misc information materials

Patient Example: Jason's Tobacco Use Assessment Form

Description: 
This is an example of a patient's responses to the Tobacco Use Assessment Form.

Tobacco Use Assessment for Jason

1. Have you ever smoked cigarettes or used any other tobacco product?
  __X__ Yes
 

_____ No

 

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Patient Example: Amy's Tobacco Assessment Form

Description: 
This is an example of a patient's responses to the Tobacco Use Assessment Form.

Tobacco Use Assessment for Amy Clark

1. Have you ever smoked cigarettes or used any other tobacco product?
  __X__ Yes
 

_____ No

 

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Description: 
This fact sheet provides information on smoking and tobacco use.
Source: 
Centers for Disease Control and Prevention
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Description: 
The calendar shows conferences that address tobacco control, some of which are training courses in tobacco cessation interventions. The conferences listed are regional, statewide, national, and international.
Source: 
National Tobacco Control Program State Exchange
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Patient Example: Jennifer's Youth Tobacco Assessment Form

Description: 
This is an example of a patient's responses to the Tobacco Use Assessment Form for Children or Teens.

Name: Jennifer Simpson

Date: 6/ 1 /2005

Have you ever smoked cigarettes or used any other tobacco product?
 
X   No
___ Yes, but just a little experimentation, for example, a few puffs of a cigarette
___ Yes, more than just experimenting. If Yes, please answer the following questions (A-C):

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Description: 
A chart detailing precautions and dosing of several nicotine replacement therapy formulations, including gum, lozenge, transdermal patch, nasal spray, and oral inhaler.
Source: 
American Academy of Family Physicians
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Adolescent Screen for Tobacco Dependence: The Hooked on Nicotine Checklist

Description: 
This checklist was first described in the Development and Assessment of Nicotine Dependence in Youth study, and was designed to screen adolescents for symptoms of tobacco dependence (DiFranza et al. 2002a). An adolescent answering yes to any of these questions is said to have some dependence on tobacco.

Name: _______________________ Date: _____________________

1. Have you ever tried to quit but couldn’t?   YES   NO

2. Do you smoke now because it’s really hard to quit?   YES   NO

3. Have you ever felt like you were addicted to tobacco?   YES   NO

4. Do you ever have strong cravings to smoke?   YES   NO

5. Have you ever felt like you really needed a cigarette?   YES   NO

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Responding to Marketing Questions

Description: 
Marketing questions deciphered.

Marketing statements by tobacco companies are explained by the image they convey and their actual countermessage.

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Children and teens are easy targets for the tobacco industry. They're often influenced by TV, movies, advertising, and by what their friends do and say. They don't realize what a struggle it can be to quit, and having cancer, emphysema, blindness, or impotence may not seem like real concerns. Children and teens don't think much about future health outcomes.
Source: 
American Cancer Society
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Patient Example: Tamika's Tobacco Assessment Form

Description: 
Patient Example: Tamika's Tobacco Assessment Form

Tobacco Use Assessment Form for Children or Teens

Name: Tamika Jones

Date: 6/ 1 /2005

Have you ever smoked cigarettes or used any other tobacco product?
_X_ No
___ Yes, but just a little experimentation, for example, a few puffs of a cigarette
___ Yes, more than just experimenting. If Yes, please answer the following questions:

Have you smoked at least 100 cigarettes in your life?
_X__ No
___ Yes

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