Nicotine Freedom - Integrating the National Cancer Institute Model - "4-A's"

by Marlene M. Maheu, Ph.D.


The National Cancer Institute advocates four steps when working with nicotine users. These steps are known as the "4-A's," and they are "ask," "advise," "assist" and "arrange for follow up." These four steps were designed primarily for medical settings and require a little modification when applied to settings where nicotine dependency is addressed professionally.

Ask. This step is directly applicable to all settings. You may want to make it a point to ask about nicotine use on your intake forms as well as during your intake interview. Be sure to include smokeless tobacco in your inquiry. Rather than asking, Do you smoke? you might consider a question such as, Do you use tobacco in any form? If the answer is negative, ask about any history of tobacco use. Just because someone isn't using tobacco now doesn't mean they have never used tobacco, nor that they never again will use tobacco. If someone has a history of tobacco use, make a note in your chart, and continue to ask about it over time if you have a long-term relationship.

If the response to your inquiry is affirmative, continue to ask more questions in a clinical rather than a judgemental tone. Good openers are What form of tobacco do you use? and Have you ever tried to cut down or stop? If, at this point, the individual seems to not want to respond, it would be in order to make a process comment such as, It seems difficult for you to talk about this. Depending on the response, you may want to simply make a note in your chart or continue gathering a nicotine history. During the history taking, you may want to ascertain whether or not the individual feels "addicted" to nicotine.

Another good question at this point is, What has happened when you did try to stop in the past? This information will help you diagnose the individual in terms of stage of readiness to change as well as in terms of appropriateness of referral for psychiatric medication if depressed or anxious. This will be discussed in further detail in the training workshop.

How To Ask About Tobacco Use

Do you use tobacco in any form?
What form of tobacco do you use?
Have you ever tried to cut down or stop?
Do you think you are addicted?
What has happened when you did try to stop in the past?

Advise. How you advise is dependent upon your setting. In a medical setting, advising is straightforward. Inform the individual that tobacco use is harmful to their health for specific reasons related to their own health history such as:

Your triglycerides are up, your mother died of a stroke, your father died of a heart attack. Your chances of dying of similar causes are greatly increased if you continue to smoke. Based on your history and current health, I strongly advise you to stop using tobacco in any form right now. I can help with the process if you need help.

If you are a chemical dependency or other type of counselor, tobacco use can be best addressed in your setting by advising people of your professional stance toward nicotine. It may come as a surprise to many, so be prepared for resistance. If you are employed in a treatment facility or in the military, your facility's policy toward nicotine will have to be communicated clearly and directly to the individual. Once again, be prepared for resistance.

In working with the resistance, empathize with the reaction of surprise, but maintain a firm stance regarding your personal support of the policy however it limits nicotine use. It is a critical error to give a double message such as:

I personally think you ought to wait until at least a year after you become clean and sober to stop smoking.

The tendency to side with the patient to build an alliance is often a strong one, and must be kept in proper perspective. Many hospitals going nicotine free have suffered from mixed messages given to patients by their disgruntled staff who may use or condone the use of nicotine themselves. Once all staff members are in accordance with the policy, patients tend to accept policies much more readily. However, restrictions on nicotine and treatment of the issue as an addiction make intuitive sense, so people generally can understand the logic of nicotine dependency treatment after adequate exposure. An example of a helpful statement may be:

It looks like this policy comes as a surprise to you. Here's my thinking. See if it makes sense to you. It's bad enough going through detox once for drugs and alcohol. I'd hate to see you go through it again a few years down the road if you decide to stop smoking. Detox is detox, and your body is going to be screaming. If you'd like, we can take care of it all at the same time. And I'll be here to help.

You can then advise individuals of their options in dealing with nicotine as determined by your facility. Whether you offer voluntary or mandatory aspects of nicotine treatment programming, the individual needs to be made aware of all the options and consequences so as to choose their own course of action. Once you have advised them of the facility's position and program options, it is up to them how to respond.

If you are an employee assistance professional, your position is much the same as the chemical dependency counselor. Your stated stance might be determined by your employer. On the other hand, you may be more in the position of a private practice psychotherapist, counselor or fitness professional who can bring up the issue as one deserving professional attention. Simply by having the question on the intake form and raising it in the initial interview, the individual is alerted to the fact that this is an important issue that can be discussed. Questioning as described previously can continue until the individual chooses to disengage from the topic. If someone attempts to disengage, it is best to let the issue drop and perhaps give them materials designed for those in the pre-contemplative or contemplative stage of readiness to change (to be discussed in a later section of this Guidebook). For others who are interested in pursuing options regarding how to become nicotine free, you can move on to the third "A," assisting.

Assist. Assisting can involve anything from setting a nicotine freedom or stop-smoking date along with giving printed materials, to offering a full NFS individual or group intervention. Different individuals will need different levels of intervention. This choice largely depends on the individual. However, since many physicians will not prescribe nicotine replacement therapy without a "behavioral program," many more individuals are attending such programs. Nicotine is beginning to be recognized as the serious addiction it truly is.

Arrange for Follow Up. This last step has been shown very important, even if it only involves a quick phone call several weeks after someone becomes nicotine free. You can work with a physician who is following up as well. Research has shown that individuals working with two or more professionals and having a greater number of contacts are more successful in the long-term.



Marlene M. Maheu, Ph.D. is the founding Director of the Nicotine Recovery Institute. She is the designer of the Nicotine Freedom System, and specializes in the treatment of nicotine-related disorders. Such disorders include underlying depression and anxiety. She has worked extensively with smokers and tobacco chewers in hospital, industrial, and private settings, and is available for individualized consultation and program design. Her program and materials have been developed after completion of her doctoral dissertation in smoking cessation, and following a decade of work with thousands of smokers.

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