arrhythmias,
acute and/chronic skin disorders
DOSING:
> 10 cigarettes/day = highest
mg/day x 6 weeks; taper to
medium mg/day x 2 weeks; taper
to lowest mg/day x 2 weeks
10 cigarettes/day = not
recommended for Nicotine Patch;
all other patches start with
medium mg/day x 6 weeks; taper
to lowest mg/day x 2 weeks
Apply patch to upper body over
non-hairy area
Remove patch at bedtime
If experience sleep disturbance
may remove 24 hour patch at
bedtime
May shower with patch
Do not cut patch in half
POSSIBLE ADVERSE EFFECTS:
local skin reactions (erythema,
pruritus, burning), headache
COST:
Nicoderm = $3.35$3.91 (1 patch)
Generic = $2.10$2.94 (1 patch)
PRODUCT:
Nicotrol Nasal Spray
2
metered spray (0.5 mg
nicotine in 50 ul aqueous
nicotine solution);
each bottle contains
~100 doses or 1 week supply
PRECAUTIONS:
pregnancy (Category D),
recent (< 2 weeks) MI,
unstable angina, serious
underlying arrhythmias,
underlying chronic nasal
disorders (rhinitis, nasal polyps,
sinusitis), severe reactive
airway disease
DOSING:
12 doses/hour
ONE dose = 2 sprays (one in
each nostril); each spray =
0.5 mg of nicotine
MAXIMUM spray = 5 doses/
hour or 40 doses/day
Do NOT sniff, swallow, or
inhale through the nostril
Tilt head back and spray
Initially use at least
8 doses/day
Duration usually
36 months
taper off as appropriate
POSSIBLE ADVERSE
EFFECTS:
nasal and/or throat irritation,
PRODUCT:
Nicotrol Inhaler
2

10 mg cartridge delivers
4 mg inhaled nicotine vapor
PRECAUTIONS:
pregnancy (Category D),
recent (< 2 weeks) MI,
unstable angina, serious
underlying arrhythmias,
underlying reactive airway
disease
DOSING:
616 cartridges/day
MAXIMUM dose =
16 cartridges/day
Initially use
6 cartridges/day
Do NOT inhale into lungs
Puff as if lighting a
cigar/pipe
Best effects with
continuous puffing
x 20 minutes
Cartridge is depleted after
~20 minutes of active
puffing
Each cartridge retains
potency x 24 hours
Duration usually
6 months
POSSIBLE ADVERSE
EFFECTS:
nasal and/or throat irritation,
unpleasant taste, hiccups,
Zyban
1

150 mg sustained released tablet
PRECAUTIONS:
pregnancy (Category B), concomitant therapy
with meds known to lower the seizure threshold
(e.g., antipsychotic/depressants, theophylline,
lithium, etc.)
CONTRAINDICATIONS:
Hx of seizure
Hx of bulimia or anorexia nervosa
MAO inhibitor inprevious 14 days
Concomitant use of bupropion
Abrupt discontinuation of alcohol or
sedatives
DOSING:
150 mg
Set QUIT date; start med 12 weeks prior
Initially 150 mg every AM for 3 days;
then 150 mg BID
MAXIMUM dose = 300 mg/day
Allow at least 8 hours between doses
Avoid HS dosing
Can be used safely with NRT products
Duration usually 6 months for maintenance;
tapering NOT necessary
POSSIBLE ADVERSE EFFECTS:
insomnia, dry mouth, nervousness/difficulty
concentrating, rash, constipation, seizure risk
(1/1000 or 0.1%)
COST:
$3.62$5.73 for 2 tablets
Chantix
2

0.5 mg, 1 mg tablet
PRECAUTIONS:
Pregnancy (Category C), severe renal
impairment (dosage adjustment is necessary)
DOSING:
Days 13: 0.5 mg po q AM
Days 47: 0.5 mg po bid
Weeks 212: 1 mg po bid
Patients should begin therapy 1 week prior
to quit date
Take dose after eating with a full glass of
water
Dose tapering is not necessary
Nausea and insomnia are side effects that are
usually temporary
Duration 12 weeks; an additional 12 week
course may be used in selected patients
POSSIBLE ADVERSE EFFECTS:
nausea, sleep disturbances (insomnia, abnormal
dreams), constipation, flatulence, vomiting
COST:
$4.00$4.22 for 2 tablets
Most packages = 2 week supply rhinitis, tearing, sneezing, rhinitis, tearing, sneezing,

THE CDC REPORTS THAT, IN THE U.S.
46 million adults smoke . . . ~430,000 adult deaths occur per year related to smoking . . .
50,000 deaths occur per year related to second-hand smoke . . . smoking costs the U.S.
~$157.7 billion/year www.cdc.gov/tobacco/sgr
cough, headache
COST:
$3.67 for 8 doses
Most packages =
2 week supply
cough, headache
COST:
$5.25$6.07 for 6 cartridges
Most packages =
2 week supply

1
GlaxoSmithKline
2
Pfizer

NOTE: The Treating Tobacco Use and Dependence Practice Guidelines by the
U.S. Department of Health and Human Services, Public Health Service (2000)
recommend combination therapy (counseling, nicotine replacement
therapy, and buproprion SR) to increase the rate of success with tobacco
cessation.Varenicline is recommended as monotherapy with counseling.