Smokers’ Quitline New York State FAX 1-866-NY-QUITS

New York State FAX
Smokers’ Quitline
TO QUIT
1-866-NY-QUITS Program

(1-866-697-8487) www.nysmokefree.com

Deaf, Hard of Hearing & Speech Disabled:
Call NY Relay Service 7-1-1 (Voice or TTY)

Request NYS Quitline: 1-866-697-8487

The New York State Smokers’ Quitline offers our Fax to Quit program to all health care providers
to help their patients stop smoking. As a confidential service, we offer counseling and other
cessation-related services to patients who use tobacco products.

How Fax to Quit Works:

Health care providers can refer their tobacco-using patients to the New York State Smokers’
Quitline using the Fax to Quit referral form.

Patients will receive a follow-up call from a Quit-Coach who will provide a stop smoking or stop
smokeless-tobacco counseling session.

Patients will receive a Stop Smoking or Stop Smokeless Tobacco packet in the mail with
information tailored to their specific situation and a listing of local stop smoking programs.

A progress report (feedback form) with information about the patient’s tobacco-use status will be
faxed back to the health care provider from the Quit-Coach.
Patients can be referred to the New York State Smokers’ Quitline as often as needed.
Patients can call the New York State Smokers’ Quitline as often as needed.
There is no limit to the number of patients a health care provider may refer.

Services and Information provided by the New York State Smokers’ Quitline:

Telephone counseling to callers who wish to stop using tobacco or to learn more about the dangers
of tobacco use.
Posters and materials for health care providers and community organizations.
A variety of literature on tobacco use and stop-smoking strategies.
Quitsite at www.nysmokefree.com containing a variety of helpful stop-smoking advice and
Internet resources.
Statewide listing of local Stop-Smoking Programs.
Statewide listing of local Tobacco Control Coalitions and contacts.
Information and enforcement referrals for the New York State Expanded Clean Indoor Air Act of
2003.

Rev: May 27 ‘04 INTRODUCTION Fax to Quit 6-04.doc/9.5

New York State Smokers’ Quitline 1 – (866) – NY – QUITS (1-866-697-8487)

FAX REFERRAL FORM

FAX TO 1-866-QUIT-FAX
(1–866–784-8329)

PATIENT CONTACT INFORMATION

Today’s date:

Patient’s name:

Date of birth:

Telephone Number (include area code): ( ) ______________ - ___________________________

Best time of day to call: Morning: ________ Afternoon: ________ Evening: ________

(9 am to Noon) (Between Noon & 5 pm) (Between 5 pm & 9 pm)

HEALTH CARE PROVIDER CONTACT INFORMATION

Health Care Provider Name

Provider Fax Number (include area code) ( ) ______________ - ___________________________

Provider Telephone (include area code) ( ) ______________ - ___________________________

PATIENT QUESTIONS

About how many cigarettes do you smoke each day? __________________________________________________

Do you plan to quit within the next 30 days? (Circle one) YES NO

If you have set a quit date, write it here: _____________________________________________________________

Are you currently using any of these stop-smoking products? (If yes, which ones, how many, and what dose do you use?)

Patch Nasal Spray Inhaler Lozenge Gum
__________ mg _____ sprays/day _____ pieces/day
_____ cartridges/day ______ lozenges/day

___ 16 hr ___24 hr ___2 mg ___4 mg ___2 mg ___4 mg

Bupropion: _________mg/day Wellbutrin®: _________mg/day Zyban®: _________mg/day

Do you have health insurance? YES NO If yes, which carrier? ___________________________
If Medicaid, what is your Medicaid number? ________________________________________________

PERMISSION

I (undersigned) give permission for the support staff of the New York State Smokers’ Quitline to contact me, coach me in
quitting smoking, and give feedback regarding my progress to the health care provider listed above, and permission for
that provider to forward the information to other relevant health care providers.

Signature: ______________________________________________________________ Date: _____/_____/_____

Rev: 6/29/2004 QUIT-COACH CONTACT & PERMISSION FORM Fax to Quit 6-04.doc/9.5

New York State Smokers’ Quitline 1 – (866) – NY – QUITS (1-866-697-8487)

Fax to Quit FEEDBACK FORM

CONTACT ATTEMPTS BY NYS SMOKERS’ QUITLINE

Patient’s Name: Quitline Counselor:

1st Call Attempt: 2nd Call Attempt: Final Attempt:

Contact Made on:

Your patient was contacted, provided assistance and advised regarding their stop-smoking process. YES NO
Materials were mailed, including a listing of local stop-smoking programs.

PHARMACOTHERAPIES USED BY PATIENT (Circle all that apply.)

Nicotine Patch Nicotine Gum Nicotine Lozenge Nicotine Inhaler Nicotine Spray Zyban/Wellbutrin/Bupropion SR

_________ mg 2 mg 4 mg 2 mg 4 mg ____ cartridges/day ____ sprays/day ________ mg/day

STOP SMOKING STAGE

Your patient’s stage in the stop-smoking process has been assessed below and is followed by a recommended support
intervention for their next office visit.

9 Stage Description Recommended Intervention

Pre-contemplation Not ready and not Advise to stop, listen and question any expression of concern about
interested in quitting. smoking to get patient thinking about changing by personalizing their risk
factors.

Contemplation Not ready to quit, but Advise to stop, discuss particular concerns about stopping smoking (e.g.,
interested in learning withdrawal symptoms) and emphasize the benefits of quitting.
what quitting will entail. Recommend re-referral to the NYS Smokers’ Quitline and provide stop-
smoking materials (Can be obtained from Quitline).

Preparation Ready to learn about CONGRATULATE, foster motivation by reinforcing patient’s
quitting and setting a commitment and determination to quit. Ask if they have set a quit date or
date. urge them to do so. Recommend/prescribe appropriate stop-moking
pharmacotherapy and refer to the NYS Smokers’ Quitline for support
services and stop-smoking material.

Action The stop smoking stage. CONGRATULATE on success of staying off cigarettes and allow patient
This stage may last up to to talk about close calls or relapses. Reinforce their need to make changes
six months or longer. in daily routine and learn new ways to fend off “triggers” (e.g., handling
stress). Assess the need for pharmacotherapy. Recommend the NYS
Smokers’ Quitline for ongoing support.

Maintenance Smoke-free for CONGRATULATE on success of staying smoke-free, confirm patient’s
approximately six new non-smoking identity (improved health, lower blood pressure, etc.),
months. and advise the patient to remind him/herself of their reasons for quitting.
Recommend the NYS Smokers’ Quitline for continued support.

Relapse Patient returned to Remind patient that most smokers relapse. Many get “back on track” and
smoking. slipping doesn’t mean they have become a smoker again. Discourage
patient from feeling guilty and encourage him or her to remember their
successes. Recommend NYS Smokers’ Quitline as a support service.

ADDITIONAL _________________________________________________________________________________________
COUNSELOR _________________________________________________________________________________________
COMMENTS:

Rev: 6/29/2004 QUIT-COACH FEEDBACK FORM Fax to Quit 6-04.doc/9.5