# Situation: The public health nurse of a Rural Health Unit (RHU) runs a tobacco and alcohol program for tricycle drivers and factory workers in the municipality. The nurse has asked a 40-year-old factory worker about his tobacco use and learned that he smokes every day. Using the 5 A's of tobacco cessation counseling, which step should the nurse take NEXT?

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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The public health nurse of a Rural Health Unit (RHU) runs a tobacco and alcohol program for tricycle drivers and factory workers in the municipality.

The nurse has asked a 40-year-old factory worker about his tobacco use and learned that he smokes every day. Using the 5 A's of tobacco cessation counseling, which step should the nurse take NEXT?

## 보기

1. Arrange a follow-up visit to review his smoking
2. Assist him in setting a quit date and a quit plan
3. Assess his readiness to quit within the next 30 days
4. Advise him clearly and personally to quit smoking **✔ 정답**

**정답: 4**

## 해설

The 5 A's used in PhilPEN tobacco counseling run Ask, Advise, Assess, Assist, and Arrange. After asking about tobacco use, the nurse gives every tobacco user clear, strong, personalized advice to quit. Readiness to quit is assessed only after this advice, and it decides whether the nurse assists with a quit plan or works to raise motivation; follow-up is arranged last.

## 심화 해설

The 5 A’s framework organizes tobacco cessation counseling into a fixed sequence: Ask, Advise, Assess, Assist, and Arrange. The scenario states that the nurse has already completed the first step by asking the factory worker about his tobacco use and learning that he smokes every day. The next step is therefore to give every tobacco user clear, strong, and personalized advice to quit. This advice must be delivered before readiness is assessed, because the purpose of the advice is to create or strengthen the motivation that the subsequent assessment will measure.

The order matters clinically. If the nurse moved directly to assessing readiness without first advising the patient to quit, the patient might not have a clear understanding of why quitting is personally important. The Advise step links tobacco use to the patient’s own health risks, symptoms, family situation, or financial concerns. For a 40-year-old factory worker, this could include cardiovascular risk, respiratory symptoms, or the cost of cigarettes. Only after this personalized message does it make sense to ask whether he is ready to quit within the next 30 days.

The remaining options belong to later steps. Assess evaluates readiness to quit within 30 days and determines the next branch of care. If the patient is ready, the nurse moves to Assist by helping set a quit date and developing a quit plan. If the patient is not ready, the nurse uses motivational strategies to build readiness before revisiting the quit plan. Arrange is the final step and involves scheduling follow-up contact to review progress, address relapse risk, and reinforce quit attempts.

| Step | Action | Key question or task |
| --- | --- | --- |
| Ask | Identify all tobacco users at every visit | Do you use tobacco? |
| Advise | Urge quitting in a clear, strong, personalized way | I strongly recommend that you quit because... |
| Assess | Determine willingness to quit within 30 days | Are you ready to quit in the next month? |
| Assist | Help set a quit date and plan; provide counseling and pharmacotherapy | Let’s set a quit date and plan together. |
| Arrange | Schedule follow-up contact | When can we follow up by phone or in person? |

The quality improvement study by Affentranger and Mulkey applied the 5 A’s in an outpatient cardiology clinic and conducted follow-up phone calls 30 days after counseling. This reinforces that follow-up belongs to the Arrange step, not the immediate next action after asking about tobacco use. The systematic review by Shieh and colleagues also describes the 5 A’s as a structured practice guide, although it uses a slightly different sequence (Assess, Advise, Assist, Agree, Arrange) for obesity counseling. The PhilPEN tobacco counseling model used in the scenario follows the order Ask, Advise, Assess, Assist, Arrange, so the sequence from the scenario takes priority.

Key point! The 5 A’s are sequential. After Ask, the nurse must Advise before moving to Assess. Do not skip ahead to quit planning or follow-up.

Watch out! Some frameworks list Assess before Advise, but the PhilPEN tobacco counseling model places Advise second. When a question specifies the 5 A’s for tobacco cessation, follow the Ask–Advise–Assess–Assist–Arrange order.

The cross-sectional study by Čivljak and colleagues examined how often hospital nurses implement the 5 A’s and found variability in practice. This highlights why licensure exams test the correct sequence: inconsistent counseling order can reduce the likelihood that a patient makes a quit attempt. The shared curriculum described by Elkhadragy and colleagues similarly emphasizes that health professionals must be trained to apply the 5 A’s consistently, because the structured sequence is what moves a patient from identification of tobacco use toward a supported quit attempt.

## 임상 시나리오

Tobacco Cessation Counseling: The 5 A's SequencePhilPEN brief intervention for primary care and public health settings
After Ask identifies a daily smoker, the next step is always Advise—give clear, strong, personalized advice to quit. This advice must come before assessing readiness, because it creates the motivation that the next step will measure.

The full sequence is Ask → Advise → Assess → Assist → Arrange. For a 40-year-old factory worker, personalize the advice by linking smoking to cardiovascular risk, respiratory symptoms, or cost of cigarettes.

CautionDo not jump to Assess before delivering the advice. Readiness to quit within 30 days is evaluated only after the patient has heard why quitting matters personally. If not ready, use motivational strategies rather than forcing a quit plan.

## 핵심 개념

- **5 A's** — A structured tobacco cessation counseling framework consisting of Ask, Advise, Assess, Assist, and Arrange, used in PhilPEN.
- **PhilPEN** — Philippine Package of Essential Noncommunicable Disease Interventions, a primary care protocol that includes tobacco and alcohol risk assessment and brief counseling.
- **Readiness to quit** — A patient's stated intention or motivation to stop tobacco use, typically assessed by asking about willingness to quit within the next 30 days.
- **Personalized advice** — Clear, strong, and individually tailored messaging that links tobacco use to the patient's own health risks, symptoms, family, or financial concerns.
- **Quit plan** — A structured strategy developed during the Assist step that includes setting a quit date, identifying triggers, and arranging support.

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