Smoking Cessation

Readiness assessment, consultation support, follow-up documentation, program evaluation, patient quit plan, consent form, prescription generation, and PMS-ready chart notes.

Shared Patient Information

Patient Name

Date of Birth

Address

Phone

Shared Pharmacist / Site

Pharmacist Name

License / OCP Number

Practice Location / Pharmacy Name

Pharmacy Address

Pharmacy Phone

Pharmacy Fax

Tab 1 Readiness Assessment & Consent

Assessment Date

Date of Enrolment

Ask Screen for Readiness

1. Interested in quitting in the next month?

Yes No

2. Willing to set a QUIT date?

Yes No

3. Would like to enrol in the FREE Quit Smoking Program?

Yes No

WARNING: Patient is not ready to enrol at this time. Provide educational materials and encourage self-reflection. No signature is required. Proceed with an information-only contact.

Advise Counselling Prompt

Quitting smoking is the most important thing you can do to protect your health now and in the future. Evidence suggests smoking cessation programs can reduce the risk of chronic disease and subsequent use of the health care system. Remind the patient that as an ODB recipient, this program is FREE.

Advise step completed — patient counselled on health risks and program benefits

Assess Ready Ruler

How important is it to QUIT SMOKING for good?

Not at all 1 2 3 4 5 6 7 8 9 10 Completely

How practical is it to quit NOW?

Not at all 1 2 3 4 5 6 7 8 9 10 Completely

How confident are you to do what it takes to quit FOR GOOD?

Not at all 1 2 3 4 5 6 7 8 9 10 Completely

Consent Patient Agreement & Enrolment

Complete this section only if the patient answered YES to all three ASK questions and agrees to set a quit date. Both signatures are required before PIN 93899941 can be claimed.

Expected QUIT Date

Patient Signature (name/initials)

Pharmacist Signature (name)

If Communication Method = Other, specify

Agreed Communication Method

In-person Telephone Email Other

Patient agrees to work with the pharmacist to stop smoking on the quit date indicated.

Patient consents to sharing health information within the circle of care to support the quit program.

Comments

Billing PIN 93899941 ($40) is submitted AFTER the first consultation meeting, provided the readiness assessment, enrolment agreement, and consent are all completed and signed. May only be claimed once per year per patient.

Tab 2 Initial Consultation

Consultation Date

Consultation Title

1 Tobacco History

Cigarettes / Day (CPD)

Years Smoking

Pack-Years (auto)

Tobacco Type

Time to First Cigarette After Waking

≤5 min 6–30 min 31–60 min >60 min

Previous Quit Attempts

Longest Quit Duration

Reasons for Previous Relapses

2 Medical / Medication History

Check all that apply — these drive contraindication screening.

Seizure disorder (active or history) Eating disorder (anorexia nervosa / bulimia) Pregnancy / breastfeeding Severe renal impairment (CrCl <30 mL/min) Recent MI or unstable angina (<3 months) Psychiatric illness (depression, bipolar, schizophrenia) Current MAOI use Diabetes Other significant condition

If other, specify

Current Medications (including OTC / herbals)

Allergies / ADRs

3 Triggers & Coping Strategies

Common Triggers (check all that apply)

Stress / anxiety Social situations / peer pressure Alcohol use Morning routine / coffee After meals Driving Boredom Work breaks

Other Triggers

Planned Coping Strategies (specific to identified triggers)

4 Pharmacotherapy Selection

Nicotine Replacement Therapy (NRT)

Nicotine Patch

Dose

Sig

Nicotine Gum

Dose

Sig

Nicotine Lozenge

Dose

Sig

Nicotine Inhaler

Cartridges/day

Sig

Nicotine Mouth Spray

Sprays/episode

Sig

NRT Start Date

Prescription Therapy

Varenicline (Champix)

Standard regimen: 0.5 mg OD × 3 days → 0.5 mg BID × 4 days → 1 mg BID × 12 weeks. Start 1–2 weeks before quit date.

GI side effect note: If nausea occurs, reduce to 0.5 mg BID. Take with food and full glass of water.

Dose (override if needed)

Start Date

Quantity / Duration

ODB LU Code 423 — Eligibility: ≥10 CPD, willing to set quit date, enrolled in counselling program.

Confirm patient meets LU 423 eligibility criteria

Bupropion SR (Zyban)

Standard regimen: 150 mg OD × 3 days → 150 mg BID × 12 weeks. Start 1–2 weeks before quit date. Allow ≥8 hours between doses.

Dose (override if needed)

Start Date

Quantity / Duration

ODB LU Code 423 — Same eligibility criteria as Varenicline.

Confirm patient meets LU 423 eligibility criteria

5 Next Steps

Confirmed Quit Date

Next Appointment Date

Next Contact Method

In-person Telephone Email Other

Resources Provided (check all given)

Smokers' Helpline (1-877-513-5333) Stop-smoking medications handout CAMH / SmokeFreOntario resources Other

Additional Pharmacist Notes

Reference Tools

Tab 3 Follow-Up Counselling Sessions

Type Session Type & Number

Session Type

Primary (Sessions 1–3) Secondary (Sessions 4–7)

Session Number

Billing: PIN 93899942 ($15) — Primary Follow-up | max 3/year
Claim after documentation is complete. Must occur within 21 days of first consultation.

Details Session Information

Session Date

Contact Method

In-person Telephone Video Email Other

Location / Other Detail

Status Quit Status

Have you had any cigarettes since your quit date?

No — still smoke-free Yes — had cigarettes

✓ Great work — congratulate the patient and reinforce smoke-free progress!

Encourage the patient to keep trying — relapse is part of the process.

Approx. cigarettes/day now

Meds Medication Review

Medication (if applicable)

Is the medication helping?

Yes No

Any bothersome side effects?

Yes No

Side Effect Details

Triggers Triggers & Strategies (Primary Sessions)

Able to overcome triggers?

Yes No

Problems with cravings or withdrawal symptoms?

Yes No

What has worked

What has not worked

Craving / withdrawal notes

Notes Additional Information

Additional Notes

Next Appointment / Follow-Up Plan

⚠ Patient wishes to withdraw from the program

Complete the Program Evaluation tab. No further sessions are billable. Patient informed of eligibility to re-enrol in 1 year.

Tab 4 Program Evaluation

Patient Evaluation Details

Evaluation Date

Date of First Consultation Used to calculate re-enrolment eligibility (1 year from this date).

Outcome Program Outcome

Select ONE outcome per patient per year. Once an evaluation PIN is claimed, no further sessions are billable for this program period.

✓ Successful Quit PIN 93899944

Patient has successfully quit smoking. Congratulate the patient on this achievement. No further sessions are scheduled or billable. Patient may re-enrol one year from the date of first consultation if needed.

Unsuccessful Quit PIN 93899945

Patient has not succeeded in quitting at this time. Inform patient of eligibility to re-enrol one year from the date of first consultation. No further sessions are billable for this program period.

Unknown Status / Withdrawal PIN 93899946

Patient could not be reached, or withdrew without indicating quit status. No further sessions are billable for this program period. Patient may re-enrol one year from the date of first consultation.

Re-enrolment: Patient was informed they may re-enrol in the program one year from the date of their first consultation.

Re-enrolment eligibility communicated to patient

Notes Additional Information

Additional Notes

Billing: Submit the applicable evaluation PIN on the date the pharmacist is made aware of the patient's quit status. No remuneration — for program tracking purposes only.
Record keeping: Retain documentation for 2 years (ODB audit) and 10 years as part of the patient health record.

Smoking Cessation

Nicotine Replacement Therapy (NRT)

Prescription Therapy

Generated Output