Prevention focus: which self-questionnaire for tobacco?

Fagerström, HONC, CDS… which self-questionnaire should be used to assess smoking?

Every consultation is an opportunity for prevention. However, between the reason for the consultation, additional examinations, treatments, and patient questions, it is not always easy to address smoking systematically.

And yet, the stakes are high. Tobacco remains the leading cause of preventable mortality in France today. According to Santé publique France, it is responsible for more than 68,000 deaths each year (1) and is a major risk factor for many pathologies, including cardiovascular diseases, cancers, and chronic respiratory diseases.

To support healthcare professionals, several validated questionnaires are available to quickly assess tobacco dependence, measure motivation to quit, or even identify the first signs of addiction.

In this article, we review the main tools used in clinical practice, their specificities, and their indications.

Why use a smoking questionnaire?

Addressing tobacco use in a consultation is not just about asking: "Do you smoke?".

Standardised questionnaires provide a more comprehensive assessment of the patient's situation and make it easier to tailor their care. They also facilitate monitoring over time based on validated criteria.

Specifically, they help to:

• assess the level of nicotine dependence;
• identify patients most at risk;
• measure their motivation to quit;
• monitor the evolution of their consumption over successive consultations;
• more easily initiate a dialogue around smoking cessation.

These tools obviously do not replace the discussion with the patient. They simply provide a structured starting point to guide the conversation.

What do health authorities recommend?

The French National Authority for Health (HAS) recommends systematically identifying the smoking status of patients and offering cessation support to every smoker, regardless of their initial motivation. (2)

For its part, the French National Health Insurance (Assurance Maladie) points out that simply discussing the subject with a healthcare professional increases the chances of successfully quitting smoking. (3) Validated questionnaires are therefore a valuable aid in objectifying the patient's situation and personalising their support.

The Fagerström Test

The Fagerström test is the best-known questionnaire for assessing physical dependence on nicotine.

It consists of six questions, focusing in particular on:

• the time between waking up and the first cigarette;
• the number of cigarettes smoked each day;
• situations where it is difficult not to smoke;
• consumption during the day.

Based on the answers, a score is calculated to estimate the level of dependence.

Why use it?

It allows for the quick identification of patients with a high level of dependence and the adaptation of the cessation strategy or nicotine replacement therapies.

Its strengths

• Quick to complete.
• Easy to interpret.
• Widely used in general medicine and tobacco cessation clinics.

Its limitations

It primarily assesses physical dependence and takes little account of psychological or behavioural aspects.

The HONC questionnaire

The Hooked On Nicotine Checklist (HONC) measures the loss of autonomy regarding tobacco.

Unlike the Fagerström test, it aims to identify the first signs of addiction, sometimes even in occasional smokers or adolescents.

Why use it?

It is particularly valuable for the early detection of an emerging dependence.

Its strengths

• Suited to young smokers.
• Detects the first signs of addiction.
• Complements the Fagerström test.

Its limitations

It is still relatively little used in everyday practice.

The Cigarette Dependence Scale (CDS)

The Cigarette Dependence Scale (CDS) offers a more comprehensive approach to dependence.

It takes into account, among other things:

• the urge to smoke;
• withdrawal symptoms;
• the difficulty in resisting a cigarette;
• the place of tobacco in daily life.

Why use it?

It provides a more complete view of dependence by also incorporating behavioural aspects.

Its strengths

• More detailed evaluation.
• Good sensitivity.
• Useful in monitoring cessation.

Its limitations

It takes a little longer to complete.

The Richmond Test

Dependence alone is not enough to support a patient.

The Richmond test helps to assess the patient's motivation to stop smoking.

Why use it?

It helps healthcare professionals tailor their support according to the patient's level of motivation.

Its strengths

• Very quick.
• Easy to use.
• Complements dependency questionnaires.

Its limitations

It does not measure dependence, only motivation.

Other questionnaires also exist

The self-questionnaires presented above do not, on their own, cover all the tools available for assessing tobacco use.

Depending on the context, other tools may be offered:

• Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ): helps to identify the behavioral and contextual dimension of smoking, beyond nicotinic dependence alone (4)
• Wisconsin Inventory of Smoking Dependence Motives (WISDM-68): analyses the different dimensions of tobacco dependence, mainly used in clinical research. (5)
• Tobacco Craving Questionnaire (TCQ): measures the intensity of the urge to smoke (specifically craving during withdrawal).
• Mondor Motivational Test: questionnaire on motivation to change, nowadays less used than the Richmond test.

The choice of questionnaire depends above all on the desired objective: measuring dependence, detecting a loss of autonomy, assessing motivation or monitoring a patient during withdrawal.

Which self-questionnaire to choose?

There is no single self-questionnaire

Each tool meets a different need.

In practice, these questionnaires are often complementary. A doctor can, for example, use the Fagerström test to estimate dependence, then the Richmond test to adapt their support according to the patient's motivation.

How to integrate these questionnaires without lengthening the consultation?

Even when they are quick, these questionnaires take a few minutes. If done during the consultation, they may be set aside due to lack of time.

Offering them before the appointment, on the contrary, allows you to have structured information available right from the start of the consultation.

At Aldebaran, the pre-consultation questionnaire integrates self-questionnaires tailored to the patient's profile and their responses. Once completed by the patient, their results are integrated into the medical summary sent to the healthcare professional before the consultation.

The doctor can thus devote more time to interacting with their patient rather than to gathering information.

Conclusion

Today, smoking assessment questionnaires are essential tools for supporting smoking patients.

Whether it is assessing dependence with the Fagerström test, detecting a loss of autonomy using the HONC, obtaining a more global view with the CDS, or measuring motivation with the Richmond test, each serves a specific purpose.

Used prior to the consultation, they allow healthcare professionals to have structured information at their disposal, better target their discussions, and more easily integrate prevention into their daily practice.