Tobacco Cessation Coaching Note (5 A's)

Date/Time: [encounter date and time]
Author: [clinician name and credentials]
Setting: [care setting and visit mode]
Counseling Time: [total tobacco cessation counseling time in minutes]

Ask

(Document tobacco use status as a discrete finding. Do not infer status from appearance, odor, or prior records—it must be explicitly asked.)

• Tobacco Use Status: [current / former / never / unable to assess]
• [Reason status not obtained and plan to reassess] (Only include if unable to assess.)

(For current or recent users, include the following.)

• [Products, amount/frequency, duration, time to first use after waking, pack-years if applicable]
• [Prior quit attempts: longest abstinence, what helped, relapse triggers, prior pharmacotherapy or quitline use]
• [Household tobacco exposure and clinical factors affecting counseling]

Advise

(Provide 1–3 patient-specific sentences. Omit for never users unless prevention-focused.)

[Personalized advice to quit or encouragement for continued abstinence] (For current users: include clear recommendation to quit, strong statement on importance, and connection to patient's health or goals. For former users or recent quitters: reinforce benefits and tie to patient goals.)

Assess

• Readiness to quit (now or within 30 days): [yes / no / unsure / not assessed]
• [Reason not assessed] (Only include if not assessed.)
• [Motivation and confidence scores (0–10), or stage of change if used]
• [Primary barriers or ambivalence]

[Motivational intervention provided and patient response] (Only include for patients not ready to quit: briefly document barriers explored, relevance/risks/rewards/roadblocks discussed, and patient response.)

Assist

(Tailor content based on readiness. Omit inapplicable elements.)

• [Quit date] (If set.)
• [Practical counseling: triggers, coping strategies, withdrawal expectations, smoke-free environment plan, social support]
• [Pharmacotherapy discussed or prescribed with rationale]
• [Referrals offered (quitline, counseling, digital tools) and patient response]
• [Motivation-building actions or harm-reduction counseling] (For patients not ready to quit.)
• [Relapse prevention, medication review, current challenges] (For recent quitters.)

Arrange

• [Follow-up timing and modality] (For quit attempts: within 1 week of quit date and again within 1 month.)
• [Focus of follow-up: abstinence status, medication tolerance, barriers, need for intensification]
• [Reassessment plan] (For patients not ready to quit: document agreed time frame to revisit cessation.)