Preparing To Quit

CLINICAL TOOLS (return to top)
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 teen’s prior quit attempts and identifying factors that may offer support or barriers to successfully quitting.

Tracking Form
Patient Tracking Form
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.

Questionnaire
Tobacco History Questionnaire
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.

PATIENT HANDOUTS (return to top)
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 for the teenager who is prepared to make and follow through on a plan to quit.

Title
Exercise Prescription
This worksheet provides information and tips for a teenager to create and implement a plan for regular cardiovascular exercise. Many teenagers who have not engaged in regular cardiovascular exercise may misinterpret their body’s response to increased activity. This “prescription” uses heart rate as a guide to monitoring exercise effectiveness. It also offers ideas for making exercise fun. This can be a central component of building alternative coping methods to tobacco use.


List of Website Resources for Teens Who Are Preparing to Quit
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.


Referral and Follow Up Form
This document contains a list of possible referrals and follow-up tasks (worksheets and journals) for the teen to complete or pursue after a provider visit. The document already lists the information for the PA Quitline and the DeterminedToQuit website, but the provider can insert individual counseling and local resources in the spaces provided.


Write Before You Light
This journal is designed to help the teen examine the relationship between his or her emotional health and tobacco use throughout the day. Teens can track projected smoking, actual smoking, associated mood, and possible environtal or social triggers that lead to craving tobacco. The journal can be easily duplicated and is accompanied by a brief set of instructions.

WEBSITES (return to top)
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 prepared to quit. For a listing of homepage addresses for all of the websites referenced by HelpTeensQuit, please click here.

Patient Website
American Cancer Society: Smokeless Tobacco
This page provides information describing smokeless tobacco products, tobacco company marketing strategies for these products, and how smokeless tobacco compares to cigarette smoking. Smokeless tobacco-related cancers are also described, as well as issues related to and strategies for quitting. Website by the American Cancer Society.


Determined to Quit: How to Quit
This “how to quit” page provides information about how to identify triggers, choose a cessation method, and devise a customized plan for quit day (“quit day checklist”) and the future. Website by the Commonwealth of Pennsylvania


Determined to Quit: Quit Companion
This “quit companion” allows the smoker to create a customized quit plan that utilizes cell phone text-messaging and communication to send personal reminders and motivational statements about triggers and staying quit. Smokers can also use this function to enter in how much they smoke, allowing the program to graphically represent the individual’s smoking patterns. Friends and family members can also use this function to send personalized emails and text messages to help a smoker stay quit. The function is able to be changed as a smoker’s habits and profile evolves. Website by the Commonwealth of Pennsylvania.


Determined to Quit: Support and Resources
This page provides personal quit stories, telephone resources, state and national websites, and books about quitting. Website by the Commonwealth of Pennsylvania.


TeenQuit: Crave Control
This page contains a list of 30 things to do instead of smoking and as a distraction when cravings strike. Website corresponds to the ASCENT program.


TeenQuit: Frequently Asked Questions
This page lists common questions and concerns about quitting smoking and living a tobacco-free, providing information or solutions to help. Website corresponds to the ASCENT program.


TeenQuit: Products that Help
This page contains a brief list and descriptions of nicotine replacement therapy and other medications to help teens quit. Encourages discussion with physician and warns that these products are not well-tested with teens. Website corresponds to the ASCENT program


TeenQuit: Quit Plan
This page allows the teen to create a quit plan customized to his or her quit date, triggers, coping strategies, support person(s), and quitting rewards. The quit plan product is printable. Website corresponds to the ASCENT program.


TeenQuit: Stressors Quiz
This page contains a checklist of common stressors that teens experience and can help a teen recognize which stressors affect him or her the most. After completion, the teen is directed to aspects of the TeenQuit website that address selected stressors. Website corresponds to the ASCENT program.

	REFERRAL (return to top) Many tobacco cessation programs are specifically designed to work with teens who are prepared to quit. We encourage you to contact your local programs to find out whether they are accepting referrals and if their program is right for your patient. For a listing of local tobacco cessation programs click here.

	Preparing to Quit
	In preparation, the teen is mentally prepared to quit and is ready to do the things that will support him or her to stop using tobacco. This is the time to practice alternative coping methods, begin cutting back on use, and implement a concrete quit plan. The following documents and web links offer ideas and tools to support your intervention.
	What You Can Do: 1) Clinical Tools Track his or her progress using a tracking form and brief questionnaires. 2) Patient Handouts Provide an informational handout describing the risks of tobacco use and rewards of quitting. 3) Websites Web-based tools that will help him or her think about the risks of tobacco use and the rewards of quitting. 4) Referral Consider an appropriate community-based referral.