Tobacco Use and Evidence- Based Cessation Methods:Systems Changes in Primary Care

December 2008December 2008

Tobacco Prevention & Control BranchTobacco Prevention & Control Branch

Division of Public Health, DHHSDivision of Public Health, DHHS

Tobacco Use

The number one preventable cause of death The number one preventable cause of death in the United States and North Carolinain the United States and North Carolina

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000

Tobacco

Diet/Phys. Inactivity

Alcohol

Microbial Agents

Toxic Agents

Motor Vehiciles

Firearms

Sexual Behavior

Illicit Drug Use

Estimated Number of Deaths

Estimated Preventable Causes of Death in NC

13,500

12,500

2,600

2,300

1,7001,300

600

500

900

Source: North Carolina State Center for Health Statistics (NC SCHS), 2002; NC Medical Journal, July/August, 2002, Vol63, #4. Makdad, 2004 and NC Mortality, 2006

2004 Surgeon General’s Report - The Health Consequences of Smoking

Smoking harms nearly every organ of the body Cessation has immediate and long-term benefits Smoking low tar cigarettes provides no health

benefits List of smoking-caused diseases includes AAA,

AML, pneumonia, cataracts, periodontitis, and

cancers of pancreas, stomach, cervix, kidney

Tobacco dependence as a chronic disease

“Tobacco dependence shows many features of a chronic disease… A failure to appreciate the chronic nature of tobacco dependence may undercut clinicians’ motivation to treat tobacco use consistently.” Dr. Michael Fiore, Chair of Treating Tobacco Use and Dependence 2008 Update, Clinical Practice Guidelines

Help for the busy practice….

North Carolina Tobacco Use Quitline

1-800-QUIT-NOW (1-800-784-8669)1-800-QUIT-NOW (1-800-784-8669) 8a.m. – 3a.m., 7 days a week; Toll-free; Confidential8a.m. – 3a.m., 7 days a week; Toll-free; Confidential All North Carolinians - youth and adultAll North Carolinians - youth and adult Proactive – Quit coaches can call tobacco users back upon Proactive – Quit coaches can call tobacco users back upon

request, or make 1request, or make 1stst call call Fax referralFax referral Multiple language Quit CoachesMultiple language Quit Coaches

Administered byAdministered by the Tobacco Prevention and Control Branch the Tobacco Prevention and Control BranchFunded byFunded by the NC Division of Public Health, NC Health and the NC Division of Public Health, NC Health and

Wellness Trust Fund, Blue Cross Blue Shield of NCWellness Trust Fund, Blue Cross Blue Shield of NC

Become an Ex www.becomeanex.org

For tobacco users who would use a web-based For tobacco users who would use a web-based cessation programcessation program

Fun, edgy, interactive websiteFun, edgy, interactive website Useful at any stage of changeUseful at any stage of change Personalized quit plan to “Relearn life without Personalized quit plan to “Relearn life without

cigarettes” cigarettes” Breaks quitting down into manageable piecesBreaks quitting down into manageable pieces Free and in English and SpanishFree and in English and Spanish

Cessation: What Works

Behavioral supportBehavioral support Treats the psychological and habit Treats the psychological and habit

aspectsaspects Pharmacotherapy Pharmacotherapy

Treats nicotine addictionTreats nicotine addiction

Works best when combinedWorks best when combined

5 A’s For Patients Willing to Quit

AskAsk about tobacco use about tobacco use AdviseAdvise patient to quit patient to quit

Refer (1-800-QUIT-NOW or local prgm)Refer (1-800-QUIT-NOW or local prgm) AssessAssess readiness to quitreadiness to quit Assist Assist in quit attemptin quit attempt ArrangeArrange follow-up follow-up

Health Care Provider’s Quick Intervention

ASKASK about tobacco use about tobacco use Every visit – make it a vital sign!Every visit – make it a vital sign!

ADVISEADVISE to quitto quit In clear, personalized statements;In clear, personalized statements;

REFERREFER patient to the NC Tobacco Use Quitline or patient to the NC Tobacco Use Quitline or other evidence based tobacco cessation resources other evidence based tobacco cessation resources Let the NC Tobacco Use Quitline help with the time Let the NC Tobacco Use Quitline help with the time

consuming work. They are experts at quit coaching consuming work. They are experts at quit coaching and will help Assess, Assist, and Arrange)and will help Assess, Assist, and Arrange)

Step 1: Ask Systematically ask every patient about tobacco use at Systematically ask every patient about tobacco use at

every visit.every visit. Start Start AskAsk process with Vital Signs process with Vital Signs Create a reminder system (stamp, sticker, EMR)Create a reminder system (stamp, sticker, EMR)

Determine if patient is current, former, or never Determine if patient is current, former, or never tobacco user.tobacco user.

Determine what form of tobacco is used.Determine what form of tobacco is used. Determine frequency of use.Determine frequency of use. DocumentDocument tobacco use status in the medical record. tobacco use status in the medical record.

Step 2: Advise

In a clear, strong, and personalized In a clear, strong, and personalized manner, urge every tobacco user to quit.manner, urge every tobacco user to quit.

““Mr. Jones, I know you are concerned about your Mr. Jones, I know you are concerned about your family history of heart disease; your risk for family history of heart disease; your risk for having a heart attack can be reduced if you quit having a heart attack can be reduced if you quit smoking”smoking”

Employ the teachable moment: link Employ the teachable moment: link visit findings with advice.visit findings with advice.

Step 3: Refer Is patient is ready to quit within 30 days?Is patient is ready to quit within 30 days? Provide information about the Provide information about the NC Tobacco Use NC Tobacco Use

Quitline Quitline Proactive ReferralProactive Referral for those ready to set a quit date for those ready to set a quit date

Request written permission to fax contact Request written permission to fax contact information to the Quitlineinformation to the Quitline

Follow-up at next visit – repeat process if necessaryFollow-up at next visit – repeat process if necessary Patients not ready to quit Patients not ready to quit should be given the should be given the

Quitline number and/or other cessation resourcesQuitline number and/or other cessation resources

Quitline can Assess, Assist, Arrange

Quitline helps patient ready to set a Quit Date, andQuitline helps patient ready to set a Quit Date, and Develop a quit planDevelop a quit plan Make up to three follow-up callsMake up to three follow-up calls Discuss pharmacotherapy, refer back to HCPDiscuss pharmacotherapy, refer back to HCP Encourage those not ready to set a quit date to Encourage those not ready to set a quit date to

call backcall back Four call program is evidence-basedFour call program is evidence-based Patient can call the Quitline anytimePatient can call the Quitline anytime

Fax Referral Program Efficient method for referring Efficient method for referring patients who patients who

want to quitwant to quit to effective cessation services to effective cessation services Physician referral of patients to cessation Physician referral of patients to cessation

programs is associated with higher rates of programs is associated with higher rates of participation than simply telling patients they participation than simply telling patients they should stop smokingshould stop smoking

Alleviates some of the problems posed by Alleviates some of the problems posed by limited time and resourceslimited time and resources

Takes the burden of initiating services off of Takes the burden of initiating services off of the patientthe patient

How Fax Referral Works1.1. Patient has been identified as a tobacco user Patient has been identified as a tobacco user willing to willing to

discuss quitting/ready to set a quit datediscuss quitting/ready to set a quit date2.2. HCP educates patient on services of NC Tobacco Use HCP educates patient on services of NC Tobacco Use

QuitlineQuitline3.3. Patient completes fax referral form providing consent for Patient completes fax referral form providing consent for

HCP to release information to initiate proactive call.HCP to release information to initiate proactive call.• Patient must provide contact information and sign the Patient must provide contact information and sign the

fax referral form.fax referral form.4.4. HCP must complete HCP must complete Provider InformationProvider Information on fax referral on fax referral

form, including form, including Name of ClinicName of Clinic5.5. Based on times provided by patient, Quitline staff will Based on times provided by patient, Quitline staff will

contact patient to begin Quitline calls.contact patient to begin Quitline calls.6.6. Quitline can provide feedback to HCP on status of patientQuitline can provide feedback to HCP on status of patient

• Accepted Services, Refused Services, Not ReachedAccepted Services, Refused Services, Not Reached • Must check HIPAA box on fax form and provide Must check HIPAA box on fax form and provide

clinic fax number, contact name and contact numberclinic fax number, contact name and contact number

Effectiveness of Quitlines Smokers who use tobacco cessation Quitlines Smokers who use tobacco cessation Quitlines

double their chances of staying quitdouble their chances of staying quit Zhu, et al., 2002. Evidence of real-world effectiveness of a telephone Zhu, et al., 2002. Evidence of real-world effectiveness of a telephone

quitline for smokers. quitline for smokers. New England Journal of MedicineNew England Journal of Medicine Borland, et al., 2001. The effectiveness of callback counseling for Borland, et al., 2001. The effectiveness of callback counseling for

smoking cessation: a randomized trial. smoking cessation: a randomized trial. AddictionAddiction

Proactive telephone counseling is more effective compared Proactive telephone counseling is more effective compared to interventions without personal contact, such as self-help to interventions without personal contact, such as self-help materials. (meta-analysis of 27 studies of the efficacy of materials. (meta-analysis of 27 studies of the efficacy of telephone quitlines) telephone quitlines) Stead, et al., 2003—Cochrane Database of Systemic ReviewsStead, et al., 2003—Cochrane Database of Systemic Reviews

Combining NRT with Quitline use increases quit ratesCombining NRT with Quitline use increases quit rates Zhu, et al., 2000. Telephone counseling as adjuvant treatment for nicotine Zhu, et al., 2000. Telephone counseling as adjuvant treatment for nicotine

replacement therapy in a "real-world" setting.replacement therapy in a "real-world" setting. Preventive MedicinePreventive Medicine

Michael C. Fiore, MD, M.P.H., Panel Chair of Treating Tobacco Use and Dependence 2008 Update, Clinical Practice Guidelines

Director, Center for Tobacco Research and Intervention, University of Wisconsin Medical School

"In my view, a doctor isn't providing an

appropriate standard of care …. if he or she

doesn't ask two key questions

—'Do you smoke?' and 'Do you want to quit?'—

(Do you use tobacco? Do you want to quit?)

and then work with that individual to make it

happen.“

Efficacy of Physician Advice to Quit

Abstinence Rate %Abstinence Rate % No advice No advice 7.9 7.9 Physician AdvicePhysician Advice 10.2 10.2

Patients expect healthcare providers to ask Patients expect healthcare providers to ask about tobacco use and advise them to quitabout tobacco use and advise them to quit

Source: Treating Tobacco Use andSource: Treating Tobacco Use and Dependence, USDHHS, Public Health Service, 2008Dependence, USDHHS, Public Health Service, 2008

Strategies for Implementation Create a Reminder System Create a Reminder System

Expand the vital signs to include tobacco useExpand the vital signs to include tobacco useUse an alternative universal identification system Use an alternative universal identification system Stamp, Sticker, Add to the EMR Stamp, Sticker, Add to the EMR

Tobacco Use and ExposureTobacco Use: (circle one): Current Former Never

Secondhand Smoke Exposure: YES NOTobacco use is the single most preventable cause of death in the US.

Pharmacotherapy Nicotine Replacement TherapyNicotine Replacement Therapy

- Patch- Patch

- Gum- Gum

- Lozenge- Lozenge

- Inhaler- Inhaler

- Nasal Spray - Nasal Spray Zyban (bupropion)Zyban (bupropion) Chantix (varenicline)Chantix (varenicline)

NRT and Cardiovascular Disease

Not an independent risk factor for acute Not an independent risk factor for acute myocardial eventsmyocardial events

Use with caution in patients who:Use with caution in patients who: are within 2 weeks of MIare within 2 weeks of MI have serious arrhythmiashave serious arrhythmias have serious or worsening anginahave serious or worsening angina

pectorispectoris

Cessation Counseling Reimbursement Medicare, BCBSNC, SHP Medicare, BCBSNC, SHP

ICD-9 Code: 305.1 (tobacco abuse)ICD-9 Code: 305.1 (tobacco abuse) File in addition to visit’s E&M codeFile in addition to visit’s E&M code Unbundled – can use a second ICD9 code Unbundled – can use a second ICD9 code

CPT Code:CPT Code: 99406 – intermediate visit (3-10 minutes)99406 – intermediate visit (3-10 minutes) 99407 – intensive visit (> 10 minutes)99407 – intensive visit (> 10 minutes)

• No modifier requiredNo modifier required Medicaid adding two new CPT codes Jan. 1, 2009

3 - 10 minutes >10 minutes Look for in January 2009 Medicaid Bulletin

o http://www.dhhs.state.nc.us/dma/bulletin.htm

ICD-9: Diagnosis codeE&M: Evaluation and management codeCPT: Current procedural terminology code

NC Prevention Partners, NC AFP Spring Family Physicians Weekend, April 18, 2008

More Cessation Counseling Reimbursement Codes Other codes:Other codes:

99401-04; 15-60 minutes (dedicated visit)99401-04; 15-60 minutes (dedicated visit) 99354 can be added to regular visit (must 99354 can be added to regular visit (must

document counseling)document counseling) 99411 is used for group counseling (per 99411 is used for group counseling (per

participant)participant) MD, PA or FNP on premises, must talk to MD, PA or FNP on premises, must talk to

groupgroup RN (etc.) may facilitate sessionRN (etc.) may facilitate session

Over the Counter Medications

Nicotine PatchNicotine Patch DoseDose: 21mg, 14mg or 7mg per 24 hours: 21mg, 14mg or 7mg per 24 hours

1 pack/day, start with higher dose, taper1 pack/day, start with higher dose, taper duration 8 weeksduration 8 weeks step down after 4 wks in 2 wk incrementsstep down after 4 wks in 2 wk increments Nicotrol is used for 16 hours, off at nightNicotrol is used for 16 hours, off at night

Adverse effectsAdverse effects: local skin reaction, insomnia, : local skin reaction, insomnia, vivid dreamsvivid dreams

ContraindicationsContraindications: Recent MI, unstable angina, : Recent MI, unstable angina, arrhythmiaarrhythmia

CostCost: 7mg box - $37: 7mg box - $37 14mg box - $47 14mg box - $47

21mg box - $4821mg box - $48

Over the Counter MedicationsNicotine GumNicotine Gum DoseDose: up to 24 pieces per day: up to 24 pieces per day

x 12 weeks (longer if needed)x 12 weeks (longer if needed) 2mg for <25 cigarettes per day2mg for <25 cigarettes per day 4mg for >25 cigarettes per day4mg for >25 cigarettes per day Chew, chew, parkChew, chew, park Avoid acidic beveragesAvoid acidic beverages

Consider using on a fixed scheduleConsider using on a fixed schedule Long term patch and gum use are effectiveLong term patch and gum use are effective Adverse EffectsAdverse Effects: Mouth soreness, hiccups, jaw ache, : Mouth soreness, hiccups, jaw ache,

dyspepsiadyspepsia ContraindicationsContraindications: As for patch: As for patch CostCost: 2mg box (100-170 pieces) ~ $45 (generic): 2mg box (100-170 pieces) ~ $45 (generic)

4mg box (100-110 pieces) ~ $63 (generic)4mg box (100-110 pieces) ~ $63 (generic)

Over the Counter Medications

Nicotine Lozenge (Commit)Nicotine Lozenge (Commit) DoseDose

2mg (1st cig. >30 min. after awake)2mg (1st cig. >30 min. after awake) 4mg (1st cig. <30 min. after awake)4mg (1st cig. <30 min. after awake) 9 (min) to 20 (max) lozenges/day9 (min) to 20 (max) lozenges/day x 12 weeks (longer if needed)x 12 weeks (longer if needed)

Allow to dissolve in mouthAllow to dissolve in mouth Avoid acidic beveragesAvoid acidic beverages Adverse EffectsAdverse Effects: Nausea, hiccups, heartburn: Nausea, hiccups, heartburn

4mg dose - headache, cough4mg dose - headache, cough ContraindicationsContraindications: as for patch: as for patch CostCost: 2mg box (72 lozenges) - $34 : 2mg box (72 lozenges) - $34 4 mg box (72 lozenges) - $394 mg box (72 lozenges) - $39 (9 lozenges/day =1 box/wk = $136-$156/mo)(9 lozenges/day =1 box/wk = $136-$156/mo)

Prescription Medications

Nicotine InhalerNicotine Inhaler DoseDose: 4mg nicotine: 4mg nicotine

80 puffs=4mg nicotine80 puffs=4mg nicotine Best effects with frequent puffing/at least 6 cartridges Best effects with frequent puffing/at least 6 cartridges

per day (can use 6-16 cartridges/day)per day (can use 6-16 cartridges/day) Use for up to 6 months Use for up to 6 months

Reduce frequency over the last 6-12 weeks of txReduce frequency over the last 6-12 weeks of tx Avoid acidic beveragesAvoid acidic beverages Adverse EffectsAdverse Effects: mouth/throat irritation, coughing, rhinitis: mouth/throat irritation, coughing, rhinitis ContraindicationsContraindications: as for patch: as for patch CostCost: 1 box (168 10mg cartridges) - $196: 1 box (168 10mg cartridges) - $196

Prescription Medications

Nicotine Nasal SprayNicotine Nasal Spray DoseDose: 1 dose = 1 mg (0.5mg per nostril): 1 dose = 1 mg (0.5mg per nostril)

1-2 doses per hour initially1-2 doses per hour initially Increase as needed for symptom reliefIncrease as needed for symptom relief 8 min/40 max doses per day for 3-6 months8 min/40 max doses per day for 3-6 months Do not sniff, swallow or inhaleDo not sniff, swallow or inhale Head titled slightly backHead titled slightly back

Adverse EffectsAdverse Effects: Nasal irritation, congestion; : Nasal irritation, congestion; transient changes in smell, tastetransient changes in smell, taste

ContraindicationsContraindications: as for patch: as for patch CostCost: $49 per bottle (100 doses): $49 per bottle (100 doses)

Prescription Medications

Zyban, Wellbutrin (bupropion SR 150)Zyban, Wellbutrin (bupropion SR 150) BeginBegin 1-2 weeks before quit date 1-2 weeks before quit date DoseDose: 150 mg in a.m. for 3 days: 150 mg in a.m. for 3 days

150 mg twice daily for 7 to 12 weeks150 mg twice daily for 7 to 12 weeks May consider long-term tx for 6 months post quitMay consider long-term tx for 6 months post quit Adverse EffectsAdverse Effects: Insomnia, dry mouth: Insomnia, dry mouth ContraindicationsContraindications: history of seizure d/o, eating d/o, recent : history of seizure d/o, eating d/o, recent

MAO inhibitor use in past 14 daysMAO inhibitor use in past 14 days CostCost: 1 box of 60 tablets : 1 box of 60 tablets

$97/month (generic)$97/month (generic) $197-$210 (brand name)$197-$210 (brand name)

Prescription Medications

Chantix (varenicline)Chantix (varenicline) Stimulates nicotine receptors. Also blocks nicotine at Stimulates nicotine receptors. Also blocks nicotine at

receptor sitereceptor site Start Chantix 1 week before quit dateStart Chantix 1 week before quit date DoseDose: 0.5 mg daily for 3 days: 0.5 mg daily for 3 days

0.5mg twice daily for 4 days0.5mg twice daily for 4 days 1.0mg twice daily for 3 months1.0mg twice daily for 3 months

May decrease dosage (1mg/day) if significant side effectsMay decrease dosage (1mg/day) if significant side effects Adverse EffectsAdverse Effects: nausea, insomnia, abnormal/vivid dreams: nausea, insomnia, abnormal/vivid dreams New warning label Jan. 2008– observe for neuro- New warning label Jan. 2008– observe for neuro-

psychiatric symptoms (post marketing data)psychiatric symptoms (post marketing data) CostCost: 1 box of 56 - $131 (~30 day supply): 1 box of 56 - $131 (~30 day supply)

Research shows that at 1 year, 21% of those on Chantix are still abstinent Research shows that at 1 year, 21% of those on Chantix are still abstinent compared to 8% with a placebocompared to 8% with a placebo

More on Pharmacotherapy Evidence exists that combined therapy improves Evidence exists that combined therapy improves

abstinence ratesabstinence rates For patients unable to use a single typeFor patients unable to use a single type

of first line agentof first line agentPatch Patch ++ gum, nasal spray, or inhaler gum, nasal spray, or inhaler Patch plus bupropriopnPatch plus bupropriopn

Patch plus buproprion is FDA approvedPatch plus buproprion is FDA approved Do not combine NRT with ChantixDo not combine NRT with Chantix Buproprion and gum Buproprion and gum may delay weight gainmay delay weight gain Buproprion and lozenge Buproprion and lozenge may delay weight gainmay delay weight gain NRT for smokers not willing to quit – promising NRT for smokers not willing to quit – promising

but warrants further researchbut warrants further research

Pregnancy and Pharmacotherapy

Abstinence early produces greatest benefitsAbstinence early produces greatest benefits Quitting at any point yields benefitsQuitting at any point yields benefits Person to person intervention should be Person to person intervention should be

offered to pregnant and post partum women offered to pregnant and post partum women that that exceeds minimal advice to quit and is exceeds minimal advice to quit and is more extendedmore extended

Inconclusive evidence that cessation Inconclusive evidence that cessation medications increase abstinence ratesmedications increase abstinence rates

NC DMA Cessation Medication Coverage Medicaid now covers ALL cessation Medicaid now covers ALL cessation

pharmacotherapypharmacotherapy Nicotine patch, gum, lozenge, nasal Nicotine patch, gum, lozenge, nasal

spray, inhalerspray, inhaler ZybanZybanChantixChantix

No Prior Authorization neededNo Prior Authorization needed Prescription required, even for OTCPrescription required, even for OTC

You only have two minutes

AAsksk every everyone about tobacco use every everyone about tobacco use AAdvisedvise to quit with a clear, strong, personalized to quit with a clear, strong, personalized

messagemessage RRefer efer to the Quitline or other resourcesto the Quitline or other resources

NC Tobacco Use QuitlineNC Tobacco Use Quitline 1-800-QUIT-NOW (1-800-784-8669) and/or1-800-QUIT-NOW (1-800-784-8669) and/or

Become an ExBecome an Ex www.becomeanex.orgwww.becomeanex.org

PPharmacotherapyharmacotherapy - recommend cessation - recommend cessation medication (few exceptions)medication (few exceptions)

Fax referral form and other resources www.QuitLineNC.comwww.QuitLineNC.com

www.tobaccopreventionandcontrolwww.tobaccopreventionandcontrol.ncdhhs.gov/cessation.ncdhhs.gov/cessation

What happens when you call the Quitline

First call - plan for 5 minutes to enrollFirst call - plan for 5 minutes to enroll Readiness to quit determinedReadiness to quit determined

Caller inquiring for others, information Caller inquiring for others, information gatheringgathering

Caller would like to speak to a Quit CoachCaller would like to speak to a Quit Coach Live transfer to a Quit Coach for those ready Live transfer to a Quit Coach for those ready

to quitto quit

Caller would like to speak to a Quit Coach One Call Program: Conversation with the Quit

Coach for support Support materials for

quitting Referral to local resources Medication information Help to develop a plan,

including setting a quit date Access to Web Coach

Four Call Program:Four Call Program: One Call program, plusOne Call program, plus Quit Coach will call backQuit Coach will call back

-- A quit date is set-- A quit date is set-- Dates and times are -- Dates and times are made for three more made for three more

calls from a Quit calls from a Quit CoachCoach

Three attempts, then Three attempts, then letter is sentletter is sent

NC Tobacco Use Quitline Web Coach and Click to Call features

Web CoachWeb Coach For those enrolled in QuitlineFor those enrolled in Quitline Progress tracking, coaching e-mailsProgress tracking, coaching e-mails Discussion ForumsDiscussion Forums

Click to CallClick to Call Click icon, enter phone number, Quitline Click icon, enter phone number, Quitline

calls within minutescalls within minutes Feature available on Web CoachFeature available on Web Coach

Take-Home Message for Health Care Providers

Ask, Advise, Refer (1-800-QUIT-NOW)Ask, Advise, Refer (1-800-QUIT-NOW) Brief cessation counseling is effectiveBrief cessation counseling is effective Longer cessation counseling is more effectiveLonger cessation counseling is more effective Pharmacotherapy can double quit ratesPharmacotherapy can double quit rates Pharmacotherapy should be offered to allPharmacotherapy should be offered to all

- few exceptions- few exceptions Evidence-based resources are availableEvidence-based resources are available

Continuing Education Options Medscape: Treating Tobacco Use and DependenceMedscape: Treating Tobacco Use and Dependence

http://www.medscape.com/viewarticle/570604http://www.medscape.com/viewarticle/570604 FreeFree Approved for 1hour CE Approved for 1hour CE AMA PRA Category 1 Credit(s)™ AMA PRA Category 1 Credit(s)™ Requires registration to MedscapeRequires registration to Medscape

TobaccoFreePatients.comTobaccoFreePatients.comhttp://www1.tobaccofreepatients.com/TopicReq?http://www1.tobaccofreepatients.com/TopicReq?

Based on NCI educational programBased on NCI educational program Available free for study and reviewAvailable free for study and review $15 per credit hour or for letter of completion$15 per credit hour or for letter of completion

Tobacco Prevention and Control Branch Resources

For downloadable For downloadable resourcesresources Visit our web site:Visit our web site:

www.tobaccopreventionandcontrol.ncdhhs.govwww.tobaccopreventionandcontrol.ncdhhs.gov

CONTACTCONTACT::

Donna Dayer, Tobacco Cessation Specialist Donna Dayer, Tobacco Cessation Specialist e-mail: donna.dayer@ncmail.net e-mail: donna.dayer@ncmail.net

Main number: 919-707-5400Main number: 919-707-5400Office: 919-707-5415Office: 919-707-5415