First Breath Guiding Principles

First Breath is an evidence-based program built upon the following recommendations and strategies:

U.S. Public Health Service’s Treating Tobacco Use and Dependence Clinical Practice Guidelines1
There are ten recommendations that include proven strategies and guidelines designed to assist clinicians and other health care providers with clients who are tobacco dependence.

  1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit.
  2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.
  3. Tobacco dependence treatments are effective across a broad range of populations.
  4. Brief tobacco dependence treatment is effective.
  5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:
    • Practical counseling (problem-solving/skills training)
    • Social support delivered as part of treatment
  6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking—except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).
  7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone.
  8. Telephone quitline counseling is effective with diverse populations and has broad reach.
  9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments to be effective in increasing future quit attempts.
  10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders.

Additional Recommendations for Pregnant Women:

    1. Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. (Strength of Evidence = A)
      • Psychosocial interventions are significantly more effective than usual care in getting pregnant women to quit while they are pregnant. These interventions involve more intensive counseling that exceed the minimal advice.
    2. Although abstinence early in pregnancy will produce the greatest benefits to the fetus and expectant mother, quitting at any point in pregnancy can yield benefits. Therefore, clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy. (Strength of Evidence = B)

5 As: Ask, Advise, Assess, Assist, and Arrange
The 5 As are an Evidence-based model for tobacco cessation intervention. The Clinical Practice Guideline calls for health care providers to systematically:

  • Ask about tobacco use – Identify and document tobacco use status for every patient at every visit.
  • Advise patients to quit – In a clear, strong and personalized manner urge every tobacco user to quit.
  • Assess willingness to quit – Ask if the tobacco user is willing to make a quit attempt.
  • Assist in quit attempt – For the patient willing to quit, use counseling and pharmacotherapy (when appropriate). For the patient unwilling to quit, use the 5Rs to discuss resistance.
  • Arrange follow-up – Schedule follow-up contact with patients to discuss progress made toward quitting.

Brief Intervention
Brief interventions are short interactions (3 – 5 minutes) designed to promote changes around a specific behavior. This approach is different from traditional behavior change counseling in that the focus is not to provide more information or educate around a topic, but instead to have a non-judgmental discussion around a behavior in question. The discussion should focus on the client’s beliefs and perspective around the behavior. The primary focus is around what the client’s goals are, as opposed to what the clinician’s goals for the client are.

A brief intervention typically has two goals:

  1. Help the client think differently about the behavior in question, as a way to increase the chances they will make a change. Actively contemplating a behavior can be a deciding factor in overcoming ambivalence and making a change.
  2. Provide skills to the client to help modify the behavior in order to reduce overall harm.

Motivational Interviewing
“A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” Motivational interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.  It is grounded in a respectful, cooperative stance between the provider and client.2

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1. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
2. Miller RW, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: The Guilford Press; 1991.