Smoking is one of the leading preventable causes of morbidity and mortality in the United States, but healthcare providers don’t always assess for tobacco use during primary care visits. And when providers do identify tobacco use, they don’t consistently provide cessation counseling and interventions. In the course of a year, it’s estimated that only half of the patients who smoke are actually advised to quit, and smoking cessation counseling is completed in less than 25% of patient clinical encounters.

Implementation of an effective tobacco cessation program within a clinical practice requires overcoming barriers and resistance to change. Integration of the 5As model into the electronic health record (EHR) can improve patient outcomes by facilitating efficiency, effectiveness, and consistency when providing smoking cessation interventions. This article provides a description of the process for implementing the 5As model and strategies you can use to overcome barriers and gain provider and staff support for practice changes.

Overcoming barriers to change

Starting our smoking cessation program required engaging our office staff. At one of our first meetings, providers and staff identified barriers—time constraints, overbooked schedules, documentation time, and reimbursement concerns—that needed to be addressed to successfully implement the program. As a team, we worked at overcoming these barriers through communication, defined roles, staff collaboration, and frequent staff meetings to assess progress.

Lack of reimbursement for time spent on cessation counseling was a significant concern, especially when dealing with an already complex patient visit. Because of insurance and coding changes, providers were unaware of reimbursement details for smoking cessation counseling. A chart audit helped provide valuable reimbursement information. To make documentation more efficient, EHR modifications were made, including prompt screens for diagnosis, coding, and patient plan. These changes improved the billing and reimbursement process. The medical assistants began recording each patient’s smoking status in the vitals, working as a team to help each other remember the new recording process.

The 5As model for smoking cessation

The providers met and agreed to use the 5As model, which can be integrated into EHR programs to help healthcare providers ask, assess, advise, assist, and arrange follow-up for smoking cessation with every patient at every encounter. (See A model for success.) After adding smoking status to the vitals screen, we incorporated the remaining 4As into the plan section of the EHR. Collaboration with the software designer helped with the programming and technology changes. With the 5As implemented into the EHR system, smoking intervention and documentation became more efficient and complete.

Teamwork makes the dream work

After completing EHR modifications and implementing the 5As program, we incorporated discussion of smoking cessation into our daily huddles. These quick meetings improved communication and reinforced the documentation of smoking status at every patient encounter.

When working as a team, provider use of the 5As model increased, barriers were eliminated, and patient smoking cessation rates improved. Overall staff communication and morale also improved as we worked together to implement the program, leading to opportunities to address operational issues and brainstorm new ideas for continued practice improvement.

Kimberly Lynch is an adult nurse practitioner with Associated Physicians of Libertyville in Libertyville, Illinois, and adjunct faculty at DePaul University in Chicago. Diana Bantz is a family nurse practitioner and serves as faculty and director of the Nursing Masters Program at Ball State University in Muncie, Indiana.

Selected references

Jamal A, Dube SR, Malarcher AM, et al. Tobacco use screening and counseling during physician office visits among adults—National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005-2009. MMWR Morb Mortal Wkly Rep. 2012;61(Suppl):38-45.

Jamal A, Homa DM, O’Connor E, et al. Current cigarette smoking among adults—United States, 2005-2014. MMWR Morb Mortal Wkly Rep. 2015;64(44):1233-40.

U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: A report of the surgeon general, 2014.

World Health Organization (WHO). Tobacco fact sheet. Updated July 6, 2015.