Description
“The label says five percent. That’s not much, is it?” The client is not asking for a lecture. They genuinely do not know what they are using.
For clinicians, coaches and quit advisors
Plenty of worksheets let you print and use them with clients. This one does too. Here is what it adds.
- You may give a client their own blank copy to keep, by email or through a secure patient portal.
- You may use it in groups you run yourself.
- You may print without limit, for as long as you practice.
- And a written license page comes as a separate sheet in the download, so your practice has something to file.
One practitioner. Not transferable to a colleague, and not for resale.
The free page, and what this set adds
Page 1, how it began, is also in the free library on its own. You can use it with clients as it is.
This set adds the four pages around it: how strong the hold is, the device and the label, the numbers worked out from that label, and a thought record for the story underneath.
Written for vaping
Not a smoking worksheet with the word cigarette crossed out. Vaping rarely comes in single, countable moments, the strength is printed in units most people cannot read, and the device may be a disposable, a pod or a tank. Every page is built around that — by a nurse with twenty-five years in pulmonary care who is also a certified quit coach.
Why the label, and not a guess
E-liquid strength is labelled in mg/ml or as a percentage, and people who vape often misjudge both, percentages most of all. A client who says “only five percent” may be using one of the stronger liquids on the market without knowing it.
Page 3 records what the label actually says and which kind of label it is. Page 4 then works out an indication from it: millilitres a day, nicotine in that liquid a day and a week, and what it costs. Each calculation is shown with its source. Where there is no label, there is no nicotine figure — only amount and cost.
What you get
Five pages — US Letter and A4 both included — 86 fields: 77 to fill in, and 9 that calculate themselves.
Plus the license page, in both sizes.
1 — My Vaping Story
How it began: the age of the first vape and of daily use, years vaping and years smoked before, and whether vaping came to stop smoking, alongside it, or without smoking at all. Ten everyday moments to tick, and the one hardest to imagine giving up. What has been tried before, what changed, and the turning point.
2 — How Strong Is the Hold
Six questions about the hold: time to the first vape, how long without it, the one hardest to give up, vaping at night, when ill, and where it is not allowed. The total and its band appear by themselves. The first and last vape of the day give the hours in between. Preparation for a conversation, not a validated measurement.
3 — What I Use
The kind of vape — disposable, pre-filled pod or cartridge, refillable tank, don’t know, or nicotine-free, as many as apply. Flavors from ten categories, and where it is usually bought. What the label says: mg/ml, percent by volume, percent by weight, percent of unknown kind, or no label. The number on the label and the kind of nicotine.
4 — My Vape in Numbers
Millilitres a day, entered directly or worked out from pods a week. Nicotine in that liquid, a day and a week, calculated by label type, as a single figure or a range. Cost a week, a month and a year. Cigarettes a day if the client still smokes, and what they want to ask at the next appointment. Every calculation is listed with its source, followed by a clear statement of what the figures are for.
5 — What I Have Told Myself
A cognitive behavioral thought record: the belief about vaping the client has carried, how true it has felt from 0 to 10, where it came from, what has actually happened in two columns, the answer they choose, how true it feels now, and one line to carry forward.
What the numbers are, and are not
The figures on page 4 are an indication for the conversation: an estimate worked out from the label and from what has been filled in. A label can be missing, unclear or wrong, amounts are easy to misjudge, and a calculation is only as accurate as the numbers entered. The result does not show how much nicotine the body takes in. It must not be used to choose, calculate or adjust nicotine replacement or any medication.
How it sits in a session
Page 1 can be filled in before the first appointment. Pages 2 and 3 work best with you, because the label often needs looking at together. Page 4 is the page to talk over: what the numbers show, and what surprised the client. Page 5 is homework, for the belief that came up.
Nothing on these pages asks the client to disclose more than they choose to. There are no diagnostic items. The hold questions give a total to talk about, not a diagnosis.
Three ways to use it
- Hand a client page 1 on its own, or all five.
- They type straight into it on a phone or tablet, with the label in their other hand.
- Or print it and use a pen.
Two sizes, both fillable
US Letter, 8.5 x 11 in — United States and Canada
A4, 210 x 297 mm — the standard size everywhere else
Both are in the download at no extra cost, and both work the same way: type on screen, or print. The fields do not show on paper.
Before you start
Open the file in Adobe Acrobat Reader — it’s free, on iPhone, Android, Mac and Windows. The calculations on pages 2 and 4 work there, on phone, tablet and computer. A browser preview or the built-in viewer on a phone will show the pages, but it won’t calculate and won’t reliably keep what a client types.
Keep the blank original blank. Save filled copies under a new name.
The practice license
One practitioner, unlimited clients, worldwide. Print for your own clients, use one-to-one and in groups you run yourself, send a blank copy to an individual client, and keep a filled copy in a client file where your recordkeeping rules require it. Not for resale, and not transferable to a colleague — each practitioner needs their own. The full terms come as a separate page in the download.
Personalized license copy, on request
The license page carries the name of this set and has fields for your name, your practice, and the date of purchase, so you can complete it yourself and keep it with your records. If you would rather have those details typeset into the page instead of typed into a form field, write to hello@cessationworksheets.com after your purchase and I will send one back. No charge — it is part of the license.
How buying works
Checkout runs through Gumroad, a payment platform used by independent creators worldwide. You pay on their secure checkout page, and your card details never reach me.
The price shown here is $7.99 before tax. VAT or sales tax is added at checkout, based on where you live, so the total can differ from country to country. You see the full amount before you pay.
Charges are processed in US dollars. Outside the United States, your bank converts the amount and may add a small fee of its own.
Straight after payment you get a download link on screen and by email, with both files — A4 and US Letter — and a receipt.
Who wrote this
I am a pulmonary nurse, trained in asthma and COPD. I work in a respiratory outpatient clinic, where I see people with asthma and COPD and run the smoking cessation consultations. I am listed in KABIZ, the Dutch quality register for healthcare professionals, which means I work to the national care standard for tobacco and nicotine dependence.
Evidence-informed and developed with reference to current tobacco-dependence and smoking-cessation guidelines, using CBT-informed behavioral tools to support structured cessation conversations.
Every page is built on national standards for tobacco dependence and on published evidence, and checked against the guidance in each. See the seven guidelines.
No lectures. No scare tactics.
Instant digital download. Nothing is shipped. No refunds once the download has been opened. If the file does not work as described, write to me and I will sort it out.
Support tool only — not medical advice, and not a substitute for the clinical judgment of the practitioner using it. The nicotine figures are an indication for conversation only and must not be used to choose, calculate or adjust nicotine replacement or any medication.