Relapse

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 reasons for the teenager’s relapse and their willingness to try quitting again.

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 with the teenager who has relapsed.

Title
List of Websites for Teens Who Relapse
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.

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 has relapsed. For a listing of homepage addresses for all of the websites referenced by HelpTeensQuit, please click here.

Patient Website
Determined to Quit: Help for Relapses
This page explains how relapses are common and provides strategies for moving on to the next quit attempt. Website by the Commonwealth of Pennsylvania.


Determined to Quit: Staying Tobacco Free
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.


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: 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: 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) 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.

	Relapse
	Since the average tobacco user tries to quit an average of 9 times, it is not uncommon for a teen to suffer a relapse. It is vitally important to stay positive, build on each small success, and learn from valuable lessons of prior attempts. 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.