ATTUD Journal Club Postings

The 5 A’s and Its Cousins

The most recent USPHS 5 A’s algorithm recommends clinicians ask and advice smokers to stop (2008 USHPS National Guidelines; Baker, Addiction 110:388‐9, 2015). If they are willing to quit, the algorithm recommends providing medication and counseling treatments. If they are unwilling to stop, it recommends a brief motivational advice protocol called the 5R’s. Since then several alternatives to the 5 A’s have been suggested. A recent article by an ATTUD member (Kim Richter, Addiction 110:381‐6, 2014) and prior articles (Aveyard, Addiction 107:1066‐73, 2011) have also recommended that all smokers receive a treatment, but they question giving different treatments dependent on the readiness of smokers. These articles cite the Cochrane review that concluded stage‐based interventions had not been validated. Instead these articles suggest all smokers should be offered medication and behavioral treatments.

My interpretation of this data has led me to a somewhat hybrid approach. I suggest that we not start with advising a smoker to quit but first describe, in brief lay terms, the treatment options available. I first start with cessation and describe the meds and types of counseling. Then I discuss that, for those not ready to quit, there is motivational “discussions” or reducing cigs/day (Cochrane suggests both are effective). And then I offer to provide any of these via myself or referral. If they are not interested in any of these, then comes the tricky part. Almost all smokers know about e‐cigs, so I probably should say something about then. Right now I am telling them that use of probably less harmful products such as e‐cigs and snus is an option but we are not sure how helpful they are. This is because of the evidence, not that these are less harmful, but that their use can lead to later cessation (although this evidence is not strong, the UK NICE has now recommended this for smokers not ready to quit (

So my takeaway is to discuss treatments before, not after, advising to quit. I like this because it put the focus on my (hopefully) normal clinician role of offering help. Would be interested in thoughts of others.