Smoking Cessation and Brief Intervention

Original Editor - Lizzie White

Top Contributors - Kim Jackson, Vidya Acharya and Laura Ritchie  


Although smoking cigarettes is on the decline in the UK population, there has been no decline since 2010, as 20% of adults still are smokers[1]. Smoking contributes/causes many health issues, practically affecting every organ system and causing severe damage to the respiratory and cardiovascular systems[2]. In 2011/12, it was estimated that 5% of all hospital admissions for adults over 35 years old, were related to smoking[3] and smoking accounts for approximately 100,000 deaths a year in the UK, as it is the leading cause of preventable deaths[4]. Stopping smoking increases life-span and has positive effects on the body from 20 minutes of stopping- where the pulse returns to normal, up to 15 years- where the risk of heart disease is that of someone who has never smoked[5]. Apart from affecting health, smoking is having a great impact financially. In 2011/12 the government spent £154.6 million on stop smoking medication and services[6]. These statistics clearly show that some intervention is needed; this essay aims to discuss how brief interventions (BI) can impact the percentage of smokers.

Cigarette smoking is a major preventable cause of morbidity and mortality. It is the major risk factor for chronic obstructive pulmonary disease in the developed world. Smoking is a chronic relapsing disease. Optimal treatment includes nonpharmacologic support, together with pharmacotherapy[7].

Brief Interventions

Simmons et al[8] describe Brief Interventions as the 5A’s model; ask, advise, assess, assist and arrange.

  1. Ask all patients whether they smoke,
  2. Advise the smokers to quit,
  3. Assess willingness to quit,
  4. Assist with quitting treatment/referrals and
  5. Arrange follow-up contact.

All staff should implement 5A’s[8].

The National Institute for Health and Clinical Excellence[9], supports Simmons et al[8] by stating that Brief Intervention consists of one or more of the following aspects:-

  • simple opportunistic advice to stop,
  • patient commitment to quit assessment,
  • an offer of behavioural or pharmacotherapy,
  • self-help material/referral to intensive support.

NICE[9] also states that BI usually takes between 5 and 10 minutes. Evidence shows that BI of 3 minutes can be effective[10]. BI often occurs through one or a small number of encounters, unlike other methods of smoking cessation such as intensive intervention, consisting of multiple counselling sessions[11]. Therefore, BI could be used by healthcare professionals (HCPs) who see a lot of patients in a short period of time[11].

As identified by Hjalmarson & Boëthius[12], refusal rates were lower for BI than extended counselling, suggesting extended treatment was less favourable to patients. After a 1 year follow up Hjalmarson & Boëthius[12] found that there was an inconsequential difference of smoking cessation for in-patients who received BI and those who received extended counselling. Both interventions used 5A’s model but extended counselling consisted of more sessions. Therefore, this study could conclude that BI is a more effective way of HCPs spending their time to implement smoking cessation as patients are more willing to participate, it is more time effective for HCPs and there is not a significant difference on smoking cessations rates between BI and extended counselling. A strength of the study undertaken by Hjalmarson & Boëthius[12] is that the follow-up date to determine cessation rates was one year. Relapse is most common in the period immediately after cessation and as abstinence increases, risk of relapse decreases[13]. The sample size of 770 smokers in Hjalmarson & Boëthius[12] is another strength of the study because there would be a variety of different people, some may have smoked for a year where others may have smoked for over ten years. It would be interesting to see whether the longer term smokers had the same cessation rate as smokers who may not have been smoking as long.

TUDCPGP[10]recommend all clinicians are trained effective BI strategies because the goal is to ensure that every patient who smokes is offered BI at each visit. An et al[14] found that the odds of recent quitting did not significantly increase with BI by one type of HCP. However, being asked by two or more types of HCP did show a substantial recent quitting increase and were more likely to make an attempt to quit. An et al[14] did not provide details of whether the BI occurred before or after patients recently quit, which could mean that one type of HCP’s BI impacted on the decision of the individual and the second was after their decision to quit. A weakness of An et al[14] is that the total number of visits within a type of HCP was not recorded, effectively a nurse could have visited five times, used BI upon every visit and a doctor may have used BI five times on the same patient. Therefore this study cannot make a conclusion on how many times BI should be used. An et al[14] found that advice from more than one type of HCP was uncommon and 37.2% of current smokers who had visited a HCP received no advice to quit. Although An et al[14] did not explore why the patient didn’t receive advice to quit, one possibility is lack of knowledge of the HCP. Raupach et al[15] states that over 90% of medical students thought smokers should be advised to quit, despite their lack of knowledge about cessation methods and approximately only a quarter felt competent to counsel smokers. Although the study Raupach et al[15] was student orientated the findings were consistent over different stages of medical education and showed students lacked relevant information.

Puschel et al[16] conducted a study which compared three groups, one intervention group and two control groups. All three groups received BI in the form of ask, advise and assess. The intervention group (Group A) received an additional smoking cessation programme where motivational discussion was the main strategy for assisting and arranging follow ups. There was two control groups, the first (Group B) had no specific cessation programme and the second (Group C) implemented a new cardiovascular programme where patients with cardiovascular risk factors were advised to quit smoking. Puschel et al., (2008) found that there was no significant difference of smoking cessation rates between groups A and C, however, there was a difference between both control groups, C had a higher cessation rate than B. The cohort of group C was of a higher socioeconomic status than A and B, but post intervention adjustments for this showed no change of results.

The difference between the control groups was the cardiovascular programme implemented in C, however, only cardiovascular risk patients were involved in this. The cardiovascular programme involved advising the patient to quit smoking, which was a part of the BI that all three groups had at the beginning of the study. Due to group C having a much higher cessation rate than group B, cessation could be related to repetition of advising the patient to quit. There is however, the possibility of the Hawthorne/observer effect where subjects modify their behaviour because they know they are being studied, meaning that any positive action (like the cardiovascular programme) has an impact[17]. Due to all three groups having initial BI, the Hawthorne effect may not be a cogent consideration.

Puschel et al[16] found that there was no difference between A and C which could suggest that the first three steps of the 5A approach, ask, advise and assess and repetition of these steps is just as effective as ask, advise, assess, assist and arrange.
Although Puschel et al[16] only studied Chilean women, Chile has a very high smoking rate and low cessation rate, so this study did not limit itself by studying such a specific population. A strength of Puschel et al[16] was that no pharmaceutical treatment was provided, which increases the assumption that BI was the cause of cessation. Another strength was that the knowledge and beliefs of smoking were assessed in all three groups and no significant difference was found, suggesting that one group was not more likely to quit due to knowledge of risks of smoking. However, a limitation of the study by Puschel et al[16] is that the smoking assessment period was only 1-3 months, meaning that information on long term differences was not available.

Clinical Application

A physiotherapist treats a lot of patients with Coronary Artery Bypass Graft (CABG). CABG is needed when the coronary arteries become blocked due to atherosclerosis[18]. Smoking is a risk factor for atherosclerosis[18] therefore it is vital patients receive BI to make them aware and advise them to quit smoking to prevent the build-up of atheroma, which should decrease the chance of further blockages.

As part of the subjective assessment, smoking status needs to be recorded by the physiotherapist. When assessing a smoker, consideration is needed when asking questions about normal sputum production and cough. The physiotherapist can advise the patient to stop smoking and make them aware of the disadvantages of smoking. The patients must be encouraged to quit smoking. for the recent quitters, their efforts should be appreciated and further follow up should be arranged with the nurse as it is difficult to keep track of the discharged patient


In conclusion, it is clear that Brief Intervention (BI) by more than one type of HCP increases smoking cessation and attempts to quit[14]. It has also been suggested that repeated BI consisting of ask, advise and assist is as effective as the full 5A’s model[16]. Therefore, if every HCP used BI in their subjective assessment of their patient, repetition of ask, advise and assist would occur as well as the patient being informed by more than one type of HCP. Evidence suggests that these two changes combined could have an impact on increasing smoking cessation and quit attempts. It has been found that there was no significant difference of smoking cessation rates between BI and extended counselling and patients are more willing to participate in BI lasting a few minutes, rather than extended counselling which lasts longer, as refusal rates were higher in the study by Hjalmarson & Boëthius[12]. TUDCPGP[10] state that BI advice to quit can increase smoking cessation and in the author’s opinion from clinical practice and reviewing the literature, they agree with the TUDCPGP[10] statement.


  1. Action on Smoking and Health. (2013c). Smoking Statistics- Who smokes and How Much. Action on Smoking and Health. Available from- [Accessed: 05/11/13].
  2. Hough, A. (2001). Physiotherapy in Respiratory Care. Third Edition. Cheltenham: Nelson Thornes Ltd.
  3. Lifestyle Statistics, Health and Social Care Information Centre. (2013). Statistics on Smoking: England, 2013. Health and Social Care Information Centre. Available from- [Accessed: 05/11/13].
  4. Action on Smoking and Health. (2013b). Smoking Statistics- Illness and Death. Action on Smoking and Health. Available from- [Accessed: 05/11/13].
  5. Action on Smoking and Health. (2013d).Stopping Smoking- The benefits and aids to quitting. Action on Smoking and Health. Available from- [Accessed: 05/11/13].
  6. Action on Smoking and Health. (2013a). Smoking Statistics. Action on Smoking and Health. Available from- [Accessed: 05/11/13].
  7. Rennard SI, Daughton DM. Smoking cessation. Clinics in chest medicine. 2014 Mar 1;35(1):165-76.
  8. 8.0 8.1 8.2 Simmons, V. N., Litvin, E. B., Unrod, M., Brandon, T. H. (2012). Oncology healthcare providers’ implementation of the 5A’s model of brief intervention for smoking cessation: Patients’ perceptions. Patient Education and Counselling. [Online]. 86. P 414-419. Available from- [Accessed: 12/11/13].
  9. 9.0 9.1 National Institute for Health and Clinical Excellence. (2006). Brief interventions and referral for smoking cessation in primary care and other settings- Quick reference guide. London: National Institute for Health and Clinical Excellence. Available from- [Accessed: 12/11/13].
  10. 10.0 10.1 10.2 10.3 The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. (2000). A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. Journal of the American Medical Association. [Online]. 283. (24). P 3244-3254. Available from- [Accessed: 05/12/13].
  11. 11.0 11.1 Cofta-Woerpel, L., Wright, K. L., Wetter, D. W. (2007). Smoking Cessation 3: Multicomponent Interventions. Behavioral Medicine. [Online]. 32. P 135-149. Available from- [Accessed: 17/11/13].
  12. 12.0 12.1 12.2 12.3 12.4 Hjalmarson, A., Boëthius, G. (2007). The effectiveness of brief advice and extended smoking cessation counselling programs when implemented routine in hospitals. Preventive Medicine. [Online]. 45. P 202-207. Available from- [Accessed: 17/11/13].
  13. Hughes, J. R., Keely, J., Naud, S. (2004). Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. [Online]. 99. (1). P 29–38. Available from- [Accessed 21/11/13].
  14. 14.0 14.1 14.2 14.3 14.4 14.5 An, L. C., Foldes, S. S., Alesci, N. L., Bluhm, J. H., Bland, P. C., Davern, M. E., Schillo, B. A., Ahluwalia, J. S., Manley, M. W. (2008). The Impact of Smoking-Cessation Intervention by Multiple Health Professionals. American Journal of Preventive Medicine. [Online]. 34. (1). P 54-59. Available from- [Accessed: 17/11/13].
  15. 15.0 15.1 Raupach, T., Shahab, L., Baetzing, S., Hoffmann, B., Hasenfuss, G., West, R., Andreas, S. (2009). Medical students lack basic knowledge about smoking: Findings from two European medical schools. Nicotine and Tobacco Research. [Online]. 11. (1). P 92-98. Available from- [Accessed: 17/11/13].
  16. 16.0 16.1 16.2 16.3 16.4 16.5 Puschel, K., Thompson, B., Coronado G., Huang, Y., Gonzalez, L., Rivera, S. (2008). Effectiveness of a brief intervention based on the “5A” model for smoking cessation at the primary care level in Santiago, Chile. Health Promotion International. [Online]. 23. (3). P 240-250. Available from- [Accessed: 29/11/13].
  17. Parsons, H., M. (1974). What happened at Hawthorne? Science. [Online]. 183. (4128). P 922–932. Available from- [Accessed: 05/12/13].
  18. 18.0 18.1 Lilly, L. S. (2011). Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty. [Online]. Philadelphia: Lippincott Williams & Wilkins. Available from- . [Accessed: 26/11/13].