5 A’s Intervention Plan Proposal
Today, smoking is one of the primary causes of significant illnesses and even death. Despite this fact, it is preventable if a person breaks the habit or seeks a professional’s help and undergoes therapy. Otherwise, several smoking-related severe illnesses such as cancer, heart diseases, and strokes can arise, which leads to several million deaths every year. The problem stands even more urgently among patients with mental disorders, contributing to higher morbidity and mortality rates in those individuals. Many psychological and social considerations affect the worsening conditions for the patients, but most importantly, the lack of intervention programs in medical units. The issue of institutional inability to provide essential smoking secession services leads to the necessity of introducing a working intervention 5 A’s plan.
Background and Significance
The significance of introducing smoking cessation programs primarily in mental health units is even greater because the problem of smoking is more prevalent there. The number of smokers with mental disorders (MD) is up to four times higher compared to the overall population (Loreto et al., 2017). It may be one of the underlying reasons why people with MD have higher mortality. It puts patients with schizophrenia, depression, and alcohol-related disorders at a higher risk of developing vascular disease and cancer (Anderson, 2017). It also severely complicates the treatment process as smoking can reduce blood levels of neuroleptics and lead to higher doses needed with the following harsher side effects. The negative impact is also supported by the lack of an actual desire to quit among the patients diagnosed with severe mental illnesses.
Harsh effects require immediate actions to be taken to prevent adverse consequences. The treatment for patients with MD typically includes the same smoking cessation treatment as for the general population but is more intense due to possible higher nicotine dependence. The smoking cessation treatment involves pharmacological and psychological methods combined to achieve better results. The pharmacological treatment consists of nicotine replacement therapy (NRT), including patches, gum, or other nicotine substitutes. Psychological support is primarily accomplished through cognitive behavioral therapy (CBT) to ensure the treatment’s effectiveness through battling mental blocks.
Problem Statement
The necessity of introducing the intervention plan becomes apparent because of the provided statistics on the increased smoking rates among patients with MD and the following comorbidity and mortality rates. Necessary practices in psychological and pharmacological fields were also reviewed as positively affecting smoking secession. However, the issue begins to arise on the stage of the actual implementation of the program. First, the problem in the current setting of a smoking-free inpatient behavioral unit with adult smokers with MD is the lack of provided counseling even with suggested NRT. The therapy in the form of CBT proves to be an evidence-based structured intervention for smoking cessation (Çelik & Sevi, 2020). The absence of the provided CBT at the inpatient behavioral unit does not create a good background for the habit break. The initial counseling in the unit is required to implement the idea of the detrimental effect of smoking on their health and increase their desire to work on quitting.
The second problem arises in an attempt to solve the issue of the lack of counseling in the unit by referring patients to the outpatient counseling center post-hospital discharge to continue the cessation program. Since patients with MD’s desire to quit smoking were evaluated as relatively low, the central point of the plan introduction becomes to successfully make them go to the outpatient counseling center to maintain their progress. This issue requires changing and enhancing the desire to actively work on the patients’ problems, which becomes a complication for the unit’s workers. The subject demands a personal approach toward the patients, a deep understanding of the mental illness’s effect on the person’s cognitive ability, and carefully tailored pieces of advice from the worker to lead the smoker.
Definition of Terms
5 A’s significant steps to intervention comprise a typically used model by medical practitioners to promote patient behavior change. It allows changing the person’s behavior by forming the patient’s desire to quit an addiction (Martínez et al., 2017). It is a universally adopted smoking cessation model in many health organizations and is supported by evidence-based guidelines. 5 A’s plan consists of 5 steps: Ask, Advise, Assess, Assist, and Arrange.
Ask is the first stage of the smoking cessation intervention model. The workers ask and document all patients’ tobacco use status or progress during every visit. Advise is the second grade of the intervention model when the patients are recommended to quit through various means. It should be personalized, clear, and strong to urge the patient to consider quitting. Assess is the third level of the smoking cessation model. At this stage, the first two steps’ effect is assessed, and the medical worker evaluates the patients’ willingness to attempt quitting. Assist in the fourth phase of the smoking cessation intervention model. The worker directs the patient to the counseling center and helps with the treatment. The CBT combined with NRT is most commonly used as smoking cessation assistance. Arrange is the fifth step of the 5 A’s model that ends the intervention process. The medical worker needs to arrange a follow-up contact to keep the patient motivated to abstain from smoking after the end of the program. It typically occurs within a week after the quit date by telephone or in person.
Project Goals
The 5 A’s intervention project intends to establish the patients’ motivation to quit smoking and actively continue the cessation program in CBT sessions at a counseling center after hospital discharge. The patients’ motivation becomes stronger with the end goal of making them quit smoking through the program. Smoking cessation desire rates among patients with MD are statistically lower than in persons without an illness (Carstens & Linley, 2020). The plan’s first objective is to successfully change the conception patients have about quitting smoking through the Ask, Advise, and Assess stages.
After establishing the desire to quit smoking in the patients, the main focus becomes to make them keep working on the treatment and cease smoking in the long term. Since the inpatient behavioral unit does not provide counseling, the project’s other goal is to direct the patient to the counseling center to continue work on smoking cessation (Knudsen, 2017). The second objective of the plan aims to arrange the patient’s reference to the outpatient counseling center post-hospital discharge to continue the cessation program in CBT through the Assist and Arrange stages.
Literature Review
The issue of the necessity of psychological interventions in smoking cessation for patients with MD has been raised in many studies before. However, with a vast amount of various services and possible programs, it becomes increasingly hard to find a proper one to implement in a particular situation. In the setting of the absence of counseling services in an inpatient behavioral unit, the situation gets complicated due to the need to refer patients to the outpatient counseling center. The review focuses on finding the optimal solution for the smoking cessation intervention, identifying the common bottlenecks in the previous studies, and determining the possible solutions to the arising problems in program implementation. The review is divided into five parts (Ask, Advise, Assess, Assist, and Arrange), according to the steps of 5 A’s plan that help find the basis and evidence for implementation. The following division allows the researcher to create practical guidelines for each step of the implementation plan. The sources include scientific findings on the effectiveness of the study and randomized trials to support it.
Ask Stage
The ask stage is the first one in the plan when the medical workers establish relationships with the patients and identify their current tobacco usage. During this stage, it is especially important to initiate contact with the patient and lay the groundwork for future cooperation (Anderson, 2017). To achieve fruitful results, it is crucial to consider the patients’ diagnosis, character, and even race peculiarities to ingratiate oneself to the person. The trial by Hooper et al. (2018) provides data representing racial disparities in treating tobacco addiction via CBT since they are considered to have more incredible difficulty quitting. The group CBT was applied in the tobacco cessation program to eliminate or at least reduce racial disparities (Hooper et al., 2018). These differences are crucial to take into account when implementing intervention programs for different ethnic or racial groups who can experience tremendous stress.
The diagnosis of a mental disorder also requires a specific approach to begin the intervention program. The article by Zvolensky et al. (2018) shows that the issue of increased anxiety within smokers prevents them from quitting and even considering it. The positive effect was noted in the results and proved to be an effective mechanism for enhancing not just anxiety reduction but also prolonging smoking cessation post-discharge in the long term.
Advise Stage
The advice stage is the next step of the intervention model when the patients are strongly urged to consider quitting. To achieve a better result in making the patients go to the outpatient center to undergo CBT, its benefits should be presented at the advice stage. The article by Aldi et al. (2018) presents a systematic review of clinical trials’ literature on pharmacological and psychological interventions for smoking cessation in patients with a mental illness. The review statistically proves the necessity of psychological interventions, especially CBT, in treating tobacco abuse in patients with psychological disorders to prevent relapse after releasing them from the unit (Aldi et al., 2018). The evidence of CBT’s effectiveness for both the treatment and smoking cessation retention effectiveness needs to be shown to show the necessity of the therapy. The article by Loreto et al. (2017) investigates the impact of the nicotine patch effectiveness combined with CBT in battling smoking in patients with and without mental disorders. The use of therapy was proved to lead to treatment success and is recommended by the authors as the best option for the smoking cessation method among patients with MD.
The patients’ depressive diagnosis often prevents them from quitting smoking. The study by Becoña et al. (2017) explores the cognitive-behavioral treatment applied explicitly to smokers with a depressive disorder. The trial assesses a CBT intervention’s efficacy and statistically proves higher abstinence rates, overall mood improvement, and lower relapse rates (Becoña et al., 2017). The following study is especially useful in implementing the advice stage of the 5 A’s plan, as it relies on detailed data that illustrates the effect of the people going through the therapy with the same symptomatology. The review by Doukani et al. (2020) supports the concept of CBT’s necessary implementation in helping battle depression. The study offers the framework for introducing a CBT intervention in patients with a depressive disorder (Vujanovic et al., 2017). It allows for educating the patients on the issue of their mental health in the retrospective of their smoking habits and introduces accessible help in the outpatient counseling centers.
Assess Stage
The third step of the smoking cessation model is Assess when the medical worker evaluates the patients’ willingness to attempt quitting. The desire component remains one of the most critical factors in the person’s effective cessation (Kathuria et al., 2019). The article by Carstens & Linley (2020) presents a comprehensive picture of the desire to quit smoking in patients with mental illnesses. Implementing intervention 5 A’s plan is the first step in making the person realize and address the issue, thus increasing the desire to quit.
The interpersonal communication impact on the effectiveness of the therapy shows the requirement for higher results in the implementation of the 5 A’s plan as well. The study by Penedo et al. (2020) analyzes the patient-therapist communication in CBTs influence in patients with depression. The establishment of trusting relationships between the therapist and the patients allows them to benefit from the long-term efficacy of tobacco addiction treatment (Penedo et al., 2020). The results vary depending on the patients’ characteristics such as age and ethnicity and the clinicians’ number of years in practice and personal attitude toward smoking (Vijayaraghavan et al., 2017). These effects combined created a direct correlation with the effectiveness of the intervention.
Assist Stage
Assist in the fourth step of the smoking cessation intervention model when the worker directs the patient to the counseling center and helps with the treatment. It often appears to be one of the most challenging steps of the program. This proves the necessary change in the provided assisted referral with careful step-by-step planning by a 5 A’s plan specifically designed for patients to quit smoking (Fellows et al., 2016). The plan’s poor execution is usually supported by the lack of familiarity with the framework in primary care and mental health units in other studies (Owens, 2019). Thus, additional education and organizational support as prerequisites for the proper implementation of the plan.
The treatment expectations directly correlate with the outcomes in patients with depression receiving group CBT. The following issue underlines the necessity of educating and assisting the patients before directing them to the outpatient mental healthcare units to create an understanding of the problem and form reasonable expectations (Vîslă et al., 2016). The consultation part of Advice in the 5 A’s plan needs to include the counseling part, and Assist needs to include effective planning to achieve better results (Wakeman et al., 2017). Thus, the therapists create the basis for long-term abstinence from smoking through the expectations shaped in the 5 A’s plan.
Arrange Stage
Arrange is the fifth step of the 5 A’s model when the medical worker needs to arrange a follow-up contact to keep the patient motivated to abstain from smoking. The article by Çelik & Sevi (2020) provides a table of CBT therapy characteristics according to the recommended number of sessions and frequency, which complies with a ready practical application to the advice intervention step. It is found successful for quitting smoking, especially combined with Nicotine Replacement Therapy (NRT) and medication.
The inability to finish the intervention program often is affected by the barriers in staff training and the absence of practical guidelines. The clinical health workers conducted a self-reported performance assessment and found the general incompleteness of plan implementation (Martínez et al., 2017). The survey found the most challenging area for applying the plan to Assist and Arrange steps that needed additional organizational support.
The review of all the intervention project steps allows the researchers to consider the necessary actions during each stage. Ask stage shows especial significance into making contact with a patient, Advice requires to present the information correctly, Assess needs to take into consideration the patients’ diagnosis and personality peculiarities. Assist and Arrange are the most problematic steps when workers need to have additional guidance. Considering all the steps together creates the basis for further research and proper plan implementation.
Theoretical and Conceptual Framework
To successfully fulfill all 5 A’s plan steps, it is essential to educate the patients about the possible ways to deal with tobacco addiction. The patients get referred to the counseling center to keep working on the program through CBT implementation. Cognitive-behavioral therapy (CBT) is a talking therapy type that aims to help the patient manage their problems by changing their thinking one’s patterns. It is commonly used to treat anxiety or depression since it effectively battles negative thinking (Çelik & Sevi, 2020). CBT immensely helps in smoking cessation as it challenges the idea of the impossibility of quitting and builds the desire to change. CBT changes the thought patterns by adjusting the interaction between thoughts, emotions, and behaviors to affect how they perceive the issue. It typically includes 10-20 sessions when the patient identifies the problem, sets goals, and learns coping skills, which is especially useful in smoking cessation as a long-term battle.
The cognitive theory of psychopathology introduced by Aaron T. Beck is the basis for the cognitive-behavioral theory. Beck’s theory of psychopathology focuses on battling negative thoughts that arise in anxious and depressed patients (Beck, 1971). Beck believed that changing cognition would lead to an inevitable change in one’s behavior. In his theory, he explored the three main cognitive mistakes of depressed people: faulty thinking, negative self-schema, and negative triad. Faulty information processing distorts the factual information about something in the cognitive process of a patient. A negative self-schema makes the patients believe the pessimistic experience is happening to them based on the information or experience that they had. The negative triad creates the endless circle of interconnected defeatism in a person’s views about oneself, the world, and the future. CBT allows the therapist to identify these thoughts and effectively challenge them when the person’s ideas about quitting smoking become blurred because of negative thinking.
Implementing a smoking intervention plan has a high significance in the modern world due to the high mortality number among smokers with mental disorders. A 5 A plan allows the workers to motivate and assist the patients in combination with replacement therapy. The cognitive-behavioral therapy concludes the smoking cessation program after the patient is referred to the outpatient counseling center upon hospital discharge. It has the potential of providing more qualitative care to smokers struggling with mental illness.
References
Aldi, G. A., Bertoli, G., Ferraro, F., Pezzuto, A., & Cosci, F. (2018). Effectiveness of pharmacological or psychological interventions for smoking cessation in smokers with major depression or depressive symptoms: A systematic review of the literature. Substance Abuse,39(3), 289-306.
Anderson, G. A. (2017). Tobacco cessation: A quality improvement project using the 5 a’s model [Unpublished doctoral dissertation]. University of Kansas.
Beck, A. T. (1971). Cognition, affect, and psychopathology. Archives of General Psychiatry, 24(6), 495.
Becoña, E., Martínez-Vispo, C., Senra, C., López-Durán, A., Rodríguez-Cano, R., & del Río, E. F. (2017). Cognitive-behavioral treatment with behavioral activation for smokers with depressive symptomatology: Study protocol of a randomized controlled trial. BMC Psychiatry, 17(1), 134.
Carstens, C., & Linley, J. (2020). Desire to quit smoking in an outpatient population of persons with serious mental illness. The Journal of Behavioral Health Services & Research.
Çelik, Z. H., & Sevi, O. M. (2020). Effectiveness of cognitive-behavioral therapy for smoking cessation: A systematic review. Psikiyatride Guncel Yaklasimlar, 12(1), 54-71.
Doukani, A., Free, C., Michelson, D., Araya, R., Montero-Marin, J., Smith, S.,… & Kakuma, R. (2020). Towards a conceptual framework of the working alliance in a blended low-intensity cognitive behavioural therapy intervention for depression in primary mental health care: a qualitative study. BMJ Open, 10(9).
Fellows, J. L., Mularski, R. A., Leo, M. C., Bentz, C. J., Waiwaiole, L. A., Francisco, M. C.,… & Stoney, C. M. (2016). Referring hospitalized smokers to outpatient quit services: A randomized trial. American Journal of Preventive Medicine, 51(4), 609-619.
Hooper, M. W., Lee, D. J., Simmons, V. N., Brandon, K. O., Antoni, M. H., Unrod, M.,… & Brandon, T. H. (2018). Reducing racial/ethnic tobacco cessation disparities via cognitive-behavioral therapy: Design of a dualsite randomized controlled trial. Contemporary Clinical Trials, 68, 127-132.
Kathuria, H., Seibert, R. G., Cobb, V., Weinstein, Z. M., Gowarty, M., Helm, E. D., & Wiener, R. S. (2019). Patient and physician perspectives on treating tobacco dependence in hospitalized smokers with substance use disorders: A mixed methods study. Journal of Addiction Medicine, 13(5), 338-345.
Knudsen, H. K. (2017). Implementation of smoking cessation treatment in substance use disorder treatment settings: a review. The American Journal of Drug and Alcohol Abuse, 43(2), 215-225.
Loreto, A. R., Carvalho, C. F. C., Frallonardo, F. P., Ismael, F., Andrade, A. G. D., & Castaldelli-Maia, J. M. (2017). Smoking cessation treatment for patients with mental disorders using CBT and combined pharmacotherapy. Journal of Dual Diagnosis, 13(4), 238-246.
Martínez, C., Castellano, Y., Andrés, A., Fu, M., Antón, L., Ballbè, M.,… & Feliu, A. (2017). Factors associated with implementation of the 5A’s smoking cessation model. Tobacco Induced Diseases, 15(1), 41.
Owens, A. (2019). Tobacco screening among adults in primary care: evaluation of the use of the 5a’s framework for treating tobacco dependence. DNP Projects, 288.
Penedo, J. M. G., Rubel, J., Krieger, T., Alalú, N., Babl, A. M., Roussos, A., & Holtforth, M. G. (2020). Effects of Patient-Therapist Interpersonal Complementarity on Alliance and Outcome in Cognitive-Behavioral Therapies for Depression: Moving Towards Interpersonal Responsiveness. Journal of counseling psychology.
Vijayaraghavan, M., Yuan, P., Gregorich, S., Lum, P., Appelle, N., Napoles, A. M.,… & Satterfield, J. (2017). Disparities in receipt of 5As for smoking cessation in diverse primary care and HIV clinics. Preventive Medicine Reports, 6, 80-87.
Vîslă, A., Constantino, M. J., Newkirk, K., Ogrodniczuk, J. S., & Söchting, I. (2016). The relation between outcome expectation, therapeutic alliance, and outcome among depressed patients in group cognitive-behavioral therapy. Psychotherapy Research, 28(3), 446–456.
Vujanovic, A. A., Meyer, T. D., Heads, A. M., Stotts, A. L., Villarreal, Y. R., & Schmitz, J. M. (2017). Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches. The American Journal Of Drug And Alcohol Abuse, 43(4), 402-415.
Wakeman, S. E., Metlay, J. P., Chang, Y., Herman, G. E., & Rigotti, N. A. (2017). Inpatient addiction consultation for hospitalized patients increases post-discharge abstinence and reduces addiction severity. Journal Of General Internal Medicine, 32(8), 909-916.
Zvolensky, M. J., Garey, L., Allan, N. P., Farris, S. G., Raines, A. M., Smits, J. A. J., Kauffman, B. Y., Manning, K., & Schmidt, N. B. (2018). Effects of anxiety sensitivity reduction on smoking abstinence: An analysis from a panic prevention program. Journal of Consulting and Clinical Psychology, 86(5), 474–485.