Nurses’ Role with
Clients/Patients
Who Use Tobacco
Created by the Registered Nurses’
Association of Ontario
RNAO BPG “Integrating Smoking
Cessation into Daily Nursing Practice”

Practice Recommendations:
1.
2.
3.
4.
5.
6.
7.
Nurses implement minimal smoking cessation
intervention (4As) with all clients.
Nurses introduce intensive smoking cessation intervention
(more than 10 minutes duration) when possible.
Nurses recognize possibility of relapse and need to reengage clients in the smoking cessation process.
Nurses should be knowledgeable about community
smoking cessation resources, for referral and follow-up.
Nurses implement smoking cessation interventions and
tailor strategies to the diverse needs of populations.
Nurses implement, wherever possible, intensive
intervention with women who are pregnant and
postpartum.
Nurses encourage people to make their homes smokefree, to protect from exposure to second-hand smoke.
Role of Nurses & Nursing Students
with clients/patients who use tobacco

Key intervention:
◦ Introduce topic with a question
 Comfortable, non-judgmental, not coercive
◦ Use reflective practice with answers
◦ Offer assistance when the smoker is ready to quit
◦ Offer advice and guidance in choosing cessation
method
◦ Support the quitting process


Nursing students can act as peer-to-peer
counselors
Provide self-help material
4As vs. 5As protocol
4As Protocol: Minimal Tobacco Intervention
 1-3 minutes in duration
Ask
Ask every client/patient if they use tobacco.
“Have you used any form of tobacco in the past six
months?”
Document tobacco use status (ie. Non-smoker, smoker,
ex-smoker)
Advise
Advise every tobacco user of the importance of quitting.
“I am concerned about how smoking is affecting your
health. Have you thought about quitting?”
Assist
Assist the smoker to quit by providing appropriate selfhelp materials and referrals.
Arrange Arrange a follow-up or referral appointment to discuss
quitting.
4As vs. 5As protocol
5As Protocol: Intensive Tobacco Intervention
 Over 10 minutes in duration
Ask
Advise
Same protocol as for 4As
Assess
Assess nicotine dependence level and readiness to quit.
Review the client/patient’s quitting history.
Assist
Assist the smoker with the choice of:
- quit date
- cessation method
- general quitting plan
This can involve providing self-help material and
possibly prescriptions.
Arrange Arrange for follow-up visit(s)
- on quit day & afterwards
Stages of Change Theory

Originally developed in the late 1970's & early
1980's by James Prochaska and Carlo DiClemente
at the University of Rhode Island

Views behaviour change as a dynamic process

Applied to a broad range of behaviours
• smoking cessation
• weight loss
• injury prevention etc.
Basic Premise
of Stages of Change Theory

People quit smoking by progressing through a
series of five successive stages

People in each stage differ from those in other
stages in important ways (dynamic)

Stages reflect how we plan, deliver and evaluate
smoking cessation interventions.
Stages of Change Model
Pre-Contemplation
Unaware or unwilling to change
 Not thinking of quitting in the next 6 months
 Spend little time thinking about smoking
 May not see it as a problem

Goal:
• To help the client/patient begin to think seriously about
quitting

What to do:
◦ Ask regarding feelings about smoking
◦ Ask about pros and possible cons of smoking
◦ Advise by offering quitting information & assistance at
any time
Contemplation



Thinking about smoking
May be thinking about quitting within 6 months
Feel ambivalent about taking the next step
Goal:
• To help smoker move towards a decision to stop smoking
• To help the client/patient feel more confident

What to do:
• Ask about pros and possible cons of smoking (decision
balance)
• Acknowledge ambivalent feelings
• Assist by reinforcing reasons for change & exploring
new ones
• Suggest they cut back or stop for a day
• Assist by offering a future visit and information
Preparation



Getting ready to stop within the next 30 days
Have set a stop smoking date
Have made a 24-hour quit attempt in the last 12
months
Goal:
• To help the smoker prepare for an anticipate positively a
quit date

What to do:
• Ask about concerns, preparations and lessons learned
from previous attempts
• Advise by identifying barriers to stopping and elicit
solutions
• Assist by Booklet, Action Plan, Nicotine Replacement,
Date for quitting (BAND)
Action
Have quit smoking within the past 6 months
 May try several different techniques
 Are at greatest risk of relapse

Goal:
• To help client/patient stay off tobacco products and
recover from relapses

What to do:
• Ask how the client is doing: relapses, temptations,
successes, NRT use
• Advise re: relapse prevention, weight gain, triggers
• Assist by focusing on successes, encourage self rewards
and increase support, elicit solutions for problems
Maintenance


Have quit for more than 6 months
Integrating smoke-free living into their
routine
Goal:
• To help the client/patient remain smoke-free for a life
time

What to do:
• Ask how the client is doing: risk situations, relapses
• Assist by offering suggestions for difficult times,
support, encouragement
• Congratulate!
The Cycle of Change

Most smokers will cycle through the
stages 3-4 times before quitting for life

Each attempt offers new learning
opportunities

Relapse is a normal event in the process
of making behavioural change
Motivational Interviewing
for health behaviour change
Designed to take 3 – 5 minutes per
session
 Psychosocial or socio-behavioural
approach (rather than biomedical)
 Focused, goal directed, client-centred
councelling style
 Aimed at eliciting behaviour change by
helping clients explore and resolve
ambivalence

5 Principles
(Counselling Techniques)
1.
2.
3.
4.
5.
Express Empathy
Avoid Arguments
Develop Discrepancy (Dissonance)
Roll with Resistance
Support Self-efficacy
6 General Skills
for Motivational Interviewing
1.
2.
3.
4.
5.
6.
Asking Open-ended Questions
Reflective Listening
Affirmations
Summarizing or Reframing
Self-motivational Statements
Personalized Feedback

See the guideline Appendix G for a detailed
description of the motivational interviewing
process
Referrals to Community for
Cessation Support

Communities vary in the amount of
cessation support resources they have
based on size, location, etc.
◦ Most communities offer cessation support through
their local public health department

Other resources are more consistently available
for clients/patients who are trying to quit
smoking
• Self help booklets & resources
• Online resources