The "5 A's" Counseling Method
An easy-to-implement, evidence-based clinical counseling approach, the "5 A's", has been recently developed and can double or even triple quit rates among pregnant smokers. This approach has been published by the U. S. Public Health Service in its Treating Tobacco Use and Dependence Clinical Practice Guideline, and by the American College of Obstetricians and Gynecologists. The approach is effective for most pregnant smokers, including low-income women, the group most likely to smoke during pregnancy.
Studies show that a brief counseling intervention of 5-15 minutes, when delivered by a trained health care professional and augmented with pregnancy-specific self-help materials, can double or, in some cases, triple smoking cessation rates among pregnant women.
The evidence-based intervention for providers to help their pregnant smokers quit is based on the following five steps (the "5 As"):
Ask patient about smoking status.
A. I have NEVER smoked, or have smoked LESS THAN 100 cigarettes in my lifetime.
B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now.
C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.
D. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I
found out I was pregnant.
E. I smoke regularly now, about the same as BEFORE I found out I was pregnant.
Provide clear, strong advice to quit with personalized messages about the impact of
smoking on mother and fetus.
Assess the willingness of the patient to make a quit attempt within the next 30 days.
Suggest and encourage the use of problem-solving methods and skills for cessation.
Provide social support as part of the treatment.
Arrange social support in the smoker’s environment.
Provide pregnancy-specific, self-help smoking cessation materials.
Periodically assess smoking status and, if she is a continuing smoker, encourage cessation.
When the "5 A's" Approach Isn't Enough
Pregnant smokers who are unable to quit with the help of the 5As may benefit from recommendations of the general PHS guideline. This guideline recommends intensive counseling from a provider with special training in the treatment of tobacco dependence; such intensive counseling might help heavily addicted smokers to quit. The guideline also advises providers to carefully consider use of medications used to treat tobacco dependence in other populations - nicotine replacement and bupropion - for pregnant women because they have not been tested for safety and efficacy among this population. Pharmacotherapies should be used only for pregnant women who smoke heavily and are unable to quit using counseling methods, and only when the potential benefits and likelihood of quitting are likely to outweigh the potential risks.