help

The Maryland

helps youyourpatients.

QuitlineTobacco

Department of Health and Mental Hygiene

TalkINg TO PREgNaNT WOMEN abOUT TObaCCO USE

Department of Health and Mental Hygiene

1-800-784-8669

all SERvICES aREPRIvaTE aNd FREE

Smoking – or being around others who smoke – exposes you and your baby to harmful chemicals that can have a lifelong impact.Nomatterhowfaralongyouareinyour pregnancy, your baby will be healthier if you quit.

Benefits for your baby if you quit tobacco:•Increasestheamountofoxygenyourbaby willgetandthechancesyourbaby’slungs will work well•Increasesyourchancesofhavinga normal-weight, healthy baby•Increasesthechancesyourbabywillcome home from the hospital when you do

Benefits for you if you quit tobacco:•Givesyoumoreenergyand•Savesyoumoney•Feelgoodaboutwhatyou’vedonefor yourselfandyourbaby’shealth

Facts about Quitting During Pregnancy:•It’snevertoolatetoquitsmokingduring your pregnancy.•Somewomencutdownthenumberof cigarettes they smoke, but quitting is the best thing you can do for you and your baby.•Afterjustonedayofnotsmoking,yourbaby will get more oxygen. •Withdrawalsymptomsarenormal,temporary, andwilllesseninacoupleofweeks.Distract yourself (keep your hands, mouth, and mind busy and think about the good you are doingforyouandyourbaby).•Weightgainduringpregnancyisnormal and is far less harmful than the risk you take by smoking.

THERE IS FREE HELP.The Maryland Tobacco Quitline 1-800-784-8669 can help you quit for good.•Itisafreeprogramthatreallyworks.•Marylanderscangethelp24/7.•Icanreferyounowandacoachwill contact you.

PROvIdER RESOURCE

Department of Health and Mental Hygiene

1-800-784-8669

all SERvICES aREPRIvaTE aNd FREE

The Fax to Assist Program allows healthcare and non-healthcare professionals refer tobacco-using individuals to Free Maryland Tobacco Quitline Services to become tobacco-free. These expert services are evidence-based and confidentialTO aSSIST?

WhaT IS

FaXHow Fax to Assist

Works

•Conductabriefinterventiontodeterminetheindividual’sreadinessto quit tobacco•FillouttheFaxtoAssistreferralformtoenrolltheindividualinQuitlineservices upon their consent•FaxthereferralformtoMarylandTobaccoQuitlinefortheQuitcoachtocontact the individual within 48 hours•ReceiveconfirmationofcontactandFax-backReportsonpatient progress(HIPAA-coveredentitiesonly)

Benefits to You

•Increaseslikelihoodofsuccessfulquitting•IntegratesQuitlineintotreatmentplan•FaxespatientprogressreportstoHIPAAcoveredentitiesonly•Supportavailable24/7•Providesevidence-basedintervention•Savestime

Studies show using brief intervention, along with phone counseling and medication, greatly increases the odds of successfully quitting tobacco.

Benefits to the

Participant

•Coachingavailable24/7foralltobaccousers•Unlimitedproactivecoachingsessionswithunlimitedinboundcalls•Assessmentwithpersonalizedfeedbacktoenhancemotivation and commitment•Reviewofquitdateandquitplan•Educationonuseofapprovedorprescribedquitsmokingmedicine•Nicotinereplacementtherapyforeligibleparticipantsifavailable•Self-helpquitguideandtailoredfactsheetsbymail•QuitlineservicesavailableinEnglish,Spanishandotherlanguages

How to get involved

•UsetheprovidedPatientFaxReferralForminyourpacket•Signupforadditionaltrainingatwww.mdquit.org

It’s EASY and FREE!

PROvIdER RESOURCE

Department of Health and Mental Hygiene

1-800-784-8669

all SERvICES aREPRIvaTE aNd FREE

QUICk hOW-TO gUIdE TO COUNSEl PaTIENTS

Takepatientsvitalsigns, and ASK about

tobacco use.

If patient uses tobacco, ADVISE to quit.

Is the patient ready to quit in the next 30 days?

REFERthemtotheMarylandTobaccoQuitline.Describethe

Quitline. Is patient ready to accept a call from a Quit Coach™?

CompleteFaxReferralFormwithpatientsignature

and fax to Quitline.

Follow-up:Examine report from Quitline with the result of the referral.Ateachvisitwithpatient,

promote cessation and assist with relapse prevention.

Encourage continued abstinence and/or assist with relapse prevention if

former tobacco user.

Provide Quitline card or brochure.

Offer other options, including medications and groups through your local health department or

health care centers.

No use or past use

No

No

Yes

Yes

Visitwww.SmokingStopsHere.com

and click onFind Local Resources!

PROvIdER RESOURCE

MARYLAND TOBACCO QUITLINE FAX REFERRAL FORM

Fax Number: 1-800-483-3114

© 2011 Alere. All rights reserved.

Confidentiality Notice: This facsimile contains confidential information. If you have received this facsimile in error, please notify the sender immediately by telephone and confidentially dispose of the material. Do not review, disclose, copy, or distribute.

FAX SENT DATE: _______/_______/_______

Provider Information:

CLINIC NAME TO APPEAR IN QUITLINE REPORTS CLINIC ZIP CODE NAME OF PROVIDER MAKING REFERRAL CONTACT NAME FAX NUMBER PHONE NUMBER I AM A HIPAA COVERED ENTITY (PLEASE CHECK ONE) (only HIPAA-covered entities receive feedback from the Quitline for clients they refer) YES NO DON’T KNOW

Patient Information:

PATIENT NAME DATE OF BIRTH GENDER MALE FEMALE ADDRESS CITY ZIP CODE PRIMARY PHONE NUMBER HM WK CELL SECONDARY PHONE NUMBER HM WK CELL LANGUAGE PREFERENCE (PLEASE CHECK ONE) ENGLISH SPANISH OTHER _____ I am ready to quit tobacco and request the Maryland Tobacco Quitline contact me to help me with my quit plan. (Initial) _____ I DO NOT give my permission to the Maryland Tobacco Quitline to leave a message when contacting me. (Initial) ** By not initialing, you are giving your permission for the quitline to leave a message.

PATIENT SIGNATURE: DATE: _____/______/______

The Maryland Tobacco Quitline will call you. Please check the BEST 3-hour time frame for them to reach you. NOTE: The Quitline is open 7 days a week; call attempts over a weekend may be made at times other than during this 3-hour time frame. 6AM – 9AM 9AM – 12PM 12PM – 3PM 3PM – 6PM 6PM – 9PM

WITHIN THIS 3-HOUR TIME FRAME, PLEASE CONTACT ME AT (CHECK ONE): Primary # Secondary #

Call 1-800-QUIT-NOW (1-800-784-8669) It’s FREE. It’s confidential. It works.

MaRylaNd TObaCCO QUITlINE FaCT ShEET FOR PREgNaNT WOMEN aNd NEW MOMS

Department of Health and Mental Hygiene

1-800-784-8669

all SERvICES aREPRIvaTE aNd FREE

The Maryland Tobacco Quitline welcomes all pregnant women and new moms. Services are FREE, quit coaches won’t judge and will talk to you about:

1. Helping you make a quit plan

2. Why quitting is good for your health

3. Staying smoke-free after giving birth Second and third-hand smoke can make your baby sick

4. Medicine options to be approved by your doctor

5. Getting support from your family and friends

6. Ongoing support, coaches are available 24/7 and speak English, Spanish, and other languages

7. Local programs if you need more help

8. Free booklets made just for you

Calls usually last 15-25 minutes. Web and text message support are also available for free.

PaTIENT haNdOUT

ThE MaRylaNd TObaCCO QUITlINE FaCT ShEET FOR NEW PaRENTS

Department of Health and Mental Hygiene

1-800-784-8669

all SERvICES aREPRIvaTE aNd FREE

The Maryland Tobacco Quitline welcomes all new parents. Services are FREE, quit coaches won’t judge and will talk to you about:1. Making a quit plan

2. Why quitting is good for your health and your family

3. The importance of staying smoke-free for the baby Second and third-hand smoke can make your baby sick

4. Medicine, the Quitline may be able to provide free medicine

5. Getting support from your family and friends

6. Ongoing support, coaches are available 24/7 and speak English, Spanish, and other languages

7. Local programs for more help

8. Free booklets made just for new parents

Calls usually last 15-25 minutes. Web and text message support are also available for free.

Call 1-800-QUIT-NOW (1-800-784-8669) It’s FREE. It’s confidential. It works.

PaTIENT haNdOUT

TALKING TO PREGNANT WOMEN ABOUT TOBACCO USE

ResouRces foR health caRe pRovideRsResouRce BRief descRiptioN

MdQuitMaryland Quitting use and initiation of tobacco

Provides brief training on tobacco interventions and the Fax To Assist Program. http://www.mdquit.org

treating tobacco use and dependenceagency for health care Research and Quality

Primarily provider-oriented website with 2008 PHS guidelines and resources to help patients quit. Includes some patient materialshttp://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

“the Brief tobacco intervention”centers for disease control and prevention

Two-page pocket scripting card for clinicians; free to download and print.http://www.cdc.gov/tobacco/campaign/tips/groups/hcp/twyd-5a-2a-tobacco-intervention-pocket-card.pdf

smoking cessation in pregnancy and Beyond: a virtual clinic

centers for disease control and prevention and others

Virtual training module for providers. Free, CDC-approved and CME credits available. Developed by CDC, Dartmouth and ACOG.https://www.smokingcessationandpregnancy.org/

“New Medicaid tobacco cessation services” state Medicaid director letter

centers for Medicare and Medicaid services

June 2011 State Medicaid Director letter summarizes Medicaid coverage for pregnant women as well as using Medicaid administrative funding to support quitlines.http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD11-007.pdf

show Your love campaign for preconception carecenters for disease control and prevention

Materials to help women achieve a healthier lifestyle. Checklists and informational materials for women available in English and Spanish.http://www.cdc.gov/preconception/showyourlove/buttons-press.html

“You can Quit smoking” agency for health care Research and Quality

Two-page, downloadable handout for pregnant women to support quit attempts; available in Spanish and Englishhttp://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/tearsheets/index.html

Department of Health and Mental Hygiene

1-800-784-8669

ALL SERvICES AREPRIvATE ANd fREE

ResouRces foR WoMeN (that caRe pRovideRs caN RecoMMeNd)ResouRce BRief descRiptioN

the Maryland tobacco Quitline 1-800-784-8669www.smokingstopshere.com

Maryland department of health and Mental hygiene

A free evidence-based cessation intervention for pregnant women which includes up to 10 calls, additional help is available 24/7. She can earn a maximum of $90 in gift cards if she completes eight calls. Text and web support are also available. http://smokingstopshere.com

women.smokefree.gov“pregnancy & Motherhood”

National cancer institute, Nih

Information, resources, tools, and positive messages for women about the benefits of quitting before/during pregnancy and during motherhood.http://women.smokefree.gov/pregnancy-motherhood.aspx

teen.smokefree.govNational cancer institute, Nih

Information, tools, and positive messages for teens about the harms of smoking and the benefits of quitting.

smokefreetXtNational cancer institute, Nih

SmokefreeTXT is a mobile text messaging service designed for adults and young adults across the United States who are trying to quit smoking.http://smokefree.gov/smokefreetxt

PROvIdER RESOURCE

&SMOKING

PREGNANT?

The Maryland Tobacco Quitlineis here to help. Call today!

• Call Quit Coaches 24/7

• Get extra help online and by text message

• Earn gift cards* for calling while pregnant and after your baby is born

Department of Health and Mental Hygiene

1-800-784-8669

All SERvICES AREPRIvATE ANd fREE

*While supplies last