The 5 As : Evidence-Based Tobacco Cessation Counseling for Pregnant and Postpartum Women

An easy-to-implement, evidence-based clinical counseling approach, the 5 As, can double or even triple quit rates among pregnant smokers. This approach has been published by the U. S. Public Health Service in its Treating Tobacco Use and Dependence Clinical Practice Guideline, and by the American Congress of Obstetricians and Gynecologists. The approach is effective for most pregnant and postpartum smokers, including low-income women, the group most likely to smoke.

Studies show that a brief counseling intervention of 5-15 minutes, when delivered by a trained health care professional and augmented with pregnancy- and/or parent-specific self-help materials, can double or, in some cases, triple tobacco cessation rates among pregnant and postpartum women.

The evidence-based intervention for providers to help their pregnant and postpartum smokers quit is based on the following five steps (the 5 As):

ASK – 1 minute

Ask patient about her smoking status using the following structured question:

Please indicate the answer that best describes your smoking:

A. I have NEVER smoked, or have smoked LESS THAN 100 cigarettes in my lifetime.
B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking
C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking
D. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I
found out I was pregnant.
E. I smoke regularly now, about the same as BEFORE I found out I was pregnant.

ADVISE – 1 minute

Provide clear, strong advice to quit with personalized messages about the impact of tobacco on the mother and fetus.

ASSESS – 1 minute

Assess the willingness of the patient to make a quit attempt within the next 30 days.

ASSIST – 3 minutes +

  • Suggest and encourage the use of problem-solving methods and skills for cessation.
  • Provide social support as part of the treatment.
  • Arrange for support in the tobacco user’s environment, such proactive referral to the state quitline.
  • Provide pregnancy- and/or parent-specific, self-help tobacco cessation materials.

ARRANGE – 1 minute

Periodically assess tobacco use status and, if she continues to use tobacco, encourage cessation.

When the 5 As Approach Isn’t Enough

Pregnant tobacco users who are unable to quit with the help of the 5As may benefit from recommendations of the general PHS guideline. This guideline recommends intensive counseling from a provider with special training in the treatment of tobacco dependence; such intensive counseling might help heavily addicted tobacco users to quit. The guideline also advises providers to carefully consider use of medications used to treat tobacco dependence in other populations – nicotine replacement and bupropion – for pregnant women because they have not been tested for safety and efficacy among this population. Pharmacotherapies should be used only for pregnant women who smoke heavily and are unable to quit using counseling methods, and only when the potential benefits and likelihood of quitting are likely to outweigh the potential risks.

Pharmacotherapies, including nicotine replacement, bupropion, and varenicline, are a viable option for postpartum women, and they should be investigated when counseling is not sufficient.