The Fagerström Test is useful for determining a patient's level of nicotine addiction. The test assesses the extent to which nicotine controls the behavior. Healthcare providers working with smokers may download and print the test from the Related Resources section, and then have their patients complete the form and determine their own scores prior to counseling. Add the points acquired from each question. The total determines whether the patient is dependent on nicotine. Withdrawal symptoms are more likely with a higher score and are likely to be stronger.

View ReferencesHide References
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991; 86(9): 119-1127.

Assess the patient's stage in the quitting process. Quitting smoking is a process of change with several stages. People typically move through stages of change in a nonlinear, cyclical fashion (Prochaska and DiClemente 1982; Prochaska and Velicer 1997). Most successful former smokers have attempted to quit many times, repeating the cycle over and over. Hover over each step to get more information.

Contented UserA stage of pre-contemplation. No intention of taking action within the next 6 months. May be uninformed or under-informed of health consequences or may have attempted change many times and lost confidence that quitting is possible. Appears unmotivated or resistant to change.
Thinking about QuittingA stage of contemplation. Intends to change in the next 6 months. Aware of pros and cons of changes. Profound ambivalence or behavioral procrastination can develop as the person balances the pros and cons.
Deciding to QuitA stage of preparation. Intends to take action soon, usually within 30 days. May have a plan, such as buying a book, joining a class, or taking to a counselor. Very Interested in changing and has already decided to do so. Setting a quit date or signing up for a smoking cessation class are 2 types of preparation. Taking Zyban(R) and setting a quit date is another example.
Quitting A stage of action. A person has made behavior modifications within the last 6 months. With smoking, this step is equated with total abstinence.
RelapsingNot actually a stage but an event: first returns to smoking. It is quickly followed by return to one of the other stages of tobacco cessation. As a clinician, you can help motivate the patient to progress toward the action stage of quitting.
Staying QuitA stage of termination. No urge to do the behavior that is being avoided (e.g. no temptation to smoke) and 100% self-efficacy in managing it. Will never return to old habit regardless of situation. Former smokers are not likely to reach the termination stage. About 20% of ex-smokers reach termination.
Trying to Stay Quit A stage of maintenance. Working to prevent relapse, although fewer urges than someone in the action stage. Maintenance may last from 6 months to 5 years; however, some smokers remain in maintenance permanently.
View ReferencesHide References
Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice. 1982; 19: 276-288. Available at: http://psycnet.apa.org/journals/pst/19/3/276/ Accessed on: 2013-10-25.
Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. American Journal of Health Promotion. 1997; 12: 38-48. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10170434 Accessed on: 2013-10-25.

Picture of woman breaking cigaretteAssess the patient's interest in quitting by asking questions such as the following:

"Do you want to quit?" "Do you feel you need to quit?" "Are you ready to quit?"

It is important to understand how the tobacco user feels about quitting in order to determine what type of assistance to provide. Many smokers are not ready to quit but know enough about adverse health effects to know that they should quit. Others are ready to quit and can be provided assistance. Even if a smoker is not actively interested in quitting, it is still important to provide an intervention appropriate for his or her current frame of mind. Regular discussions about quitting can be effective.

A health professional's advice is respected. Patients want to believe their doctor's advice. Therefore, they must know you have an opinion about tobacco use.

Make a clear but caring statement, such as:

"As someone who is interested in your health and well-being, I think you should stop using tobacco, and very soon."

Even brief advice can significantly increase patient quit rates and long-term abstinence rates. As little as 3 minutes of advice has been shown to be effective (Fiore et al. 2008). Likewise, advise nonsmokers not to start using tobacco.

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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. Available at: https://www.ncbi.nlm.nih.gov/books/NBK63952/ Accessed on: 2013-09-26.

Establishing every patient's tobacco use status is like determining any other vital sign. As an alternative to a questionnaire completed by the patient, smoking status of patients can be assessed while vital signs are measured. The results may be entered in the patient record with the other vital signs. Making tobacco use queries a part of vital signs increases the likelihood of clinician intervention (Fiore et al. 2008)

Smoking Status Incorporated Into the Chart

VITAL SIGNS
Blood Pressure:
Pulse:
Weight:
Temperature:
Respiratory Rate:
Tobacco Use: Current Former Never

Or Added to a Vital Signs Sticker

Wt.________________ BP________________

** Tobacco-Free **

View ReferencesHide References
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. Available at: https://www.ncbi.nlm.nih.gov/books/NBK63952/ Accessed on: 2013-09-26.

Tobacco use status information must be readily available to healthcare providers and clinic staff. Mark tobacco use status on the patient record. The clinic receptionist or records manager can put a tobacco use identifying mark on each patient's chart -- "Free From Tobacco" or "Tobacco User" -- in a discrete area of the record to protect patient confidentiality. Absence of the tobacco use marker indicates a patient has not been asked about tobacco use. Making record identification a part of clinic routine increases the likelihood of clinician intervention (Fiore et al. 2008)

Example of a Tobacco Free sticker Example of a Tobacco User sticker

Some other ideas for where to store patient tobacco use information include the following:

  • With identification stickers on the patient record
  • With the vital signs
  • In electronic records
  • With an alternative universal identification system

(Fiore et al. 2008).

Some computer reminder systems may be customized to prompt you to enter this information.

View ReferencesHide References
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. Available at: https://www.ncbi.nlm.nih.gov/books/NBK63952/ Accessed on: 2013-09-26.

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