Five "A's" of counseling to prevent smoking initiation in children and adolescents

Child's age	Ask	Advise	Assess	Assist	Arrange
Early childhood (0 to 4 years)	Ask parents: About their smoking habits and those of other household members (Forms to assist in screening are available from CEASE)*	Advise parents to maintain a smoke-free environment. Message should include health risks to parent and child and importance of parents as role models for child. (Educational and motivational materials available from CEASE)*	Assess readiness to quit among parents or other household smokers.	Assist parents in quit attempt by referral to self-help materials and/or to their own clinician. Quit support^¶: Smokefree.gov (800-QUIT-NOW) National Cancer Institute (877-44U-QUIT)	Arrange follow-up visit within 3 months if a parent smokes; check on parents' progress at each pediatric follow-up visit.
School age (5 to 12 years)	Ask child: How do you feel when someone is smoking near you, and what you do about it? Do you think that it is harmful to try smoking, and do you think that you will smoke when you are older? Have you tried smoking, and do you have friends who smoke?	Advise child to stop experimenting or give praise for remaining a nonsmoker and/or making an effort to avoid smoke exposure. Remind child of the negative short-term effects of tobacco use, including smell and decreased athletic performance, and personalized health risks (eg, exacerbation of asthma). Advise parents to quit if they are smokers and to give clear antismoking messages to their children. (Educational and motivational materials available from CEASE)*	Assess risk factors for initiating smoking or progressing to regular smoking, including level of experimentation, smoking among peers, depressive symptoms, school performance and attendance, and adverse experiences.	Assist parents in quit attempt if needed^¶. Assist child in developing refusal skills and avoiding exposure. Assist parents in efforts to prevent smoking in their children, through modeling, firm antismoking messages, and smoking bans.	Arrange follow-up visit within 1 to 2 months for any child who is experimenting with smoking or has concerning risk factors for smoking. Refer as needed for any identified risk factors, such as social or learning difficulties or mental health issues.
Adolescents and young adults	Ask adolescent: About smoking behavior in a confidential setting About smoking among peers About use of smokeless tobacco	Advise teens who are smoking to quit, reinforcing personalized health risks and danger of addiction. Praise teens who are not smoking, and remind them of health risks.	Assess motivation and symptoms of tobacco dependence in teens who are smoking. Assess risk factors for smoking initiation among those who are not smoking.	Assist teens who are smoking in quit attempt; include nicotine replacement and referrals as needed^Δ. Assist parents in efforts to prevent smoking in their children, through modeling, firm antismoking messages, and smoking bans.	Arrange follow-up visit within 1 month for any teen who is smoking to support quit attempt or assess motivation and barriers to quitting^Δ. Refer as needed for any identified risk factors, such as social or learning difficulties or mental health issues.

This guidance is based upon the "5 A's" model for tobacco cessation in adults^[1], modified for use in children and for prevention of tobacco initiation^[2]. The strategy can be adapted to prevent vaping initiation, although this has not been specifically studied.

* CEASE (Clinical Effort Against Secondhand Smoke Exposure), from Massachusetts General Hospital.
¶ Refer to UpToDate content on management of smoking cessation in adults.
Δ Refer to UpToDate content on management of smoking and vaping cessation in adolescents.

References:

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: US Department of Health and Human Services. Public Health Service; 2008
Klein JD, Camenga DR. Tobacco prevention and cessation in pediatric patients. Pediatr Rev 2004; 25:17.

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Five "A's" of counseling to prevent smoking initiation in children and adolescents