Assessment Tools Assessing Nicotine Addiction
Columns - Assessment Tools
Monday, 31 May 1999

The following form is an assessment tool counselors can use in determining the extent of nicotine addiction in their clients. The questionnaire should be graded on the following scale:

 

 

0 – Not at all or not applicable • 1 – A little bit • 2 – Somewhat • 3 – Quite a bit • 4 – Most or all of the time

 

Counselors should encourage clients to answer as honestly as possible and should review those areas that indicate frequent high usage and low usage of nicotine in planning a smoking-abstinence program.

 
01. I want a cigarette/nicotine within five minutes of waking up in the morning.
02. I want a cigarette/nicotine just before I go to bed at night.
03. I want a cigarette/nicotine after I eat a meal.
04. I want a cigarette/nicotine with, or after, dessert or with a cup of coffee.
05. I want a cigarette/nicotine when I see someone else lighting a cigarette or smoking.
06. I want a cigarette/nicotine when I see an ad for cigarettes or nicotine.
07. I want a cigarette/nicotine when I am late or when I am kept waiting.
08. I want a cigarette/nicotine when I am angry or frightened.
09. I want a cigarette/nicotine when I am criticized or when I make a mistake.
10. I want a cigarette/nicotine when I am lonely.
11. I want a cigarette/nicotine when I get bad news.
12. I want a cigarette/nicotine when I watch TV.
13. I want a cigarette/nicotine when I am driving a car.
14. I want a cigarette/nicotine when I hear the telephone ring.
15. I want a cigarette/nicotine when I have to do things that I don’t like to do.
16. I want a cigarette/nicotine at a party.
17. I want a cigarette/nicotine when I haven’t had one in 15 minutes.
18. I want a cigarette/nicotine when I haven’t had one in half an hour.
19. I want a cigarette/nicotine when I haven’t had one in one hour.
20. I want a cigarette/nicotine when I haven’t had one in more than one hour.
21. I want a cigarette/nicotine when I want to be part of the crowd.
22. I want a cigarette/nicotine when other people are smoking.
23. I want a cigarette/nicotine when I am faced with making a difficult decision.
24. I want a cigarette/nicotine just before an important meeting.
25. I want a cigarette/nicotine when things don’t work out the way I expected they would.
26. I want a cigarette/nicotine when I wake up in the middle of the night.
27. I want a cigarette/nicotine when I get short-tempered or irritable.
28. I want a cigarette/nicotine when I start craving a cigarette.
29. I want a cigarette/nicotine when I start having trouble concentrating.		 01. 0  1  2  3  4
02. 0  1  2  3  4
03. 0  1  2  3  4
04. 0  1  2  3  4
05. 0  1  2  3  4
06. 0  1  2  3  4
07. 0  1  2  3  4
08. 0  1  2  3  4
09. 0  1  2  3  4
10. 0  1  2  3  4
11. 0  1  2  3  4
12. 0  1  2  3  4
13. 0  1  2  3  4
14. 0  1  2  3  4
15. 0  1  2  3  4
16. 0  1  2  3  4
17. 0  1  2  3  4
18. 0  1  2  3  4
19. 0  1  2  3  4
20. 0  1  2  3  4
21. 0  1  2  3  4
22. 0  1  2  3  4
23. 0  1  2  3  4
24. 0  1  2  3  4
25. 0  1  2  3  4
26. 0  1  2  3  4
27. 0  1  2  3  4
28. 0  1  2  3  4
29. 0  1  2  3  4
 

 
In each issue, Assessment Tools provides effective, functional information designed to supplement and enhance the assessment process. We look forward to your input, and we encourage you to send in assessment tools and instruments of your own. Please send your ideas and suggestions to Professional Counselor, Assessment Tools, 3201 SW 15th St., Deerfield Beach, FL 33442; or fax to (954) 360-0034.
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