As we have learned from the previous module, tobacco dependence is a complex behavioral condition

that involves biological, psychological and sociocultural influences. This is why it is as expected that not
everyone who uses tobacco is ready to quit. Most tobacco users have tried to quit at one time or another
while some have tried multiple times. Research shows that at any given time about 20% of tobacco users
are ready to quit while 40% are thinking about quitting, and another 40% are not ready to quit (Prochaska
and Velicer, 1997).

With tobacco users having varying dispositions on their readiness to quit, it is helpful to know how ready
a person is to quit when intervening, so that you can:

 Give the right help. There are ways to be helpful even with people who are not ready to quit.
 Be efficient and effective. Spend time on those who are ready to quit and less on those who are not.

READINESS TO CHANGE MODEL

The Readiness to Change Model, as shown in Figure 2.1, (Prochaska and Velicer, 1997; Health Partners
Limited Liability Corporation, 2011) is a simple method used to identify a person’s readiness to quit using
tobacco. The model proposes that the change process between a smoker who is not ready to quit
smoking to the termination of that behavior is a long process of contemplation, preparation, action and
maintenance. After considering tobacco cessation, a smoker becomes ready to quit and makes specific
plans to stop smoking. After carrying out this plan, the smoker’s task now becomes maintaining tobacco
cessation until the termination of the behavior. It is important to note that a smoker may transcend from
one stage to another and may undergo relapse.

BTI: Module 2. BTI Essentials 1

 Figure 2.1. The Readiness to Change Model (Adapted from Prochaska et al., 1997)

To help you identify at which stage a smoker currently lies, the readiness to change may also be quanti-
fied through a time frame:

Table 2.1. Readiness to Change Timeframe.

Stage Time Frame

1. Not ready to quit Has no intention to quit within the next 6 months

2. Thinking about quitting Intention to quit in the next 6 months

3. Ready to quit Willing to set a quit date within the next 30 days

4. Quitting Stop smoking for less than 6 months

5. Staying quit Remained tobacco-free for more than 6 months

6. Relapse Using tobacco again after a period of being a tobacco-free

THE 5 A’s

The key components of a brief tobacco intervention can be summarized in five words: Ask, Advice, As-
sess, Assist, and Arrange (Figure 2.2). An intervention should be relevant to the person receiving it and
should include both the risks of using tobacco and the rewards of quitting. The brief intervention should
be repeated to encourage tobacco users to quit and allow for changes in their readiness to quit (Fiore et
al., 1996).

BTI: Module 2. BTI Essentials 2

 Figure 2.2. The 5 A’s Approach of Brief Tobacco Intervention

The 5 A’s is a goal-oriented approach to brief tobacco intervention which effectively aims to address
tobacco use among the patients by focusing on their needs based on their readiness to quit. Let’s look at
each of these steps.

The first step in providing brief tobacco intervention is to ASK about tobacco use. This is important in
identifying a patient’s tobacco use and smoking patterns. You have to ask about tobacco use at every
encounter to identify and locate tobacco smokers. Make it a routine. For workplaces, schools and parti-
cularly healthcare settings, it is important to identify tobacco use as part of standard procedures. For
instance, in health facilities, inquiring about tobacco use is part of vital signs like blood pressure.

BTI: Module 2. BTI Essentials 3

Including tobacco cessation education, posters, flip charts, and other visible messages can help prepare
tobacco users for the intervention.

Keep your questions simple, ensuring that you ask in a friendly way and avoid being accusatory:

 “Do you use tobacco?”

 “Does anyone else in your house use tobacco?”

After asking, ADVISE those who use tobacco to quit. Urge every tobacco user to quit in a clear, strong
and personalized manner. Remember the 5 R’s for effective advice:

 Relevant information;
 Emphasis on Risks and
 Rewards – refer to the “Benefits of Quitting” sheet;
 Identification of Roadblocks; and
 Repetition at each encounter.

Tobacco users respond best to advice that is relevant to their health concerns, age, and prior quitting ex-
perience. Customize your advice to fit the person. Tobacco users who complain of a chronic cough can
be advised to quit as a way of improving their lungs. Mothers who smoke might be willing to consider
quitting as a way of helping her child who suffers frequent ear infections. When advising tobacco users
to quit, remember to focus on the risks they associate with tobacco. The risks that seem most relevant to
the person can be highlighted.

The rewards of quitting are also important motivators. Quitting results in immediate and long-term bene-
fits, not only for the tobacco users themselves, but also for their friends, families, and co-workers. The
more relevant benefits of quitting to the tobacco users should be emphasized. A list of risks associated
with tobacco use and benefits of quitting is included in the Tools Section.

Perceived roadblocks may affect the tobacco user’s readiness to quit. Identifying barriers and offering
help to overcome them is effective. Typical barriers include withdrawal symptoms, fear of failure, weight
gain, lack of support, depression, and enjoyment of tobacco.

Repetition promotes effective outcomes. Advice to quit should be repeated every time you intervene with
tobacco users. As long as you are respectful and offer advice as “someone who cares,” most tobacco
users will be willing to listen. Also, you can never know when the “right moment” will happen. Repeat mo-
tivational messages to every tobacco user at each encounter.

BTI: Module 2. BTI Essentials 4

Again, remember to give advice in a clear, strong and personalized manner:

 “As your friend, I need you to know that quitting smoking is the most important thing you can do to
protect your current and future health. If you are thinking of quitting at this time, I can help you get
started.”
 “Ms. Cruz, if you quit smoking now, I’m sure that your child will come less often to the emergency
room for his asthma. If you want to try, I can help you.”
 “Tobacco is very expensive! Right now, you are smoking ___ pack a day. At about Php ____a pack,
you could save almost Php___ a year if you quit.”

The next step is to ASSESS the tobacco user’s willingness to make a quit attempt. You may look back at
the Readiness to Change model. Ask every tobacco user if they are willing to quit at this time or within
the next 30 days. If they are willing, then they are ready to quit and you may proceed to ASSIST the indi-
vidual toward a successful quit attempt. If not willing, provide non-judgmental support and information
to get the person thinking about quitting - “Benefits of Quitting” hand-out. If a member of a particular
population (adolescent, pregnant, racial/ethnic minority), you may provide additional information specific
to that population.

Tobacco users who are willing to make a quit attempt at the time of the encounter need assistance in
developing a Quit Plan. The core components of a Quit Plan include:

1. Setting a quit date;

2. Identifying social support;
3. Providing specific problem-solving suggestions;
4. Giving information about medications;
5. Providing self-help materials; and
6. Referring to intensive services, if appropriate.

We will talk more about the Quit Plan and the guidelines on helping someone create one in module 4.

Remember, tobacco users who are unwilling to consider quitting can also be assisted. Helping someone
prepare to consider quitting is a valuable form of assistance and can be delivered very quickly. It is NOT
necessary (or even helpful) to try to talk to tobacco users who are not ready to quit into quitting. Those
who are unwilling or not ready to make a quit attempt at the time of the intervention may be ready the
next time.

BTI: Module 2. BTI Essentials 5

For those who are unwilling or not ready to make a quit attempt at the time of the intervention, you
should:

 Avoid being judgmental or trying to pressure the tobacco user into quitting.
 Offer self-help materials or literature that emphasizes the benefits of quitting tobacco.
 Provide a brief motivational intervention as previously outlined.

To ensure that their attempt becomes or remains successful, ARRANGE for follow-up visits whenever
possible. Follow-up may be as simple as an invitation to talk about quitting in the future. It may also be
arranged for a specific time, such as when a person returns to a dental clinic or TB DOTS center. It is par-
ticularly important to arrange follow-up contact with a tobacco user who is making a quit attempt.
Whenever possible, arrange the follow-up within a week after the individual’s quit date, and regularly
(optimally on a weekly basis) thereafter.

Remember to:

 Ask about tobacco status.

 Congratulate those who are tobacco-free and support them in staying quit.
 Support those who have relapsed and assist them to make a new quit attempt.

An important aspect of a brief tobacco intervention is prevention to guide those that are showing inclina-
tion or are exposed to tobacco smoke. This raises the 6th A, which is to ANTICIPATE children and
adolescents' exposure to secondhand smoking and early experimentation (e.g. chewing or smoking
tobacco).

Beginning around age 10, ask about:

 Exposure to secondhand smoke, and

 Actual tobacco use.

BRIEF INTERVENTION FLOWCHART

To assist and provide you with an easy visualization of the application of the 5 A’s when intervening with
tobacco users, a brief tobacco intervention flowchart is presented in the next page. The Brief Intervention
Flowchart is a tool that outlines the recommended steps to take when providing brief interventions. The
flowchart is divided to three panels to help deliver brief interventions that match a person’s readiness to
quit tobacco use.

BTI: Module 2. BTI Essentials 6

BTI: Module 2. BTI Essentials 7
 Figure 2.3. Brief Intervention Flowchart

BTI: Module 2. BTI Essentials 8

 KEY POINTS TO REMEMBER

 The Readiness to Change Model involves four stages:

1. Not Ready to Quit,
2. Thinking About Quitting,
3. Ready to Quit, and
4. Quitting, and Staying Quit/Relapse
 Keep in mind that, at any point in time in the model, an individual may transcend from one stage to
another.
 When intervening with a tobacco user, it is helpful to know how ready that person is to quit in order
to give the right help and be an efficient and effective BTI provider.
 Tobacco dependence is a chronic condition so tobacco users typically cycle through multiple
periods of “Relapse”.
 The brief intervention should be repeated to encourage tobacco users to quit and allow for changes
in their readiness to quit. Repetition promotes effective outcomes.
 The key components of BTI can be summarized in five words: Ask, Advice, Assess, Assist, and
Arrange.

BTI: Module 2. BTI Essentials 9

 This e-book and related documents are intended for use
by a broad range of healthcare and non-healthcare
professionals (private or government). It is based on the
Brief Tobacco Intervention training curriculum developed by
Health Partners Limited Liability Corporation in Guam, USA,
and is customized based on the Philippine context.

All rights reserved.

The mention (if any) of specific companies or of certain

manufacturer’s product does not imply that they are endorsed or
recommended by the Department of Health (DOH) in reference over
others of a similar nature. Reproduction in full or in part of this e-
book for educational or other non-commercial purposes are
authorized without any prior written permission from the copyright
holder, provided the source is fully acknowledged as indicated
below. Reproduction for profit or for commercial purposes is
prohibited without written permission from the copyright holder.

Suggested citation: Department of Health (2019). Philippine Brief

Tobacco Intervention Course E-book. Manila, Philippines:
Department of Health.