Quit Smoking Counselling


Counselling clients to quit smoking may be a part of your practice no matter what kind of therapy you do. While many clinicians may wish to refer clients to others for this work, learning the skills to handle smoking cessation may be a valuable addition to your work with clients in other areas and so is worth the time.

In Canada, about 1 in 5 individuals smoke (Statistics Canada, 2014) and this level has been going down, as it has in most western countries, for many years. Tobacco smoking often begins in the teen years (U.S. Department of Health and Human Services, 2012) with the Surgeon General noting that “vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.”

Smoking often affects the poor, mentally ill and other marginalized groups. (Passey & Bonevski, 2014) The mortality rate of both male and female smokers is three times higher than non-smokers and the rate of heart attack in middle aged men is four times higher. (CDC, n.d.)

Most individuals who attempt to quit smoking will require multiple attempts to quit, with sources citing between 5 and 30 (Chaiton, et. al., 2016).

Benefits of Quitting Smoking

The following list of health benefits comes from the World Health Organization (n.d.), and may help convince a smoker who believes that there is no point in quitting, to attempt to do so:

Within 20 minutes of your last cigarette, your heart rate and blood pressure drop.

Within 12 hours, the carbon monoxide level in your blood drops to normal.

2-12 weeks, your circulation improves and your lung function increases.

1-9 months, coughing and shortness of breath decrease.

1 year, your risk of coronary heart disease is about half that of a smoker’s.

5 years, your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.

10 years, your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases.

15 years, the risk of coronary heart disease is that of a nonsmoker’s.

The benefits are clear! But that doesn’t mean quitting smoking is easy.

Nicotine Withdrawal

When a client stops their regular smoking, they begin to experience withdrawal symptoms within about 2 hours (Medline, 2015) as the nicotine begins to leave their bloodstream. The Mood and Physical Symptoms Scale (West & Hajek, 2004) is a tool for measuring withdrawal symptoms. These symptoms can include depression, anxiety, irritability, restlessness, hunger, inability to concentrate, poor sleep and more.

Assessment of Smoking Behaviours

The Fagerstrom Test for Nicotine Dependence is a common measure of smoking-related behaviour. It asks six questions:

  1. How soon after waking do you smoke your first cigarette?
  2. Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
  3. Which cigarette would you hate to give up?
  4. How many cigarettes in a day do you smoke?
  5. Do you smoke more frequently in the morning?
  6. Do you smoke even if you are sick in bed most of the time?

See my article on assessments for substance use disorders for more information on the Fagerstrom Test.

Interventions to Quit Smoking

Nicotine Replacement Therapy (NRT)

Nicotine replacement therapy (NRT) includes products like patches, gum, inhalers and lozenges. Use of nicotine replacement therapy nearly doubled a client’s ability to quit smoking in a Cochrane review (Silagy, et. al., 2012) NRT is contraindicated  in the following groups (Department of Health, Western Australia, 2012):

  • Lactating women
  • Smokers under 12 years of age

As well, those:

  • Between 13 and 18
  • With severe heart problems

Should receive NRT under physician supervision. Additional recommendations (e.g. for people with diabetes, mental health issues or from specific cultural groups) are found in the Clinical Guidelines in the References. In general, clients should receive medical support from a GP who can properly monitor them when taking any medications, including NRT.

Motivational Interviewing

Motivational interviewing (MI) is a brief intervention that aims to highlight and amplify intrinsic motivation and intent to quit smoking that already exists in clients. (Rollnick & Allison, 2001) Some elements of motivational interviewing include (Sciacca, 2009):

  • Change and sustain talk, messages from the client that indicate either a willingness to change or a desire to keep things the way they are
  • Rolling with resistance, and recognizing a client’s desire not to change may be the result of the clinician’s approach, the client’s unreadiness or both
  • Ensuring empathy to build a strong relationship
  • Identifying discrepancies, for instance where a client’s values (“I want to be there for my children”) conflict with their behaviours (“My daughter had to wait in the rain so I could have a smoke”)

There is a large body of research (e.g. the metareview by Lundahl & Burke, 2009) supporting the effectiveness of motivational interviewing in helping clients to quit smoking or using other substances.

The 5 A’s of Quitting Smoking

The 5 A’s describe simple set of steps for a brief tobacco intervention, they come from MDQuit (2012).

  1. Ask – It’s important to ask the patient about their smoking. Do they smoke at all?
  2. Assess – If they do smoke, how much do they smoke. You may wish to use the Fagerstrom criteria for this (see above, Assessment for Substance Use Disorders)
  3. Assist – Help the client make an informed decision about their smoking behaviour if they wish to cut down.
  4. Advice – Provide information on the risks of continuing and the benefits of quitting.
  5. Arrange – Finally, arrange some form of followup if possible to check on their progress.

Quit Smoking Training

The Government of Western Australia has produced the Brief Tobacco Intervention Training Program designed to teach basic cessation skills to clinicians (nurses and doctors) in advising clients on how to quit smoking. It is available freely online and takes about 2 hours to complete.

The California Smokers Helpline provides a number of free courses and online webinars covering a variety of smoking cessation-related topics that may be eligible for Continuing Education (CE) credits.

In Canada, the Centre for Addiction and Mental Health provides the Training Enhancement in Applied Cessation Counselling and Health (TEACH) program, comprised of online and in-person workshops to teach clinicians skills in smoking cessation.


Centers for Disease Control and Prevention. (n.d.) “CDC – Fact Sheet – Tobacco-Related Mortality – Smoking & Tobacco Use”. Retrieved on August 11, 2016 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/

Chaiton, M., Diemert, L., Cohen, J., Bondy, S., Selby, P., Philipneri, A., & Schwartz, R. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open, 6(6), doi:10.1136/bmjopen-2016-011045

Department of Health, Western Australia. (2011) Clinical guidelines and procedures for the management of nicotine dependent inpatients. Perth: Smoke Free WA Health Working Party, Health Networks Branch, Department of Health, Western Australia; Retrieved on August 11, 2016 from http://www.health.wa.gov.au/smokefree/docs/Clinical_guidelines.pdf

Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. Journal Of Clinical Psychology, 65(11), 1232-1245. doi:10.1002/jclp.20638

Medline. (2015). Martin, L.J. “Nicotine and tobacco” Retrieved on August 11, 2016 from https://medlineplus.gov/ency/article/000953.htm

MDQuit. (2012) “Brief Interventions & 5 A’s | MDQuit.org” Retrieved on August 11, 2016 from http://mdquit.org/cessation-programs/brief-interventions-5

Passey, M., & Bonevski, B. (2014). The importance of tobacco research focusing on marginalized groups. Addiction, 109(7), 1049-1051. doi:10.1111/add.12548

Rollnick S., & Allison J. (2001) Motivational interviewing. In: Heather, N., Peters, T.J, & Stockwell T. International handbook of alcohol dependence and problems. New York, NY: Wiley; pp. 593-603.

Sciacca, K. (2009) “MOTIVATIONAL INTERVIEWING –MI, GLOSSARY & FACT SHEET” Retrieved on August 11, 2016 from http://www.motivationalinterview.net/miglossary.pdf

Silagy, C., Lancaster, T., Stead, L., Mant, D. & Fowler, G. (2007) Nicotine replacement therapy for smoking cessation (Review). The Cochrane Library. (3)

Statistics Canada. (2014) “Smoking, 2014”, Retrieved on August 11, 2016 from http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14190-eng.htm

U.S. Department of Health and Human Services. (2012) Preventing Tobacco Use Among
Youth and Young Adults: A Report of the Surgeon General. Retrieved on August 11, 2016 from http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

West, R. & Hajek, P. (2004). Evaluation of the mood and physical symptoms scale (MPSS) to assess cigarette withdrawal Psychopharmacology, 177, 195-199.

Cite this article as: MacDonald, D.K., (2016), "Quit Smoking Counselling," retrieved on June 26, 2019 from http://dustinkmacdonald.com/quit-smoking-counselling/.
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Assessments for Substance Use Disorders


Substance use disorders (also known as substance abuse) are a group of conditions where an individual experiences “the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.” (SAMHSA, 2015)

There are a variety of assessment tools used for determining the severity of the substance use disorder. These are reviewed below.

CAGE Alcohol Questionnaire

The CAGE Alcohol Questionnaire (O’Brien, 2008) is a four-item test to assess alcohol abuse. The letters “CAGE” are an acronym to help you remember the four questions:

  1. Have you ever felt you should cut down on your drinking?
  2. Have people annoyed you by criticizing your drinking?
  3. Have you ever felt bad or guilty about your drinking?
  4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Each question is scored yes or no, with one point per yes. A score of 2 or higher represents clinically significant potential for alcohol abuse. (Malet, et. al., 2005) There is also a modified scale for Drug Use, below:

CAGE Questions Adapted to Include Drug Use (CAGE-AID)

The psychometric properties of the CAGE-AID were tested in Dyson et. al. (1998) where it was found to be an effective tool.

  1. Have you ever felt you ought to cut down on your drinking or drug use?
  2. Have people annoyed you by criticizing your drinking or drug use?
  3. Have you felt bad or guilty about your drinking or drug use?
  4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Self-Administered Alcoholism Screening Test-Revised (SAAST-R)

The Self-Administered Alcoholism Screening Test (SAAST) was originally a 35-item self-administered test for alcohol abuse developed by Swenson & Morse in 1975 (see the Reference List for the citation – I haven’t been able to track down the original to read it.) It was updated by Vickers-Douglas, et. al. (2005) as the SAAST-R, and this is the version presented below.

The SAAST-R has shown good validity and reliability in subsequent studies (Patten, et. al., 2006)


  1. In your entire lifetime, have you ever had a drink of an alcoholic beverage?
  2. Have you ever felt that you used more alcohol than the average person?
  3. Have your close friends, relatives, or spouse ever worried or complained about your drinking?
  4. Have you ever had to struggle to stop drinking after one or two drinks?
  5. Have you always been able to stop drinking when you wanted to?
  6. Have you ever found that over time you needed to drink more and more alcohol to get the same effect?
  7. Have you ever gotten into physical fights when drinking?
  8. Has your drinking ever created problems between you and your spouse, parents, or other people you care about?
  9. Have you ever lost friendships because of your drinking?
  10. Have you ever gotten into trouble at work or school
  11. Have you ever lost a job because of your drinking?
  12. Have you ever neglected your obligations, your family, your work, or school activities for two or more days in a row because of drinking?
  13. Because of your drinking, have you ever given up or spent less time doing important recreational, social, or work activities?
  14. Have you ever spent a lot of your time getting alcohol, drinking alcohol, or recovering from drinking?
  15. Have you ever found that, over time, drinking the same number of drinks had less effect?
  16. Have you ever used alcohol in the morning or at the beginning of the day?
  17. Have you ever felt the need to cut down on you drinking?
  18. Within several hours or days of not drinking or drinking less than usual, have you ever experienced: (count each of the following present as one “yes” for the total score)
    1. restlessness, anxiety, or pacing?
    2. shaking?
    3. trouble sleeping?
    4. nausea or vomiting?
    5. seizures?
    6. hearing voices, seeing things, or feeling things on your skin that were not really there?
  19. Have you ever used alcohol to get rid of or reduce any of the above symptoms?
  20. Have you ever used alcohol to prevent any of the above symptoms from occurring?
  21. Have you ever had more to drink than you planned?
  22. Have you ever been told by a doctor to stop drinking (not including when you were pregnant, nursing, or taking a medication that should not be used or taken with alcohol)?
  23. Have you ever been a patient in a hospital or treatment facility because of problems related to your drinking?
  24. Have you ever continued to drink despite knowing you had a physical problem (for example, blackouts, liver disease) or a mental health problem (for example, depression) caused or made worse by your drinking?
  25. Have you ever been arrested, ever for few hours, because of driving while intoxicated?
  26. Other than driving-related arrests, have you ever been arrested, even for a few hours, because of your behavior while drinking?
  27. Have you repeatedly driven a car, truck, boat, or recreational vehicle or operated machinery when you had too much to drink?
  28. Have you ever received treatment for alcoholism?
  29. Have you ever attended a meeting of Alcoholics Anonymous (AA) because of your drinking?

The below items are used for the clinician’s benefit but are not calculated into the total score:

  1. How recently have you used any alcohol?
    1. Never have 6 <1
    2. In the past month
    3. 2 to 3 months ago
    4. 4 to 6 months ago
    5. 7 to 9 months ago
    6. 10 to 12 months ago
    7. 13 months to 2 years ago
    8. 2.1 to 5 years ago
    9. More than 5 years ago
  2. Which of the following best describes your entire life experience regarding use of alcohol?
    1. I have never used alcohol in my entire lifetime
    2. I currently use alcohol and I have never had a drinking problem
    3. I no longer use alcohol and I have never had a drinking problem
    4. I no longer use alcohol, but in the past I had a drinking problem
    5. I currently have a drinking problem
    6. Other

SAAST-R Scoring

In the original SAAST the cut-off score was greater-than or equal to 6 indicating the potential for alcoholism, with 10 indicating probable alcoholism (Davis & Morse, 1987), but in the revised SAAST-R the cut-off score is 4. (Patten, et. al., 2006) Given that the moderate to severe options explored in the original SAAST have not been validated yet, attempting to apply those ratings (e.g. equating a score of 10 on the SAAST-R with a score of 10 on the SAAST) should be done with caution.

Drug Abuse Screening Test (DAST)

The Drug Abuse Screening TEST (DAST) was developed as a 28-item self-report test for substance use or drug abuse by the Psychologist Harvey Skinner. It was based on the Michigan Alcohol Screening Test (MAST) but with the word alcohol changed to drugs. Subsequent review shortened the tool from 28 items to 20 and then to 10. It is now available in those two formats, the DAST-10 and the DAST-20.

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) provides a copy of the DAST-20 along with a review of its psychometric properties showing it is an effective tool for identifying struggling with addiction (2008).

The DAST-10 is available from the National Institute on Drug Abuse (n.d.). The DAST-20 and the DAST-10 have an extremely high reliability (r = 0.97) indicating they are virtually identical in their output scores. (Villalobos-Gallegos, 2015)

DAST Scoring

Each item in the DAST is scored yes or no, and the “yes” responses are summed to create a final score. On the DAST-20, a score of 6 or higher indicates an issue with drugs, while a score of 16 indicates severe addiction. (EMCDDA, 2008) on the DAST-20. The DAST-10 was found to have an optimal cut-off score of 4. (Evren, et. al., 2016)

Fagerstrom Test for Nicotine Dependence

The Fagerstrom Test for Nicotine Dependence is a 6-item tool for assessing nicotine dependence or severity of smoking addiction. It was developed in 1991 by Karl-Olov Fagerström. There are 3 yes/no items that are scored “0” (no) or “1” (yes), and 3 multiple choice items scored from 1-3. (NIDA, n.d.)

The items on the Fagerstrom Test are as follows (see the link for a printable version). The scores are in brackets:

  • How soon after waking do you smoke your first cigarette?
    • Within 5 minutes (3)
    • 5-30 minutes (2)
    • 31-60 minutes (1)
  • Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
    • Yes (1)
    • No (0)
  • Which cigarette would you hate to give up?
    • The first in the morning (1)
    • Any other (0)
  • How many cigarettes in a day do you smoke?
    • 10 or less (0)
    • 11 – 20 (1)
    • 21 – 30 (2)
    • 31 or more (3)
  • Do you smoke more frequently in the morning?
    • Yes (1)
    • No (0)
  • Do you smoke even if you are sick in bed most of the time?
    • Yes (1)
    • No (0)

The Fagerstrom Test has demonstrated fair reliability and validity but requires more comparative studies to test its validity. (Meneses-Gaya, 2009)

Fagerstrom Test Scoring

From the Brief Tobacco Intervention Training Program (BTITP) at Curtin University Australia comes the following scoring chart:

  • Score of 1-2 = low dependence; monitor for withdrawal symptoms but no Nicotine Replacement Therapy (NRT) necessary
  • Score of 3-4 = low to moderate dependence on nicotine; NRT can be offered
  • Score of 5-7 = moderate to high dependence on nicotine; NRT can be offered alone or in combination (e.g. patches with lozenges and gum)
  • Score of 8+ = high dependence on nicotine; NRT can be offered alone or in combination (e.g. patches with lozenges and gum)

The BTITP program provides a chart with recommendations for NRT:

nicotine replacement chart substance use tool

More Information

More information can be obtained from the book “Sourcebook of Adult Assessment Strategies (Nato Science Series B:)



Dyson, V. )., Appleby, L., Altman, E., Doot, M., Luchins, D., & Delehant, M. (1998). Efficiency and validity of commonly used substance abuse screening instruments in public psychiatric patients. Journal Of Addictive Diseases, 17(2), 57-76.

EMCDDA. (2008) EMCDDA | “Drug Abuse Screening Test (DAST-20)” Retrieved on July 31, 2016 from http://www.emcdda.europa.eu/html.cfm/index3618EN.html

Evren C, Can Y, Mutlu E, et al. Psychometric Properties of The Drug Abuse Screening Test (DAST-10) in Heroin Dependent Adults and Adolescents with Drug Use Disorder. Dusunen Adam: Journal Of Psychiatry & Neurological Sciences [serial online]. December 2013;26(4):351-359. Available from: Academic Search Complete, Ipswich, MA. Accessed July 31, 2016.

Malet, L., Schwan, R., Boussiron, D., Aublet-Cuvelier, B., & Llorca, P. (2005). Original article: Validity of the CAGE questionnaire in hospital.European Psychiatry, 20484-489. doi:10.1016/j.eurpsy.2004.06.027

Meneses-Gaya, I.C., Zuardi, A.W., Loureiro, S.R., & Crippa, J.A. (2009). Psychometric properties of the Fagerström Test for Nicotine Dependence. Jornal Brasileiro de Pneumologia, 35(1), 73-82.https://dx.doi.org/10.1590/S1806-37132009000100011

NIDA. (n.d.) “Instrument: Fagerstrom Test For Nicotine Dependence (FTND) | NIDA CTN Common Data Elements”. National Institute on Drug Abuse. Retrieved on July 31, 2016 from http://cde.drugabuse.gov/instrument/d7c0b0f5-b865-e4de-e040-bb89ad43202b

O’Brien, C.P. (2008) The CAGE Questionnaire for Detection of Alcoholism. Journal of the American Medical Association300(17):2054-2056. doi:10.1001/jama.2008.570.
Patten, C. A., Vickers, K. S., Offord, K. P., Decker, P. A., Colligan, R. C., Bronars, C., & … Hurt, R. D. (2006). Validation of the Revised Self-Administered Alcohol Screening Test (SAAST-R). American Journal On Addictions, 15(6), 409-421. doi:10.1080/10550490600996322

SAMHSA. (2015). “Substance Use Disorders | SAMHSA” Retrieved on July 31, 2016 from http://www.samhsa.gov/disorders/substance-use

Swenson, W.M., & Morse, R.M. (1975); “The Use of a Self-Administered Alcoholism Screening Test (SAAST) in a Medical Center;” Mayo Clinical Proceedings, 50, 204-208.

Vickers-Douglas, K., Patten, C., Decker, P., Offord, K., Colligan, R., Islam-Zwart, K., & … Hurt, R. (2005). Revision of the Self-Administered Alcoholism Screening Test (SAAST-R): A Pilot Study. Substance Use & Misuse, 40(6), 789-812. doi:10.1081/JA-200030662

Villalobos-Gallegos, L., Pérez-López, A., Mendoza-Hassey, R., Graue-Moreno, J., & Marín-Navarrete, R. (2015). Psychometric and diagnostic properties of the Drug Abuse Screening Test (DAST): Comparing the DAST-20 vs. the DAST-10. Salud Mental, 38(2), 89-94.

Cite this article as: MacDonald, D.K., (2016), "Assessments for Substance Use Disorders," retrieved on June 26, 2019 from http://dustinkmacdonald.com/assessments-substance-use-disorders/.

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