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CLINICAL TOOLS
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The following are questionnaires and databases that can be incorporated into a patient's chart or used to monitor quality. For more information and additional tools regarding quality improvement, please click here. The questionnaires here are tailored to assessing the teenager's willingness to change and the perceived risks and benefits of their tobacco use. |
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Tracking Form
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Patient Tracking Form
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This tracking form records the patient’s stage of change, actions taken by the provider, actions taken by the patient, and any provider comments concerning a tobacco use discussion during an appointment. It can be in a patient’s chart for future reference and to track movement along the
stages of change.
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Questionnaire
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Tobacco History Questionnaire
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This questionnaire is designed to assess the length of tobacco use, level of addiction, triggers, perceived benefits of tobacco use, number of previous quit attempts and quit methods, and personal challenges of quitting of a patient who reported tobacco use previously or through the Tobacco Use Questionnaire. It can be given directly to patents for completion or used by the provider as guidance for gathering information. |
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PATIENT HANDOUTS
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The following are informational forms that clinicians can hand to patients or parents. They can be edited or printed on your practice letterhead, although we cannot vouch for the accuracy of information once they are altered. These informational handouts were designed with the teenager who is not interested in quitting in mind. |
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List of Website Resources for Teens Who Have No Interest in Quitting
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This document can be given to the patient by a provider who wishes to direct him or her to the websites and links listed in the following section, allowing the teen to explore and utilize these web resources on his or her own time or between visits. Description language has been changed for the teen audience.
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Mood Journal
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This journal template can be printed and copies for the teenager to track how their mood is affected by daily events and their capacity to practice effective coping methods. It can help them to correlate stress, mood, and coping. |
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Why Should I Quit?
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This worksheet is designed to help teens identify clear reasons why they think they need to continue using tobacco and why quitting may be better for them in the long run. It can be copied and used every one or two weeks to help teens see if their decisions about smoking have changed and if they want to talk someone about it.
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WEBSITES
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The following are direct links to tools and solutions from websites other than HelpTeensQuit. By clicking on the link, you will be taken directly to the clinical resource that may be helpful for a teen who is not ready to quit. For a listing of homepage addresses for all of the websites referenced by HelpTeensQuit, please click here. |
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Patient Website
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Stress Management: How to Reduce, Prevent, and Cope with Stress
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This website provides a comprehensive guide to recognizing stress, what teens can do about stress and stressful situations, and offers simple and effective strategies for stress reduction which include making a stress journal, thinking of coping strategies, and creating a healthy diet and exercise routine. Also provides links to pages containing advice on how to handle burnout, job stress, and relationship stress. Website created by HelpGuide.org. |
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TeenQuit: Gallery of Gore
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This page contains pictures of diseased tongues, lungs, gums, lips, teeth, and feet caused by tobacco use. The teen can print out these pictures in cigarette-pack sized images to place on the outside of his or her pack in order to encourage tobacco use awareness and motivate to quit. Website corresponds to the ASCENT program. |
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TeenQuit: Piggy Bank Cost Calculator
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This page contains a cigarette cost calculator that allows the teen to enter the number of cigarettes smoked per day, how many years the teen plans to smoke (or has smoked already), and the cost of a pack of cigarettes. TeenQuit then calculates the amount of money the teen would save (or has spent) in order to motivate the teen to quit. Website corresponds to the ASCENT program. |
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TeenQuit: Real Stories
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This series of pages allows the teen to read several quit stories and think about the authors’ motivations to quit and quit methods. Website corresponds to the ASCENT program. |
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Tips for Coping with Stress
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This webpage offers specific tips and strategies for identifying stress triggers and trying out new ways for teens to manage time to keep them from feeling overwhelmed by problems or issues. An extensive list of specific stress situations provides further links that can help them with individual issues. Website by the Mayo Clinic.
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REFERRAL (return to top)
In general, referring a teen who is resistant to quitting to a tobacco cessation program may be counterproductive. However, depending on the perceived benefits of tobacco use, other referrals could help the teen explore alternative coping strategies. For example, a teen may say that smoking helps to ‘calm his nerves’, and therefore meeting with a counselor may be helpful. Or a teen who says she needs to smoke in order to maintain her weight might be willing to meet with a dietician or nutrition expert in addition to initiating a conditioning program. Of course, calling a local tobacco cessation specialist for additional ideas, and to discuss them when would be the appropriate time for a referral is strongly encouraged. For a listing of local tobacco cessation programs click here. |
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