Tobacco Cessation

Overcoming Barriers to Tobacco Counseling

Healthcare providers do face several challenges when implementing tobacco cessation counseling into a clinical practice routine. These various factors influence the healthcare professionals’ performance in offering smoking cessation support.

The identification of current practices and significant barriers is important to help improve the performance of healthcare professionals in their delivery of cessation services in clinical settings.

Below are common barriers that limit the delivery of tobacco treatment along with recommendations to help overcome each barrier.

Time constraints / lack of time for meaningful interventions:

  • Brief cessation advice, as short as three minutes has been proven to be effective in increasing tobacco cessation.
  • Institute brief cessation structured approaches – 5A’s (Ask Advise, Assess, Assist, Arrange) or 2A’s and R (Ask, Advise, Refer).
  • Establish a workflow and determine roles for tobacco use screening and documentation.
  • Create a system of nonphysician members of the health care team (e.g., nurse, health educator) to provide patients with information and support for quitting.
  • Utilization of telehealth to provide better follow up and a support for ongoing monitoring and adherence to tobacco cessation.

Competing priorities:

  • Develop office routines and practice patterns that could improve management of patients that smoke or use tobacco.
  • Institute health systems change strategies that aim to screen every patient for tobacco use and offer every tobacco user help to quit at every visit.
  • Changes may include revising organizational policies, administrative and clinical processes, information technologies, staff training, performance feedback, and quality improvement initiatives to support tobacco use treatment.
  • The goal is to make screening and treatment automatic, rather than depending on providers to remember to act.

Inadequate institutional support for providers:

  • Health-care systems can support physician interventions by instituting effective systems-level changes that make screening and brief cessation intervention a standard part of every office visit.
  • Identify one or two key champions and assemble a multidisciplinary team.
  • Adopt or update a unit, practice, or system-wide policy to reflect prioritization of tobacco treatment.
  • As a multidisciplinary group, conduct an assessment of your clinic/system and develop an action plan to address the current gaps.

Lack of skills in addressing smoking:

  • Provider-reminder systems increase health-care providers' assessment and treatment of tobacco use in a range of clinical settings and populations.
  • Provider reminder systems remind or prompt providers to screen and treat patients for tobacco use and can be implemented as chart stickers, vital sign stamps, medical record flow sheets, checklists, or as part of electronic medical records that allow clinicians to screen for tobacco use and nicotine dependence.
  • Conduct onboarding and annual trainings on tobacco policies, systems, and procedures.
  • Familiarize providers with evidence based structured brief cessation approaches such as the 5A’s model (Ask, Advise, Assess, Assist and Arrange).
  • Collaboration with state and community based tobacco coalitions and to assist in development and training for providers.
  • Collaboration with state Quit lines that provided one-on-one training for providers.

Provider perception that cessation interventions are ineffective:

  • Establish approaches and tools for arranging follow-up for patients who use tobacco and for providing referral to internal or external resources that can serve as an adjunct to treatment provided by the clinician.
  • Health systems can use EHR data to show progress toward patient benchmarks and identify area of successful intervention.

Patient willingness to engage in intervention or provide accurate information:

  • Express empathy
    • Be non-judgmental; listen reflectively; accept ambivalence; see the perspective through the patient’s eyes. Accurately understanding the patients experience can facilitate change.
  • Develop discrepancy
    • Help patients perceive differences between present behavior and desired lifestyle change. Patients are more motivated to change when they see what they are doing will not lead them to a future goal.
  • Avoid argumentation
    • Gently diffuse client defensiveness. Confronting patient’s denial can lead to drop out and relapse. When the patient demonstrates resistance to change, providers should change strategy.
  • Roll with resistance
    • Reframe patients thinking/statements; invite patients to examine new perspectives.
  • Support self-efficacy
    • Provide hope; increase patient’s self-confidence in ability to change behavior; highlight other areas where the patient has been successful.

Both providers and patients need to know what services are actually covered:

  • Conduct onboarding and annual trainings on elements of comprehensive cessation coverage.
  • Internally develop a system where every identified tobacco user is provided with/educated on information on tobacco coverage benefits.

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Reviewed 10/10/2024