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Survey of Tobacco Cessation Practices

The following questions ask about your tobacco cessation practices. Please answer each question to the best of your ability.

Thank you!

(One selection allowed per column)

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

* must provide value

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(One selection allowed per column)

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

* must provide value

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3. Have you ever taken a continuing education (CE) course that was focused on tobacco cessation counseling?

* must provide value

Yes

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(One selection allowed per column)

* must provide value

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5. Counsel ADULT patients

* must provide value

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6. Counsel ADOLESCENT (12-17 YEARS) patients

* must provide value

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7. Counsel PREGNANT patients

* must provide value

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8. Given the choice between providing one-on-one counseling and referring to an outside tobacco cessation program, which are YOU most likely to choose for the AVERAGE ADULT patient who uses tobacco in your practice?

* must provide value

Refer to an outside program only

Provide one-on-one counseling AND refer to an outside program

Provide one-on-one counseling only

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9. Given the choice between providing one-on-one counseling and referring to an outside tobacco cessation program, which are YOU most likely to choose for the AVERAGE ADOLESCENT (12-17) patient who uses tobacco in your practice?

* must provide value

Refer to an outside program only

Provide one-on-one counseling AND refer to an outside program

Provide one-on-one counseling only

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10. Given the choice between providing one-on-one counseling and referring to an outside tobacco cessation program, which are YOU most likely to choose for the AVERAGE PREGNANT patient who uses tobacco in your practice?

* must provide value

Refer to an outside program only

Provide one-on-one counseling AND refer to an outside program

Provide one-on-one counseling only

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11. Considering the following tobacco-related products, which are EXPLICITLY listed in your medical/dental history questionnaire?

Select ALL that apply.

* must provide value

Cigarettes

Cigars

Pipes

Smokeless tobacco (chewing tobacco, snuff, dip, spit)

Electronic cigarettes

Other (please specify)

Please specify "Other"

12. Considering the following tobacco cessation options, which of the following have you used in the LAST 60 DAYS?

Select ALL that apply.

* must provide value

Providing printed materials (e.g., educational brochures)

Referral to a telephone "quit line"

Referral to a non-dental health care provider

Referral to a psychotherapist

Referral to a group therapy program

Other (please specify)

Please specify "Other"

13. Considering the following tobacco cessation pharmacotherapies, which of the following have you recommended/prescribed in the LAST 60 DAYS?

Select ALL that apply.

* must provide value

Recommending an over-the-counter transdermal patch (e.g., NicoDerm CQ)

Recommending an over-the-counter nicotine polacrilex gum (e.g., Nicorette gum)

Recommending an over-the-counter polacrilex lozenge (e.g., Nicorette lozenges)

Prescribing an intranasal nicotine spray (e.g., Nicotrol NS)

Prescribing a nicotine oral inhaler (e.g., Nicotrol inhaler)

Prescribing bupropion (e.g., Zyban)

Prescribing varenicline tartrate (e.g., Chantix)

Other (please specify)

Please specify "Other"

14. The MPResD network is requesting funding to conduct a tobacco cessation research study. The project will involve asking dentists and dental hygienists to refer patients to a tobacco cessation program in their area and then tracking the effectiveness of the referral program over time. It will not involve any pharmacotherapies. Would you be interested in participating in a project like this?

* must provide value

Yes

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15. What type of practitioner are you?

* must provide value

Dentist

Dental specialist

Dental hygienist

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16. Are you licensed to practice in Maryland?

* must provide value

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.