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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 how the teen is coping with having recently discontinued tobacco use. |
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Guide to Nicotine Replacement Therapies
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This brief guide to nicotine therapies is tailored to recommendations and the needs of teenagers. |
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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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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 teen who has recently quit. |
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Exercise Prescription
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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. |
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Referral and Follow Up Form
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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. |
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Write Before You Light
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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. |
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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 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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Determined to Quit: Quit Companion
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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. |
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Determined to Quit: Staying Tobacco Free
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This page and its links provide strategies for adopting a smoke-free lifestyle and dealing with cravings. Teens can also find a list of 101 things to do besides smoking for coping ideas, as well as a link to fun online games for distraction during cravings. Website by the Commonwealth of Pennsylvania. |
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Determined to Quit: Support and Resources
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This page provides personal quit stories, telephone resources, state and national websites, and books about quitting. Website by the Commonwealth of Pennsylvania. |
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TeenQuit: Crave Control
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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. |
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TeenQuit: Frequently Asked Questions
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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. |
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TeenQuit: Know Your Stats
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This page allows the teen to enter his or her average cigarettes per day and hypothetical quit date and the website will calculate the number of future cigarettes smoked, amount of minutes lost from life from smoking future cigarettes, average amount of money spent on future cigarettes, and offer financially-equivalent alternative activities. Website corresponds to the ASCENT program. |
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TeenQuit: Preventing Relapse
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This page warns the teen that relapse is common after quitting and offers some strategies to prevent it from happening. Website corresponds to the ASCENT program. |
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TeenQuit: Stressors Quiz
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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. |
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REFERRAL (return to top)
Many tobacco cessation programs offer support for clients during the first few months after completing a quit plan. 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. Additionally, mental health professionals may be able to offer support with any effects on mood or behavioral problems that are exacerbated by quitting. For a listing of local tobacco cessation programs click here. |
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