Know the Guidelines

ACOG publishes the CME-accredited self-instruction guide and tool kit Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking includes photocopy-ready materials, a flow sheet for a patient's medical record, a quick-reference card, checklist among other tools.

The most widely used and evidence-based guidelines for smoking cessation counseling is an intervention that uses the mnemonic the 5A's. These are:

  • Ask about tobacco use
  • Advise to quit
  • Assess wiliness to make a quit attempt
  • Assist in quit attempt
  • Arrange follow-up

Reports of the efficacy of this 5A's framework cite cessation rates from 30-70% when compared to traditional physician advice (Melvin et al., 2000). The protocol has also been tested with different patient populations and adapted to maternal smoking. ACOG now recommends that motivational interviewing techniques be used in conjunction with the 5A's.

More detailed recommendations for the ACOG guidelines are available for each step. These include:

Ask – Systematically identify all tobacco users. Document when a patient quits, or if still smoking, document if woman has cut down the number of cigarettes smoked. Record the status as a vital sign. When applicable, use Electronic medical records (EMR) program a reminder in to the EMR system to screen for tobacco use.

Advise – Use clear, strong, and personalized messages. Acknowledge difficulty of quitting. Provide pregnancy-specific educational materials that communicate the health risks and benefits of quitting for both mother and baby. Give specific feedback about the fetus. Use positive language, avoid admonishment. Hartmann (2000) offered this statement as a suggestion for clinicians:

quotation mark

I know I'm asking you to do something that takes a lot of effort, but my best advice for you and your baby is to quit smoking. Quitting smoking will help you feel better and provide a healthier environment for your baby.

quotation mark

Assess – Assess the patient's stage of readiness. Determine if the patient is willing to choice a specific quit-date within 30 days. Try to move to next stage of readiness. If unwilling to set a quit date use the 5'Rs. Document current stage in patient's chart.

Assist – Write a "prescription to quit" (see also last section). Fax a referral to the quit-line or refer directly to 1-800-QUIT-NOW. Sign a quit contract, discuss strategies, triggers, problem-solving and enlisting social support around quitting. Suggest a "quit buddy".

Arrange – Program a reminder in the EMR to follow up on smoking status at every visit or arrange for a follow-up telephone call.


When a client is not ready to take action the 5R's can be used.

  • Relevance – Assist patient to identify motivational factors and tailor importance for her personal situation.
  • Risks – Encourage client to identify negative consequences of smoking.
  • Rewards – Ask how quitting might benefit her and her family.
  • Roadblocks – Help patient identify barriers to quitting and explore how to overcome these barriers.
  • Repetition – Repeat at every visit. Remind that most people make repeated attempts to quit before being successful and that every new attempt encourages her likelihood of quitting.