Nicotine Dependence: The Fagerstrom Test and HONC

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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!

If you need to study for your national licensing exam, try the free samplers at: LicensureExams


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.

Episode Transcript

Speaker 1 (00:17):
Thank you so much for joining us.
Smokes, cigs, butts, dip, chew,chaw and pinch just to bring
you up to date on tobacco slangI remember when I was back in
high school and wasinvestigating the effects of
smoking on the activity of micefor the science fair Believe it
or not Phillips Morris sent me a300-page full-color book on the
advantages of smoking, withendorsements from numerous

(00:40):
physicians and politicians.
And you could actually smoke onairplanes, movie theaters,
publics and even classrooms incollege.
Bet you'll never see that inyour lifetime.
Well, anyway, today I'm talkingabout the Fagerstrom Test for
Nicotine Dependence and theHooked on Nicotine Checklist, or
HONC as it's called.
And honestly, these aren't justtools you pull out randomly.

(01:01):
They're game changers when youneed to figure out exactly how
dependent your client is onnicotine and what kind of
treatment approach is going towork best, and maybe even get
you that extra point on yourlicensing exam that will push
you over the top.
So pay attention.
Well, let me start with theFagerstrom test, because this
one's been around for a while.
Karla Fagerstrom developed theassessment instrument and it's

(01:25):
basically become the goldstandard for measuring nicotine
dependence.
What this test does is it looksat the physical aspects of
addiction.
You know the stuff that happensin your body when you're hooked
on nicotine.
It's asking questions like howsoon after you wake up do you
smoke your first cigarette, anddo you find it difficult to not
smoke in places where it'sforbidden?

(01:46):
So what's the point?
The whole point is to figureout how physically dependent
someone is on nicotine, not justpsychologically.
Now why does this matter somuch?
Well, think about it this wayIf you've got a client who
lights up within five minutes ofwaking up, that's telling you
something completely differentthan someone who waits until
after lunch for their firstsmoke.
The first person they'redealing with serious physical

(02:09):
withdrawal symptoms that kick inovernight.
Their body is literallyscreaming for nicotine the
moment they're conscious.
That's a very differenttreatment situation than someone
who smokes more out of habit orsocial situations.
The test has six questions andeach one is weighted differently
because and this is key not allsmoking behaviors indicate the
same level of dependence.

(02:29):
That first question about timeto first cigarette, that's worth
up to three points because it'ssuch a strong predictor of
dependence.
Compare that to do you smokemore frequently during the first
hours after waking than duringthe rest of the day, which is
only worth one point waking thanduring the rest of the day,
which is only worth one point.
The total score ranges fromzero to 10.
And, generally speaking, ascore of eight or higher

(02:50):
indicates high dependence.
So let's talk reliability andvalidity here, because you need
to know the instrument isactually measuring what it
claims to measure.
The Fagerstrom has solidinternal consistency.
The validity that's where thistest really shines.
It correlates strongly withbiochemical markers, which is
basically proof that peoplearen't just making stuff up when

(03:10):
they answer these questions.
Plus, it predicts treatmentoutcomes really well.
Clients with higher Fagerstromscores typically need more
intensive interventions and havea harder time quitting without
pharmacological support.
When you're using theFagerstrom in private practice,
timing matters.
You don't want to give this tosomeone who just walked into
your office who is stressedabout being there.

(03:31):
Wait until you've built somerapport and they're comfortable
being honest about their smokinghabits.
Also and this is something I'veseen therapists mess up don't
assume the score stays the same.
Over time Someone's dependencelevel can change, especially if
they've been trying to cut backor if their life circumstances
have shifted.
Here's a practical tip that'llsave you some headaches when

(03:52):
you're interpreting scores,don't just look at the total
number.
Pay attention to which specificquestions they scored high on.
A client who scores high on thetime to first cigarette
question is dealing withdifferent challenges than
someone who scores high ondifficulty not smoking in
forbidden places.
The first person needs helpmanaging physical withdrawal,
while the second might need morebehavioral interventions around

(04:14):
impulse control andenvironmental triggers.
Now let's talk about the Honk,the Hooked on Nicotine checklist
.
This one's newer, developed byDeFranza and his colleagues, and
it takes a completely differentapproach.
Where the Fagerstrom focuses onestablished smoking patterns
and physical dependence, theHonk is all about identifying
the very early signs of nicotinedependence in adolescents ages

(04:37):
12 to 15.
We're talking about those firstsubtle changes that happen when
someone's brain starts gettinghijacked by nicotine.
The Honk has 10 yes or noquestions, and here's what makes
it special Even one yes answersuggests some level of
dependence.
That might sound crazy at first, but the research backs this up
.
Questions like have you evertried to quit but couldn't?

(05:00):
Or is it hard to keep fromsmoking in places where you're
not supposed to, are picking upon loss of autonomy, which is
really the core feature ofaddiction.
What's brilliant about the honkis that it can catch dependence
in people who've only beensmoking for a few weeks or
months.
The Feierstrom wasn't designedfor that.
It's looking at moreestablished patterns, but with

(05:21):
the honk you might identify anadolescent who's only been
experimenting with cigarettesbut is already showing signs
that their brain is adapting tonicotine in ways that predict
future problems.
The reliability of the honk isactually quite good.
The validity is where it getsreally interesting, though.
The honk correlates withbiological markers of dependence
, but more importantly, itpredicts future smoking behavior

(05:44):
.
Kids who score positive on thehonk are much more likely to
become daily smokers and have amuch harder time quitting later
on.
So when do you use each tool?
The honk is your go-to whenyou're working with adolescents
who are just starting to smokeor when you suspect they might
be minimizing their level ofdependence.
The Fagerstrom, on the otherhand, is what you want for
established smokers who areready to quit and need a

(06:04):
treatment plan that matchestheir level of physical
dependence.
The Fagerstrom, on the otherhand, is what you want for
established smokers who areready to quit and need a
treatment plan that matchestheir level of physical
dependence.
Here's something that comes upon exams a lot the relationship
between these tools andtreatment planning.
If someone scores high on theFagerstrom, especially on that
time to first to cry question.
They're probably going to neednicotine replacement therapy or
other medications.
Their withdrawal symptoms aregoing to be intense and

(06:27):
willpower alone usually isn'tenough.
But suppose someone scorespositive on the honk but low on
the Fagerstrom.
In that case you might focusmore on behavioral interventions
and helping them understand howtheir brain is already changing
in response to nicotine.
Let me give you a case examplethat brings this all together in
response to nicotine.
Let me give you a case examplethat brings this all together.

(06:49):
Sarah is a 32-year-old mentalhealth therapist who comes to
see you because her doctor toldher she needs to quit smoking.
She's been smoking for abouteight years, currently about a
pack a day.
When you give her theFagerstrom she scores an eight.
That's high dependence.
Specifically, she smokes herfirst cigarette within five
minutes of waking up.
She smokes more in the morninghours and she finds it really
hard not to smoke in placeswhere it's forbidden.

(07:12):
What's that tell you?
Sarah's dealing withsignificant physical dependence.
Her nicotine levels dropovernight and she's experiencing
withdrawal symptoms that wakeher up or kick in immediately
when she wakes up.
The fact that she smokes morein the morning suggests her body
is trying to get back to abaseline nicotine level and the

(07:33):
difficulty not smoking inforbidden places.
That's her experiencingcravings that are strong enough
to override social norms andrules.
For Sarah you're probably goingto recommend a combination
approach.
The high Fagerstrom scoresuggests she'll benefit from
nicotine replacement therapy,maybe a patch for steady state
nicotine levels plus gum orlozenges for breakthrough
cravings.
You'll also want to work withher on that morning routine,

(07:55):
because that first cigarette isso automatic it's probably
happening before she's evenfully conscious.
Maybe you help her plan a newmorning routine that builds in
some delay and alternativeactivities.
Here's something that trips up alot of people on exams the
difference between dependenceand addiction.
Dependence is about thephysical and psychological
changes that happen when someoneuses nicotine regularly.

(08:16):
Addiction includes dependence,but also involves continued use
despite harmful consequences andthe whole life disruption piece
.
Someone can be dependent onnicotine without meeting
criteria for tobacco usedisorder, especially in the
early stages.
And speaking of tobacco usedisorder, let's talk about how
these assessment tools connectto DSM-5-TR diagnoses.

(08:37):
The DSM-5-TR has tobacco usedisorder with severity
specifiers mild, moderate orsevere based on how many
criteria someone meets.
Neither the Fagerstrom nor theHonk directly maps onto DSM-5-TR
criteria but they give youreally useful information that
supports your diagnostic process.

(08:58):
A high Fagerstrom scoreespecially that early morning
smoking pattern is going toalign with criteria.
Like tobacco is often taken inlarger amounts or over a longer
period than was intended andthere's a persistent desire or
unsuccessful efforts to cut downor control tobacco use.
The honk picks up on thoseearly loss of control

(09:20):
experiences that might indicatesomeone's heading toward meeting
more criteria over time.
So while you can't just plug ina test score and get a
diagnosis, these tools help yougather the clinical information
you need to make that DSM-5-TRdetermination.
Another exam tip pay attentionto the specific populations.
These tools have been validatedwith the figure.

(09:43):
Strum has been used with adultswho are established smokers.
The honk has been validatedwith adolescents.
If you see a question about a14-year-old who smokes
occasionally, the honk isprobably your better choice for
assessment.
One more thing that comes upfrequently how to handle clients
who you suspect aren't beingcompletely honest about their
smoking.
This happens more than youmight think, especially with

(10:03):
adolescents or in situationswhere there might be negative
consequences for admitting tosmoking.
The hop can actually be helpfulhere because the questions are
phrased in a way that focuses onsubjective experiences rather
than specific behaviors.
It's easier for someone toadmit they've felt like they
needed tobacco than to admitthey smoke two packs a day.
But let's talk about culturalconsiderations too, because this

(10:26):
stuff matters in real practice.
Both tools were developed andvalidated primarily with white
Western populations, and smokingpatterns can vary significantly
across different culturalgroups.
Some cultures have verydifferent attitudes toward
tobacco use and the socialaspects of smoking might be more
or less important than thephysical dependence aspects.
You want to be thoughtful abouthow you interpret scores and

(10:48):
make sure you're understandingyour client's smoking behavior
in the context of their culturalbackground.
The other thing to keep in mindis that these tools are just
starting points.
They give you importantinformation about level of
dependence, but they don't tellyou everything you need to know
about your client's relationshipwith smoking.
You still need to do a thoroughassessment of triggers,
motivation to quit, previousquit attempts, social support,

(11:12):
mental health factors and allthe other stuff that influences
treatment success.
So here's the bottom line Boththe Fagerstrom and the Honk are
solid, evidence-based tools thatgive you different but
complementary information aboutnicotine dependence.
The Fagerstrom tells you aboutestablished patterns of physical
dependence and helps you matchtreatment intensity to

(11:33):
dependence level.
The Honk catches dependenceearly and helps you identify
clients who might be developingproblems before they become
entrenched.
Used together, they give you areally comprehensive picture of
where your client stands andwhat kind of intervention is
most likely to help them succeed.
That's all you need to know andremember.
It's in there.