Headings
Tobacco use history · Readiness to quit · Previous attempts · Counseling given · Medication · Quit date · Follow-up
When to use it
Use this for a visit set aside to help someone quit tobacco or nicotine, whether it is the first attempt or a repeat try. It captures readiness, what failed before and the chosen medication, and it fixes a quit date so the follow-up call has a clear target. Brief advice given inside another visit can go in that note instead.
Example
Fictional example
Tobacco use history
T.L., 46. One pack per day for 25 years, 25 pack-years. First cigarette within 10 minutes of waking.
Readiness to quit
Ready now. Motivated by new grandchild.
Previous attempts
Nicotine patch alone in 2022, relapsed after 3 weeks during a stressful move.
Counseling given
Identified triggers: morning coffee and driving. Plan to change routine and remove cigarettes from car. Quitline number given.
Medication
Varenicline 0.5 mg daily for 3 days, then twice daily for 4 days, then 1 mg twice daily for 12 weeks. Nausea and sleep changes discussed.
Quit date
October 5, day 8 of varenicline.
Follow-up
Phone call 1 week after quit date. Visit in 4 weeks.