Assessing Nicotine Dependence

Author: Terry A. Rustin
Date: August 1, 2000

Family physicians can assess the smoking behavior of their patients in a few minutes, using carefully chosen questions. The CAGE questionnaire for smoking (modified from the familiar CAGE questionnaire for alcoholism), the "four Cs" test and the Fagerstrom Test for Nicotine Dependence help make the diagnosis of nicotine dependence based on standard criteria. Additional questions can be used to determine the patient's readiness to change and the nature of the reinforcement the patient receives from smoking. These tools can assist family physicians in guiding patients to quit smoking--the single most important thing smokers can do to improve their health. (Am Fam Physician 2000; 62:579-84,591-2.)

Family physicians can diagnose, evaluate and treat nicotine dependence within the limited time frame of an office visit.(1) This article describes several assessment strategies. Family physicians can select the one that best fits their style of practice. The information gathered by these assessments can then be used to provide individualized treatment plans.

CAGE Questionnaire

The CAGE questionnaire is a simple, accurate tool that has been used for many years to screen patients for addictive disorders.(2,3) The CAGE questions have been revised to apply to smoking behavior,(4) as shown in Table 1, and can be included in a clinical interview.

Examples of actual patient responses to these questions include the following:

Cut down: "I wanted to quit smoking, but I couldn't do it, so I switched to a low-tar cigarette."

Annoyed: "Last week, my granddaughter said to me, 'Grandma, I wish you would stop smoking,' and I snapped at her, 'Well, I'm old enough to smoke--are you?'"

Guilty: "I should have stopped smoking long ago--my family wouldn't have to suffer on my account like this if I had."

Eye-opener: "I smoke my first cigarette before my feet hit the floor."

Experience has shown the CAGE questionnaire to be nonthreatening. In one study, medical outpatients were given the CAGE questions embedded in a self-administered questionnaire about health habits, and most of them did not realize that they were filling out an assessment for addictions.(4)

'Four Cs' Test

Psychiatrists, psychotherapists, social workers and addiction counselors rely on criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) to diagnose substance dependence.5 These criteria apply to all addictive substances (e.g., alcohol, opioids, cannabis, amphetamines) and can be grouped into four categories that conveniently begin with the letter "C":

1. Compulsion--the intensity with which the desire to use a chemical overwhelms the patient's thoughts, feelings and judgment.

2. Control--the degree to which patients can (or cannot) control their chemical use once they have started using.

3. Cutting down--the effects of reducing chemical intake; withdrawal symptoms.

4. Consequences--denial or acceptance of the damage caused by the chemical.

The four Cs test can be used to assess a patient's dependence on nicotine (Table 2). Family physicians who feel comfortable discussing psychologic issues with their patients may prefer this approach, which documents a DSM-IV-based diagnosis of nicotine dependence.(6)

Fagerstrom Test

Patients who quit smoking and relapse within two or three weeks usually do so to relieve withdrawal symptoms secondary to their physical dependence on nicotine. The Fagerstrom Test for Nicotine Dependence is a standard instrument for assessing the intensity of this physical addiction.(7) The Fagerstrom test helps family physicians document the indications for prescribing medication for nicotine withdrawal. In the version shown in Figure 1, the language has been modified for American smokers.

The higher the Fagerstrom score, the more intense is the patient's physical dependence on nicotine. Higher scores indicate that treatment of withdrawal symptoms, usually with nicotine replacement therapy, will be an important factor in the patient's plan of care.

Assessing Reinforcement

Patients who quit smoking but relapse more than six weeks later are not smoking to relieve withdrawal symptoms; their relapses are caused by a desire to smoke (craving) induced by internal or external events. Assessing how each patient's smoking serves as a reinforcer can help the family physician identify potential relapse triggers for that person.

Physicians who have never smoked must make an effort to understand why smokers find cigarettes so reinforcing. Asking the following questions of a patient can help identify the reinforcing aspects of smoking behavior:


"Lots of smokers like the way a cigarette feels in their fingers. Or, they enjoy the puffing, the smoke and the warmth of a cigarette. What about you?"


"Lots of smokers have special things they like to do with a cigarette, such as what they do with the cigarette pack, the way they open it, the way they light up and the way they puff on the cigarette. What about you?"


"What sort of people smoke (the patient's brand of cigarettes)? What are they like?"


"Lots of smokers discover that cigarettes help them deal with stressful feelings, such as anger, frustration or boredom. What about you?"

Smoker's Profile

Elements gathered from the preceding assessments have been formulated into a smoker's profile; this profile is now available, along with explanatory material for patient use, on the author's Web site (http://www.Quitand The site includes an eight-page questionnaire to gather demographic information about patient smoking.8 There is no charge for patients or professionals to access this site or download the information.

The smoker's profile scores the intensity of the following four reasons that people smoke cigarettes: to relieve stress, to perform a conditioned response, to relieve withdrawal symptoms or to treat an underlying depressive state (Table 3).

Readiness to Change

After using one or more of the assessment tools, the family physician will have sufficient information to know what a patient needs to do to quit smoking. However, the physician will not yet know if the patient is ready to make a serious attempt to quit. Merely asking "Do you currently smoke?" gathers information about the patient's behavior but not about the cognition behind the behavior. Knowing the patient's cognitive set is crucial to success in quitting smoking because advice and treatment must match the patient's cognitive stage to be effective.

The Transtheoretical Model of Change is based on discrete stages along the continuum of change in cigarette smoking behavior. These stages are termed precontemplation, contemplation, preparation, action, maintenance and relapse (Table 4).(9-11)

Several instruments have been designed to measure the patient's readiness to change. The best known is the University of Rhode Island Change Assessment (URICA).(12) However, most physicians will do just as well with the following two-question assessment to determine the patient's stage of change:

1. "Do you currently smoke?"

2. (If yes): "What are your thoughts and feelings about quitting smoking?"


Patients in the precontemplation stage respond with a nonambiguous answer, indicating that they have no intention of changing. Some actual responses by smokers in this stage have been the following:

Anger: "Just get off my back, all right?"

Entitlement: "Who are you to tell me what to do?"

Ignorance: "I already smoke a low-tar cigarette, so there's no need to quit."

Denial: "Some people get lung cancer from smoking, but it won't happen to me."

Defiance: "I'll smoke if I want to."

The goal of counseling patients in the precontemplation stage is to introduce ambivalence, so they will begin to consider quitting; prescribing medication and strategies for cessation does not help these patients quit smoking.


Patients in the contemplation stage usually respond with two answers, one about wanting to quit and the other about wanting to continue smoking. Some actual responses by smokers in this stage have been:

"I want to quit smoking, but I don't think I'll be able to."

"I like smoking, but I'm concerned about this cough."

The goal of counseling patients in the contemplation stage is to explore both sides of their ambivalence (with the emphasis on how their lives will improve after quitting), which helps them resolve in favor of quitting.


Patients in the preparation stage respond with a nonambiguous answer, indicating that they have reached a resolution. Even though they are still smoking, they have made the decision to quit. They typically respond with statements like these:

"You finally convinced me to quit smoking, Doc."

"I've heard there's some new medication out to help me quit."

The goal of counseling patients in this stage is to assess their previous attempts to quit and identify what worked before (to build on prior successes) and what were the barriers to success in the past.

Patients in the precontemplation stage and patients in the contemplation stage have not yet decided to quit smoking; only patients in the preparation stage have reached that point.


The physician's responsibility is to guide patients one stage at a time toward the point where they actually stop smoking--which is the action stage. Although this transition takes some patients many years, others move fromcontemplation through preparation and into action within a single clinical encounter.

The author serves as a member of the speakers bureau for Glaxo Wellcome. He has previously been a member of the speakers bureau for CIBA-Geigy and Marion Merrell Dow.


(1.) The Agency for Health Care Policy and Research smoking cessation clinical practice guideline. JAMA 1996;275:1270-80.

(2.) Crowe RR, Kramer JR, Hesselbrock V, Manos G, Bucholz KK. The utility of the Brief MAST and the CAGE in identifying alcohol problems: results from national high-risk and community samples. Arch Fam Med 1997;6:477-83.

(3.) Morton JL, Jones TV, Manganaro MA. Performance of alcoholism screening questionnaires in elderly veterans. Am J Med 1996;101:153-9.

(4.) Lairson DR, Harrist R, Martin DW, Ramby R, Rustin TA, Swint JM, et al. Screening for patients with alcohol problems: severity of patients identified by the CAGE. J Drug Educ 1992;22:337-52.

(5.) American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:181.

(6.) Miller NS. Nicotine addiction as a disease. In: Cocores JA, ed. The clinical management of nicotine dependence. New York: Springer-Verlag, 1991:66-80.

(7.) Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991;86:1119-27.

(8.) Rustin TA. Quit and stay quit: a personal program to stop smoking. Center City, Minn.: Hazelden, 1994.

(9.) DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 1991;59:295-304.

(10.) Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller WR, Heather N, eds. Treating addictive behaviors: processes of change. New York: Plenum, 1986:3-27.

(11.) Rustin TA, Tate JC. Measuring the stages of change in cigarette smokers. J Subst Abuse Treat 1993; 10:209-20.

(12.) DiClemente CC, Hughes SO. Stages of change profiles in outpatient alcoholism treatment. J Subst Abuse 1990;2:217-35.

This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.

TERRY A. RUSTIN, M.D., is an assistant professor at the University of Texas Health Science Center, Houston, and a clinical assistant professor at Baylor College of Medicine. He is also director of the Dual Disorders Programs at the Mental Health and Mental Retardation Authority of Harris County, Texas. Dr. Rustin has developed a treatment program for nicotine dependence based on addiction recovery principles. He received his medical degree from the University of Oregon Medical School, Portland.

Address correspondence to Terry A. Rustin, M.D., 1502 Taub Loop, Houston, TX 77030. Reprints are not available from the author.

TABLE 1CAGE Questionnaire Modifiedfor Smoking Behavior[*]1. Have you ever felt a need to Cut down or control your smoking, but had difficulty doing so?2. Do you ever get Annoyed or angry with people who criticize your smoking or tell you that you ought to quit smoking?3. Have you ever felt Guilty about your smoking or about something you did while smoking?4. Do you ever smoke within half an hour of waking up (Eye-opener)?[*]--Two "yes" responses constitute a positive screening test.Information from Lairson DR, Harrist R, Martin DW, Ramby R, RustinTA, Swint JM, et al. Screening for patients with alcohol problems:severity of patients identified by the CAGE. J Drug Educ 1992;22:337-52.TABLE 2Assessing Nicotine AddictionUsing the "Four Cs" TestCompulsionDo you ever smoke more that you intend?Have you ever neglected a responsibility because you were smoking, or so you could smoke?ControlHave you felt the need to control how much you smoke but were unable to do so easily?Have you ever promised that you would quitsmoking and bought a pack of cigarettes that same day?Cutting down (and withdrawal symptoms)Have you ever tried to stop smoking? How many times? For how long?Have you ever had any of the following symptoms when you went for a while without a cigarette: agitation, difficulty concentrating, irritability, mood swings? If so, did the symptom go away after you smoked a cigarette?ConsequencesHow long have you known that smoking washurting your body?If you continue to smoke, how long do you expect to live? If you were able to quit smoking today and never start again, how long do you think you might live?Table 3Smoker's ProfileStress reliefWhen you're frustrated or angry, do you automatically think about smoking a cigarette?If you're upset or scared, does a cigarette help you calm down?Do you rely on cigarettes when you're under stress?Recall a time when you stopped smoking for a while. After you stopped smoking, did you want a cigarette more whenever you got upset or angry? Did you miss cigarettes more when you were under a lot of stress or tension?Conditioned responsesHow often do you smoke while you're driving a car or drinking a cup of coffee?If you're with someone who's smoking, do you automatically smoke, too?Do you usually smoke a cigarette during or after a meal?Recall a time when you stopped smoking for a while. Did being around smokers make it hard to not smoke? Were there certain people, places or things that made you want to smoke?Relief of withdrawal symptomsWhen do you smoke your first cigarette of the day?Do you get irritable if you have to go more than two hours without a cigarette?Do you have trouble concentrating if you're not smoking?Recall a time when you stopped smoking for a while. Did you get irritable or moody during the first few days after you stopped? Did you have trouble concentrating during the first few days after you stopped?Elevation of depressed moodRecall a time when you stopped smoking for a while. Did you become more depressed?When you woke up in the morning, did you feel that you could spend all day in bed?How was your energy level after you stopped smoking?TABLE 4Summary of Physician Counseling Based on the Stages of Change Patient response to: "What are your thoughts and feelingsStage of readiness about quitting smoking?" Goal of interventionPrecontemplation "I like to smoke." Introduce ambivalenceContemplation "I like to smoke, but I Resolve ambivalence know I need to quit."Preparation "I'm ready to quit." Identify successful strategiesAction "I'm not smoking, but I Provide solutions to still think about specific relapse smoking from time triggers to time."Maintenance "I used to smoke." Solidify patient's commitment to a smoke-free lifeStage of readiness Typical physician interventionPrecontemplation "Your emphysema will improve after you've quit smoking."Contemplation "How will your life be better after you've quit smoking?"Preparation "Choose a 'quit day' and let's make plans for it."Action "How can you deal with your desire to smoke in those situations?"Maintenance "This would be a good time to share your experience with other people."

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