CHAPTER9. TOBACCO USE 239 Tobacco use:(circle one) ret)→ Advised to quit Former Ready to M quit in next Never 30days?□N Figure 9.1. A tobacco-use "vital sign"stamp, which can appear prominently on the patient's chart where vital signs are recorded to remind the clinician and staff to systematically assess smoking status at each visit. The traditional version, illustrated in the U.S. Public Health Service guideline(12), only contains the information in the left-most column of the version shown here(the first of the 5 As, "Ask"). This second generation stamp,courtesy of Stephen F. Rothemich, MD, MS, is designed for also obtaining and documenting the second and third as(“ Advise”and“ Assess”). short, clear, and memorable. Personalization of the message by referring to the patient's clinical condition or family history may add to the effectiveness of the advice. The type of motivation that will help smokers quit varies greatl from patient to patient. Although almost any clinical encounter provides an opportunity to discuss smoking, timing of the advice can be very important The so-called teachable moment is that time when a patient's circumstances make him or her more receptive to advice. Teachable moments occur when patients are affected by diseases caused by smoking, but they may also occur following auscultation or pulmonary function testing, or when a friend or relative is Assess if the smoker is willing to make a quit attempt. Patients'level ofinterest in stopping smoking is usually evident in discussions with the clinician. Ifit is not, ask patients if they want to stop. See Chapter 5 for further information about the transtheoretical model and stages of readiness to change, which includ precontemplation, contemplation, preparation, action, and maintenance(see pages 132-133) Patients not ready to make a quit attempt (precontemplation or contemplation stages)may respond to a motivational intervention. Th clinician can motivate patients to consider a quit attempt with the 5 Rs Relevance- encourage the patient to indicate why quitting is personally relevant Risks-ask the patient to identify potential negative consequences of tobacco use Rewards--ask the patient to identify potential benefits of stopping tobacco Roadblocks--ask the patient to identify barriers or impediments to quitting Repetition--repeat motivational intervention at every clinic visit