Thank you for taking the time to complete this survey. The answers you provide will be used to help the Washington Department of Health (DOH) understand existing cessation services that healthcare providers in Washington currently provide, including referral sources, as well as factors that help or hinder a provider's ability to provide cessation services to patients/clients. The findings from this survey will inform further assessments of cessation services and resources available for Washington residents, as well as a statewide database of services. Most of the survey questions reference "tobacco or nicotine products". We are using this as an umbrella term to include all forms of commercial tobacco and nicotine products, including: - Cigarettes, cigars, cigarillos, pipes - Vapor products, e-cigarettes, vape pens - Hookah, waterpipe - Chewing tobacco, snuf, snus, spit, dip - Nicotine products such as lozenges and strips for recreational, non-medical use (not NRT) Some Native American/American Indian tribes use tobacco as a sacred medicine and in ceremony to promote physical, spiritual, emotional, and community well-being. This traditional tobacco is different from commercial tobacco, which is tobacco that is manufactured and sold by the commercial tobacco industry, and is linked to addiction, disease, and death. In an effort to acknowledge and honor the difference, it will be referred to as "commercial tobacco" in this survey, even if it is only written as "tobacco" or "tobacco/nicotine". Staff and/or leadership may collaborate to answer the survey questions, but we ask that each organization compile this information and submit one survey. If you have any questions or issues completing this survey, please do not hesitate to reach out to Beck Wright at beck.wright@redegroup.co. Thank you!
What is the name of the practice/organization associated with these survey responses?
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Which of the following best describes your role at this organization?
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Direct services provider (ex. doctor, nurse)
Direct services support staff (ex. medical assistant)
Administrative staff (ex. billing, front office)
Organization management or leadership (ex. clinic manager, director)
Other
Which Washington county(ies) do you provide services in?
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Which of the following best describes your practice/organization?
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What types of insurance does your organization accept?
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Which age ranges are served by your facility?
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Does your organization have a specific focus on any of the following historically underserved populations? (check all that apply)
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Which languages do you provide services in?
The next few questions pertain to tobacco/nicotine use. Tobacco/nicotine products include any commercial tobacco or nicotine product such as cigarettes, hookah, cigars, cigarillos, smokeless tobacco, e-cigarettes, and vape pens/devices. It does not include FDA approved nicotine replacement therapy products such as gum or lozenges. Please estimate the percentage of patients/clients who receive services at your organization who currently use a tobacco or nicotine product:
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None
Less than 20%
20% to 39%
40% to 59%
60% to 80%
More than 80%
Don't know
Choose not to answer
Please estimate the percentage of staff at your organization who currently use a tobacco or nicotine product:
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None
Less than 20%
20% to 39%
40% to 59%
60% to 80%
More than 80%
Don't know
Choose not to answer
Are patients/clients asked on their medical history form if they use tobacco or nicotine products?
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Yes
No
Not sure
Are patients/clients asked verbally if they use tobacco or nicotine products?
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Yes, as a required question
Yes, as common practice, but not required
Sometimes, at the discretion of the practitioner
No
Not sure
Which health professional (s) ask about a client's/patient's smoking status?
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If a patient/client shares that they use tobacco or nicotine products, do you assess their willingness to quit?
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Yes
No
Not sure
If a patient/client says they are ready to quit, do you provide services onsite?
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Yes
No
Not sure
What types of services are provided by your organization?
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Do you provide/prescribe pharmacotherapy to assist tobacco or nicotine cessation?
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Yes
No
Not sure
What types of pharmocotherapy are provided or prescribed to patients/clients?
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If a patient/client says they are ready to quit, are they referred for external/outside cessation services?
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Yes
No
Not sure
Are patients/clients referred to the Washington State Quitline?
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Yes
No
Not sure
Are patients/clients who are veterans referred to veteran-specific services?
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Yes
No
Staff who provide cessation referrals are unaware of a patient's veteran status (N/A)
Where are veterans refered for cessation services?
If applicable, please list other additional cessation referral sources:
Please tell us a bit about your relationship with organizations you refer to for cessation services, in particular, what type of partnership you have with them.
Which information sources do you use to stay up-to-date about available cessation resources?
The next question pertains to the smoking and/or nicotine policy at your organization. For this question, tobacco/nicotine products include any commercial tobacco or nicotine product such as cigarettes, hookah, cigars, cigarillos, smokeless tobacco, e-cigarettes, and vape pens/devices. It does not include FDA approved nicotine replacement therapy products such as gum or lozenges. Which of the following statements best describe the smoking and/or nicotine use policy at your organization?
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Smoking is prohibited everywhere on our property (indoors and outdoors)
All tobacco/nicotine use (including vaping) is prohibited everywhere on our property (indoors and outdoors)
Smoking is prohibited inside all buildings with a setback for outdoor smoking that extends more than 25 feet from entrances and exits.
All tobacco/nicotine use (including vaping) is prohibited inside all buildings with a setback for outdoor tobacco/nicotine use that extends more than 25 feet from entrances and exits
All tobacco/nicotine use (including vaping) is prohibited inside all buildings and within 25-feet from entrances and exits
All tobacco/nicotine use (including vaping) is prohibited inside all buildings and there are no rules for tobacco/nicotine use outside on our property
Other
We do not have an organizational policy, but we follow WA state and/or local county laws regulating smoking and/or vaping in public places
Have providers at your facility received training in tobacco/nicotine treatment?
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Yes
No
Not sure
Where/from whom did providers receive training in tobacco/nicotine treatment?
Is there a "tobacco champion" within your organization, or someone who leads this work?
Yes
No
Not sure
Are you or someone from your organization interested in information about WA Department of Health's Provider Training?
Yes
No
Not sure
Please include the name of the individual interested in receiving WA DOH provider training:
Please include the position of the individual interested in receiving WA DOH provider training.
Please include the email of the individual interested in WA DOH provider training:
Optional: Please share additional information regarding challenges or barriers associated with providing tobacco/nicotine dependence treatment services:
If not currently doing so, what do you think would encourage providers to treat tobacco/nicotine dependence?
Optional: Do you have anything else that you would like to share with us regarding your organization's policies and practices related to tobacco/nicotine use and/or treatment?
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