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Workplace Health & Safety

Workplace Health & Safety

Workplace Health & Safety
Workplace Health & Safety Paper
Workplace Health & Safety Paper

Despite immense efforts and progress made to ensure a decrease un smoking rates among US adults in the past fifty years, tobacco smoking continues to account for an estimated 500,000 deaths annually and up to 18% of the adult population still smoke (Satterfield et al., 2018). The rates of smoking exceed 30% in high-risk populations such as those with substance and mental health disorders, uninsured and those with a low income. Besides, vulnerable populations bear the highest burden of tobacco-related illnesses. Most smokers have the urge cease smoking. An estimated 60% of smokers visited a healthcare provider in 2017. However, most of them never got cessation help nor are they assessed for readiness to quit (Satterfield et al., 2018). Workplace Health & Safety Paper

Based on the recommendations provided by the USPHS (the United States Public Health Service), every healthcare provider should assess patients for their smoking status and the urge to quit and recommend the 5A’s model as the most effective. There is evidence from studies conducted in different settings to demonstrate that some healthcare providers use the 5A’s model to assess patients for the urge to quit. However, some of them Ask and Advice patients to quit smoking, they do not assess for their readiness (40%-65%), assist them (39%-58%) nor arrange for follow-up (3%-12%)(Satterfield et al., 2018).


The assisting step, which aims at offering help on cessation and pharmacotherapy, increases the quitting chances by 40%. Besides, the arranging step where adjustments are made in treatment based on relapses has been linked with a 45% increase in chances to quit (Ockene et al., 2016). However, limited time, inadequate knowledge, the attitude of healthcare providers, competing demands and lack of self-efficacy are proven to result in non-adherence to the 5A’s.

The training of healthcare providers and the use of electronic prompts have demonstrated some improvement in adhering to the 5A’s (Warren, et al., 2015). However, most studies do not have the appropriate rigor and this limits the ability to make final recommendations. Apart from saving the time of healthcare providers and improving the quality of interventions, the implementation and acceptance of the 5A’s is still a challenge which influences the behavior of healthcare providers (Malone et al., 2019). Besides, sustaining the adherence of healthcare providers who use it is a huge challenge and this results in less robust outcomes. Ideally, currently, existing evidence suggests that training healthcare providers on the 5A’s tool would improve their understanding and implementation of the tool in clinical practice.

Literature Search Method

Sampling Strategy

I conducted an initial search for literature in numerous electronic databases. In Cochrane scientific database, I used the keywords tobacco cessation, smoking cessation, clinician education, nurse’s education, 5A’s tool, and counseling. For an even more refined search outcome, I used the Boolean search operators ‘or’ and ‘and’. This search resulted in three articles. One article was excluded as it focused on educating clinicians about the CAGE questionnaire as an assessment tool for smoking cessation while the other article was withdrawn. The PubMed database search used the following keywords: counseling, tobacco cessation, smoking cessation, 5A’s tool, and nurse’s education. I activated the following filters when conducting the PubMed database search: RCTs, meta-analysis and systematic reviews published in English in the last 5 years. This search resulted in twenty articles. When ‘or’ and ‘and’ additional search phrases were used, the number of articles decreased to 10. Workplace Health & Safety Paper

Besides, the search included the reference lists of all the relevant articles. A similar search strategy was used to get more articles from weekly PubMed updates. However, this search paid a lot of emphasis on non-experimental and experimental articles with improved counseling rates or smoking cessation as the primary outcome measures. The search outcome included systematic reviews that discussed training clinicians on the 5A’s, used 5A’s as an assessment tool for smoking cessation and how relevant they were to the PICOT question.

Inclusion/Exclusion Criteria

The overall search incorporated English peer-reviewed articles. The articles used either non-experimental designs or experimental designs such as RCTs, systematic reviews and meta-analysis. The search also incorporated articles with the intervention of educating clinicians or medical students to use the 5A’s model to improve rates of smoking cessation counseling or smoking cessation as the primary outcome measure. Therefore, the overall search excluded articles published after the past 5 years, articles published in other languages apart from English and articles whose interventions were not educating clinicians about the 5A’s smoking cessation tool.

Studies that discussed educating healthcare providers about other smoking cessation tools other than the 5A’s smoking cessation tool were also excluded. This resulted in six articles. Seven of twenty-three articles met the inclusion criteria. However, based on how the topic was specific, some of the seven articles did not address the PICOT. The articles found addressed the following issues: educating clinicians on cessation, counseling, and using the 5A’s model.

Literature Review Findings

General Findings

Nurse’s Role in Smoking Cessation

For quite long, nurses have served as patient counselors and educators. Nurses have also promoted health in community and primary care settings. They spend a long time with patients during consultations and share information to improve patients’ knowledge and understanding of specific issues to promote individual health and increase patient satisfaction rates (Park et al., 2015). Therefore, nurses are more active in giving patients lifestyle modifications and behavioral interventions as an integral aspect of their practice. Nichter et al. (2018) explains that, for nurses increase their effectiveness, they should engage in healthy decisions and behaviors such as quitting smoking. This also positions them as role models to patients they attend to in community and primary care settings. Nichter et al. (2018) further proposes the use of cessation policies to encourage the sharing of tasks and collaboration between nurses and other healthcare providers in efforts towards smoking cessation.Workplace Health & Safety Paper

There were evident barriers that prevent nurses from counseling patients on cessation and providing cessation services. Currently, between 20-45% of nurses in the US smoke. According to Ocean (2018), the fact that some nurses’ smoke deters them from providing cessation counseling services to patients. Another barrier is that the nursing education curriculum provides very little information and instructions on counseling skills to use when advising patients about cessation (Hasan et al., 2019). Instead, patients only receive advice on how smoking is harmful. Without the appropriate training, nurses will continue to lack the appropriate knowledge and self-efficacy to counsel patients about smoking cessation. Neither will they take part in behavioral interventions.

Another barrier according to Ganz et al., (2015) is that most nurses have restricted time and competing priorities. This prevents them from counseling patients about smoking cessation and assisting them to quit. He further explains that it is very little or no reimbursements for smoking cessation and this deters most nurses from giving cessation counseling and helping patients quit.

ICAN (The Indigenous Counseling and Nicotine) QUIT intervention
Smoking in pregnancy is a major contributor towards potential health gaps with numerous contributing factors at provider, systemic, individual and community levels. However, according to Gould et al., (2017), most healthcare providers lack confidence, skills, knowledge, and optimism to address smoking in pregnant women. ICAN QUIT is an intervention that was implemented by Gould et al., (2017) through the Behavior Change Wheel to develop webinars for training healthcare providers to provide culturally competent cessation care. This included cessation counseling and Nicotine Replacement Therapy. The intervention incorporated appealing cultural resources to indigenous gravid women who accounted for lower literacy levels. The intervention proved to be highly efficient in improving strategies to manage smoking cessation in pregnant women and educating healthcare providers on how to counsel patients on cessation and initiate cessation treatment to pregnant women.

Quit Tobacco International

Nichter et al. (2018) refer to Turkish healthcare system that has undergone major transformations over the years to improve service delivery and the quality of care. A major shift was the transformation to output and a performance-oriented system where there are changes in the remuneration of the services provided by nurses with hospital revenue tied directly to the quality and volume of services provided. It is essential to understand the extent that shifts in the health policy of Turkey have influenced efforts to quit smoking in community and clinical settings. Very few studies have scrutinized nurses’ roles in smoking cessation in Turkey. Besides, there is very minimal information about the implementation of cessation counseling in clinical practice. Nichter et al. (2018) refer to Quit Tobacco International as an effective program to train nurses about basic cessation counseling which they should integrate into routine practice. Turkish nurses are undergoing training to understand the significance of cessation by talking about how smoking worsens an already existing health issue and how households are endangered by secondhand smoke. This training adds on current research on ways that patients can be encouraged to quit.Workplace Health & Safety Paper

Chosen Intervention-Educating Clinicians on Smoking Cessation Tools.

Malone et al., (2019) conducted a mixed-methods study whose purpose was to establish the acceptability and feasibility of an intervention change by nurses in managing tobacco dependence among inpatients. The researchers used qualitative methods in a pre and post-study design to administer questions on the use of tobacco in routine nursing care and when filling admission assessment forms. Among patients who were ready to quit smoking, the researchers provided NRT and cessation counseling. Other inpatients were referred to a telephone tobacco cessation-counseling program ‘Quitline’. Malone et al., (2019) found no improvement in the smoking status of inpatients (83%-90%).

The provision of nurse-led NRT increased from 0-34% with a subsequent increase in acceptance of NRT from 50%-64% and referrals to telephone tobacco cessation-counseling program ‘Quitline’ (0-4%) (Malone et al., 2019). Besides, three major themes emerged from this study: a therapeutic alliance between tobacco smoking patients who want to quit and nurses, the involvement of nursing leadership and educating nurses about smoking cessation tools. Generally, the study showed that educating nurses on smoking cessation, cessation tools and cessation interventions increased the ability to provide NRT to inpatients (Malone et al., 2019). However, educating nurses on smoking cessation tools increases patient support for those who are not ready to quit or be counseled.

Ganz et al. (2015) conducted a study whose aim was to explore the beliefs, attitudes, and practices of nurses on providing cessation services to patients. The participants were 707 nurses who completed online surveys. The results revealed how nurses believed in the effectiveness of evidence-based managements that should be used to manage patients with the urge to quit smoking. Nevertheless, the study revealed that most occupational health nurses acknowledged the lack of appropriate knowledge of smoking cessation tools, guidelines, and training. It was concluded that training nurses on smoking cessation tools, evidence-based interventions and guidelines would improve nursing practice (Ganz et al., 2015). Besides, nursing leaders should ensure that policies at organizational level that relate to providing services on cessation promote the efforts of patients’ to quit.

Most organizations have implemented the use of 5A’s model as supported by evidence-based research for smoking cessation. In the study by Martínez et al., (2017), the researchers examined behavioral, individual, cognitive and managerial issues associated with the performance and use of the 5A’s assessment tool among Catalonia clinicians. Cross-sectional surveys were held among clinicians who were enrolled in an online training course on smoking cessation. For the first 3A’s: Ask, Advise and Assess, the standard deviation was moderate: 6.4, 7.1 and 6.3 respectively (Martínez et al., 2017). For the last 2A’s; Assist and Arrange, the standard deviation was low: 4.4 and 3.2 respectively. There was a high correlation between Arrange and Assist. Increased competency and positive experiences were associated positively with using 5A’s model and support from the organization.


According to Martínez et al. (2017), the most relevant way to increase nurses’ competency to use the 5A’s assessment tool and improve counseling on smoking cessation is through continuous training. Martínez et al. (2017) also found that clinicians did completely conduct the 5A’s assessment. He therefore recommended the training of nurses and availing guidelines on smoking cessation. The researchers also emphasize the need for organizational support during the implementation of the ‘Assist’ and ‘Arrange’ steps.Workplace Health & Safety Paper

According to Ockene et al. (2016), clinicians should develop the required competencies for counseling about smoking cessation and tobacco dependence treatment early in nursing education. In an RCT study whose aim was to determine how a tobacco dependence treatment curriculum affected skills in smoking cessation counseling, Ockene et al. (2016) examined ten medical schools in the US that were to receive education on traditional tobacco treatment and counseling. The participants who were medical students filled objective structured clinical examinations, pre and post surveys. The primary outcome measure in this study was skilled in tobacco cessation counseling and treatment using 5A’s model. The secondary outcome was self-reported skills by students on performing the 5A’s, smoking cessation and pharmacotherapy counseling (Ockene et al. 2016).

Even though the findings of this study were not significant statistically, they were clinically significant. Most students used the 5A’s model for tobacco counseling (mean of 8.7). Most items completed by the medical students were ‘Assist’ and ‘Arrange’ items where information on Quitline and other behavioral strategies was shared. Besides, medical students reported a high self-efficacy for counseling on pharmacotherapy, ‘Assist’ and ‘Arrange’ items. Ockene et al. (2016) concluded that medical and nursing schools in the US should incorporate a curriculum or lessons on tobacco treatment. This includes knowledge of smoking cessation, smoking cessation tools (5A’s model) and pharmacotherapy.


Literature review findings illustrate that educating clinicians about the smoking cessation assessment tools increases the rates of cessation counseling in community and primary healthcare settings. The findings also demonstrated that there are very limited studies on the methods used to educate clinicians on the 5A’s smoking cessation tool. There were also limited findings on what clinicians should expect after applying the 5A’s tool to counsel patients in communities and primary care settings.


A major limitation of this literature review is that most of the studies used small sample sizes, different healthcare providers and even medical students. This, therefore, limits the ability to apply the findings to the general population. Besides, some of the articles had significant recall biases such that, other than using audio-recordings of conversations with primary care providers, the studies used patient-reported data of the 5A’s. In other studies, the staff was briefly trained about the 5A’s smoking cessation tool and compliance rates on cessation counseling were only done through follow-up SMS texts and telephone calls.Workplace Health & Safety Paper

Conclusion of Findings

This study purposed to determine whether educating clinicians on the smoking cessation tool (5A’s model) could influence an increase in the rates of cessation counseling in communities and primary care settings. 5A’s model was noted as a significant smoking cessation tool. The studies supported educating clinicians on smoking cessation tools (5A’s) to increase the rates of cessation counseling in community counseling. It was also noted that different clinician training methods were vital to adhere to the 5A’s smoking cessation tool in practice. Therefore, nurses should utilize effective training plans to educate clinicians on smoking cessation tools. Other important findings were incorporating organizational leadership in training and formulating policies that increase adherence to the use of cessation assessment tools.

Potential Practice Change

The available studies on the study topic support that clinicians should be educated on cessation assessment tools, particularly the 5A’s model. If most clinicians fail to receive the appropriate training, most patients with the urge to quit or those who have tried to quit can fail to receive the necessary support to achieve good outcomes. Lack of knowledge on the best smoking cessation tools does not only affect clinicians but also patients who seek assistance to quit smoking. This effect worsens when there is a lack of knowledge to differentiate between withdrawal symptoms, aversive abstinence syndrome and actual cessation symptoms. Educating clinicians is not only a nurse leadership role. Instead, organizational leadership in primary care institutions and community leaders can also be involved. Ongoing evaluation should be done at specific intervals to determine if clinicians comply with all the requirements of the 5A’s model and if patients receive the required support at all stages in the model.


Tobacco smoking is a vital issue of public health significance and a major risk factor for numerous malignancies and chronic illnesses. Globally, an estimated 3 million people die annually of diseases related to tobacco smoking. By the year 2030, this figure is expected to increase to more than 10 million deaths every year. The United States Public Health Service recommends the screening of all patients for their smoking status with cessation assistance.

Healthcare professionals play an integral role in efforts to decrease the prevalence of smoking by giving smoking cessation counseling, active involvement in the tobacco control debate and supporting smoking-cessation efforts at the community level.Workplace Health & Safety Paper

The findings of this study focus on the essence of ensuring that clinicians are educated on smoking cessation tools(5A’s model) as it increases the chances of smoking cessation counseling which is linked to high smoking cessation scores and subsequent follow-up. It is recommended that further studies should focus on different education/training strategies that can be used to educate clinicians about smoking cessation tools.


Golechha M. (2016). Health Promotion Methods for Smoking Prevention and Cessation: A Comprehensive Review of Effectiveness and the Way Forward. International journal of preventive medicine, 7, 7. https://doi.org/10.4103/2008-7802.173797

Ganz, O., Fortuna, G., Weinsier, S., Campbell, K., Cantrell, J., & Furmanski, W. L. (2015). Exploring smoking cessation attitudes, beliefs, and practices in occupational health nursing. Workplace health & safety, 63(7), 288-296.

Gould, G. S., Bar-Zeev, Y., Bovill, M., Atkins, L., Gruppetta, M., Clarke, M. J., & Bonevski, B. (2017). Designing an implementation intervention with the Behaviour Change Wheel for health provider smoking cessation care for Australian Indigenous pregnant women. Implementation Science, 12(1), 114.

Hasan, S. I., Hairi, F. M., Tajuddin, N. A. A., & Nordin, A. S. A. (2019). Empowering healthcare providers through smoking cessation training in Malaysia: a pre-intervention and post-intervention evaluation on the improvement of knowledge, attitude, and self-efficacy. BMJ Open, 9(9), e030670.

Martínez, C., Castellano, Y., Andrés, A., Fu, M., Anton, L., Ballbe, M., & Feliu, A. (2017). Factors associated with the implementation of the 5A’s smoking cessation model. Tobacco induced diseases, 15(1), 41.

Malone, V., Ezard, N., Clifford, B., Middleton, S., McInnes, E., & Bonevski, B. (2019). A systems change intervention for nurse-led smoking cessation care in hospitals. Collegian, 26(2), 235-241.

Nichter, M., Çarkoğlu, A., Nichter, M., Özcan, Ş., & Uysal, M. A. (2018). Engaging nurses in smoking cessation: Challenges and opportunities in Turkey. Health Policy, 122(2), 192-197.

Ockene, J. K., Hayes, R. B., Churchill, L. C., Crawford, S. L., Jolicoeur, D. G., Murray, D. M., & Adams, M. (2016). Teaching medical students to help patients quit smoking: outcomes of a 10-school randomized controlled trial. Journal of general internal medicine, 31(2), 172-181.

Ocean, A. (2018). Implementing a Smoking Cessation Educational Module for Clinical Staff Members Who Care for Mentally Ill Outpatients.

Park, E. R., Gareen, I. F., Japuntich, S., Lennes, I., Hyland, K., DeMello, S., & Rigotti, N. A. (2015). Primary care provider-delivered smoking cessation interventions and smoking cessation among participants in the National Lung Screening Trial. JAMA internal medicine, 175(9), 1509-1516. DOI:10.1001/jamainternmed.2015.2391

Satterfield, J. M., Gregorich, S. E., Kalkhoran, S., Lum, P. J., Bloome, J., Alvarado, N., Muñoz, R. F., & Vijayaraghavan, M. (2018). Computer-Facilitated 5A’s for Smoking Cessation: A Randomized Trial of Technology to Promote Provider Adherence. American journal of preventive medicine, 55(1), 35–43. https://doi.org/10.1016/j.amepre.2018.04.009

Warren, G. W., Dibaj, S., Hutson, A., Cummings, K. M., Dresler, C., & Marshall, J. R. (2015). Identifying targeted strategies to improve smoking cessation support for cancer patients. Journal of Thoracic Oncology, 10(11), 1532-1537.




Workplace Health & Safety Paper

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