Passing your National Licensing Exam
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Passing your National Licensing Exam
Nicotine Dependence: The Fagerstrom Test and HONC
Nicotine dependence isn't just about willpower—it's a complex physiological and psychological phenomenon that requires sophisticated assessment tools to properly understand and treat. Today we dive into the science behind two gold-standard assessments that every mental health professional should know: the Fagerstrom Test for Nicotine Dependence and the Hooked on Nicotine Checklist (HONC).
The Fagerstrom Test has become the benchmark for measuring physical dependence in established smokers. We break down its six weighted questions and explain why that first morning cigarette is such a powerful predictor of addiction severity. You'll learn how to interpret scores, what they reveal about withdrawal patterns, and how they should guide your treatment recommendations. Whether your client needs nicotine replacement therapy or could succeed with behavioral interventions alone—this test gives you concrete data to inform those critical clinical decisions.
Meanwhile, the newer HONC assessment revolutionizes how we identify addiction in its earliest stages, particularly among adolescents. Discover why even one "yes" answer signals the beginning of brain changes that predict future smoking behavior, and how this tool catches dependence weeks or months before traditional assessments. We'll walk through a detailed case example that demonstrates how to integrate these complementary tools in clinical practice, connect them to DSM-5-TR diagnostic criteria, and adapt your interpretation for cultural considerations. Whether you're preparing for licensing exams or looking to enhance your clinical skills, these evidence-based assessment strategies will transform how you approach nicotine dependence in your practice.
What assessment tools do you currently use with clients struggling with tobacco use? Share your experiences and questions in the comments below!
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This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG, CRCC, or any state or governmental agency responsible for licensure.
Thank you so much for joining us. Smokes, cigs, butts, dip, chew, chaw and pinch just to bring you up to date on tobacco slang I remember when I was back in high school and was investigating the effects of smoking on the activity of mice for the science fair Believe it or not Phillips Morris sent me a 300-page full-color book on the advantages of smoking, with endorsements from numerous physicians and politicians. And you could actually smoke on airplanes, movie theaters, publics and even classrooms in college. Bet you'll never see that in your lifetime. Well, anyway, today I'm talking about the Fagerstrom Test for Nicotine Dependence and the Hooked on Nicotine Checklist, or HONC as it's called. And honestly, these aren't just tools you pull out randomly. They're game changers when you need to figure out exactly how dependent your client is on nicotine and what kind of treatment approach is going to work best, and maybe even get you that extra point on your licensing exam that will push you over the top. So pay attention. Well, let me start with the Fagerstrom test, because this one's been around for a while. Karla Fagerstrom developed the assessment instrument and it's basically become the gold standard for measuring nicotine dependence.
Speaker 1:What this test does is it looks at the physical aspects of addiction. You know the stuff that happens in your body when you're hooked on nicotine. It's asking questions like how soon after you wake up do you smoke your first cigarette, and do you find it difficult to not smoke in places where it's forbidden? So what's the point? The whole point is to figure out how physically dependent someone is on nicotine, not just psychologically. Now why does this matter so much? Well, think about it this way If you've got a client who lights up within five minutes of waking up, that's telling you something completely different than someone who waits until after lunch for their first smoke. The first person they're dealing with serious physical withdrawal symptoms that kick in overnight. Their body is literally screaming for nicotine the moment they're conscious. That's a very different treatment situation than someone who smokes more out of habit or social situations. The test has six questions and each one is weighted differently because and this is key not all smoking behaviors indicate the same level of dependence. That first question about time to first cigarette, that's worth up to three points because it's such a strong predictor of dependence. Compare that to do you smoke more frequently during the first hours after waking than during the rest of the day, which is only worth one point waking than during the rest of the day, which is only worth one point. The total score ranges from zero to 10. And, generally speaking, a score of eight or higher indicates high dependence. So let's talk reliability and validity here, because you need to know the instrument is actually measuring what it claims to measure. The Fagerstrom has solid internal consistency. The validity that's where this test really shines. It correlates strongly with biochemical markers, which is basically proof that people aren't just making stuff up when they answer these questions. Plus, it predicts treatment outcomes really well.
Speaker 1:Clients with higher Fagerstrom scores typically need more intensive interventions and have a harder time quitting without pharmacological support. When you're using the Fagerstrom in private practice, timing matters. You don't want to give this to someone who just walked into your office who is stressed about being there. Wait until you've built some rapport and they're comfortable being honest about their smoking habits. Also and this is something I've seen therapists mess up don't assume the score stays the same. Over time Someone's dependence level can change, especially if they've been trying to cut back or if their life circumstances have shifted. Here's a practical tip that'll save you some headaches when you're interpreting scores, don't just look at the total number. Pay attention to which specific questions they scored high on. A client who scores high on the time to first cigarette question is dealing with different challenges than someone who scores high on difficulty not smoking in forbidden places. The first person needs help managing physical withdrawal, while the second might need more behavioral interventions around impulse control and environmental triggers.
Speaker 1:Now let's talk about the Honk, the Hooked on Nicotine checklist. This one's newer, developed by DeFranza and his colleagues, and it takes a completely different approach. Where the Fagerstrom focuses on established smoking patterns and physical dependence, the Honk is all about identifying the very early signs of nicotine dependence in adolescents ages 12 to 15. We're talking about those first subtle changes that happen when someone's brain starts getting hijacked by nicotine. The Honk has 10 yes or no questions, and here's what makes it special Even one yes answer suggests some level of dependence. That might sound crazy at first, but the research backs this up. Questions like have you ever tried to quit but couldn't? Or is it hard to keep from smoking in places where you're not supposed to, are picking up on loss of autonomy, which is really the core feature of addiction. What's brilliant about the honk is that it can catch dependence in people who've only been smoking for a few weeks or months.
Speaker 1:The Feierstrom wasn't designed for that. It's looking at more established patterns, but with the honk you might identify an adolescent who's only been experimenting with cigarettes but is already showing signs that their brain is adapting to nicotine in ways that predict future problems. The reliability of the honk is actually quite good. The validity is where it gets really interesting, though. The honk correlates with biological markers of dependence, but more importantly, it predicts future smoking behavior. Kids who score positive on the honk are much more likely to become daily smokers and have a much harder time quitting later on.
Speaker 1:So when do you use each tool? The honk is your go-to when you're working with adolescents who are just starting to smoke or when you suspect they might be minimizing their level of dependence. The Fagerstrom, on the other hand, is what you want for established smokers who are ready to quit and need a treatment plan that matches their level of physical dependence. The Fagerstrom, on the other hand, is what you want for established smokers who are ready to quit and need a treatment plan that matches their level of physical dependence. Here's something that comes up on exams a lot the relationship between these tools and treatment planning. If someone scores high on the Fagerstrom, especially on that time to first to cry question. They're probably going to need nicotine replacement therapy or other medications. Their withdrawal symptoms are going to be intense and willpower alone usually isn't enough. But suppose someone scores positive on the honk but low on the Fagerstrom. In that case you might focus more on behavioral interventions and helping them understand how their brain is already changing in response to nicotine. Let me give you a case example that brings this all together in response to nicotine. Let me give you a case example that brings this all together.
Speaker 1:Sarah is a 32-year-old mental health therapist who comes to see you because her doctor told her she needs to quit smoking. She's been smoking for about eight years, currently about a pack a day. When you give her the Fagerstrom she scores an eight. That's high dependence. Specifically, she smokes her first cigarette within five minutes of waking up. She smokes more in the morning hours and she finds it really hard not to smoke in places where it's forbidden. What's that tell you? Sarah's dealing with significant physical dependence. Her nicotine levels drop overnight and she's experiencing withdrawal symptoms that wake her up or kick in immediately when she wakes up. The fact that she smokes more in the morning suggests her body is trying to get back to a baseline nicotine level and the difficulty not smoking in forbidden places. That's her experiencing cravings that are strong enough to override social norms and rules. For Sarah you're probably going to recommend a combination approach. The high Fagerstrom score suggests she'll benefit from nicotine replacement therapy, maybe a patch for steady state nicotine levels plus gum or lozenges for breakthrough cravings. You'll also want to work with her on that morning routine, because that first cigarette is so automatic it's probably happening before she's even fully conscious. Maybe you help her plan a new morning routine that builds in some delay and alternative activities.
Speaker 1:Here's something that trips up a lot of people on exams the difference between dependence and addiction. Dependence is about the physical and psychological changes that happen when someone uses nicotine regularly. Addiction includes dependence, but also involves continued use despite harmful consequences and the whole life disruption piece. Someone can be dependent on nicotine without meeting criteria for tobacco use disorder, especially in the early stages. And speaking of tobacco use disorder, let's talk about how these assessment tools connect to DSM-5-TR diagnoses. The DSM-5-TR has tobacco use disorder with severity specifiers mild, moderate or severe based on how many criteria someone meets. Neither the Fagerstrom nor the Honk directly maps onto DSM-5-TR criteria but they give you really useful information that supports your diagnostic process. A high Fagerstrom score especially that early morning smoking pattern is going to align with criteria. Like tobacco is often taken in larger amounts or over a longer period than was intended and there's a persistent desire or unsuccessful efforts to cut down or control tobacco use. The honk picks up on those early loss of control experiences that might indicate someone's heading toward meeting more criteria over time. So while you can't just plug in a test score and get a diagnosis, these tools help you gather the clinical information you need to make that DSM-5-TR determination.
Speaker 1:Another exam tip pay attention to the specific populations. These tools have been validated with the figure. Strum has been used with adults who are established smokers. The honk has been validated with adolescents. If you see a question about a 14-year-old who smokes occasionally, the honk is probably your better choice for assessment. One more thing that comes up frequently how to handle clients who you suspect aren't being completely honest about their smoking. This happens more than you might think, especially with adolescents or in situations where there might be negative consequences for admitting to smoking. The hop can actually be helpful here because the questions are phrased in a way that focuses on subjective experiences rather than specific behaviors. It's easier for someone to admit they've felt like they needed tobacco than to admit they smoke two packs a day.
Speaker 1:But let's talk about cultural considerations too, because this stuff matters in real practice. Both tools were developed and validated primarily with white Western populations, and smoking patterns can vary significantly across different cultural groups. Some cultures have very different attitudes toward tobacco use and the social aspects of smoking might be more or less important than the physical dependence aspects. You want to be thoughtful about how you interpret scores and make sure you're understanding your client's smoking behavior in the context of their cultural background.
Speaker 1:The other thing to keep in mind is that these tools are just starting points. They give you important information about level of dependence, but they don't tell you everything you need to know about your client's relationship with smoking. You still need to do a thorough assessment of triggers, motivation to quit, previous quit attempts, social support, mental health factors and all the other stuff that influences treatment success. So here's the bottom line Both the Fagerstrom and the Honk are solid, evidence-based tools that give you different but complementary information about nicotine dependence. The Fagerstrom tells you about established patterns of physical dependence and helps you match treatment intensity to dependence level. The Honk catches dependence early and helps you identify clients who might be developing problems before they become entrenched. Used together, they give you a really comprehensive picture of where your client stands and what kind of intervention is most likely to help them succeed. That's all you need to know and remember. It's in there.
