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Table 1 Survey questions used to capture data on the 5As

From: Physician and patient concordance of report of tobacco cessation intervention in primary care in India

5As Patients’ survey Physicians’ survey
Ask Have you been asked about your tobacco consumption habit during today’s visit? Do you take the history of tobacco usage of the patients who come to you?
Advise Did your physician advise you to quit tobacco? Do you tell people who come to you to quit tobacco use?
Assess Did your physician ask for your willingness to quit? Do you ask whether patient is willing to quit tobacco?
Assist Did your physician inform you about different medicines for quitting? During the past 12 months, did you suggest nicotine replacement therapy such as a patch or gum?
Did your physician suggest ways to quit tobacco use? During the past 12 months, did you perform one time counselling to your patients to help them quit?
Did your physician provide you any printed material (take away material)? Have you ever given any printed material (take away material) to the patient?
Arrange Did your physician inform you about the further follow up at higher centres? During the past 12 months, did you arrange for counselling with follow-ups?
Did your physician tell you when to return for follow-up counselling?