Development of an Instrument to Document the 5A's for Smoking Cessation

Background: The widely recommended 5A's strategy for brief smoking cessation includes five tasks: Ask, Advise, Assess, Assist, and Arrange. Assessments of the 5A's have been limited to medical-record review and self-report. Using observational data, an instrument to assess the rate at which the 5A's are accomplished was developed. Methods: The 5A's Direct Observation Coding scheme (5A-DOC) was developed using published 5A's guidelines and was refined using observed clinician-patient interactions. The development sample consisted of 46 audio-recorded visits of smokers with their physician (n=5), collected in 2000. The 5A-DOC was next applied to a second sample of 131 visits with 28 physicians between 2005 and 2008. Inter-rater reliability was assessed and frequencies reported. Analyses were completed in 2008. Results: Three observations shaped the development of the 5A-DOC: (1) patients accomplish 5A's tasks; (2) some communication actions accomplish multiple 5A's tasks simultaneously; and (3) sequence is important. Inter-rater agreement for identifying each task was moderate to excellent (kappa=0.58-1.0). When smoking status was established (Ask, n=78), 61% Assessed readiness, and 50% contained Assist. In all, 73% failed to complete the 5A's adequately. Conclusions: Accounting for patient activity in smoking-cessation discussions is essential to accurately capture the degree to which the 5A's have been accomplished. The 5A-DOC can be applied to audio or transcript data to reliably assess which of the 5A's tasks have been accomplished. Clinician performance of the 5A's was modest, and findings suggest that clinician training should focus on Assess and the timing of this task, and alignment with patients' reported readiness.