| Question |
Answer choices |
| Please select your current position |
Physician or advanced practice provider |
| Registered nurse |
| Respiratory therapist |
| Student |
| EMS |
| Pharmacist |
| Other |
| What type of clinician are you? |
Attending physician |
| Resident physician |
| Fellow |
| Physician assistant |
| Nurse practitioner |
| How important do you believe it is for your patients to stop smoking cigarettes? |
Extremely important |
| Very important |
| Somewhat important |
| Slightly important |
| Not important |
| Have you ever received smoking cessation training (course, formal lecture, etc.)? |
Yes |
| No |
| What type of training did you receive? Mark ALL THAT APPLY |
Live session (instructor-led virtual or in-person) |
| Online module (self-directed) |
| Lecture during professional school |
| CE lecture (after obtaining a license) |
| Receive training FROM my healthcare provider (as a patient) |
| Other |
| How often do you ask your patients about their tobacco use? |
Never |
| Rarely |
| Sometimes |
| Usually |
| Always |
| For patients who report tobacco use or have it documented in their chart, how often do you: Explicitly ADVISE THEM to QUIT (e.g., "It is very important for your health that you stop smoking") |
Never |
| Rarely |
| Sometimes |
| Usually |
| Always |
| For patients who report tobacco use or have it documented in their chart, how often do you: ASSESS their WILLINGNESS to QUIT (e.g., ask them if they are willing to start a quit attempt/set a quit date, want resources or medication, etc.) |
Never |
| Rarely |
| Sometimes |
| Usually |
| Always |
| For patients who report tobacco use or have it documented in their chart, how often do you: Use any CESSATION INTERVENTION (QuitLine, furnish cessation medication, including nicotine replacement, motivational interviewing, provide literature, etc.) |
Never |
| Rarely |
| Sometimes |
| Usually |
| Always |
| Please describe your comfort in your ability to offer smoking cessation COUNSELING to someone who is READY TO QUIT. |
Very comfortable |
| Somewhat comfortable |
| Uncomfortable |
| Very uncomfortable |
| Please describe your comfort in your ability to offer smoking cessation COUNSELING to someone who is NOT READY TO QUIT. |
Very comfortable |
| Somewhat comfortable |
| Uncomfortable |
| Very uncomfortable |
| What is your willingness to provide non-pharmacologic smoking cessation interventions? Interventions could include but are not limited to, counseling (>3 min), literature, and outside referral. |
Extremely Willing |
| Very willing |
| Somewhat willing |
| Slightly willing |
| Not willing |
| How often do you OFFER formal smoking cessation to your patients (>3 minutes)? |
Never |
| Rarely |
| Sometimes |
| Usually |
| Always |
| If you provide formal smoking cessation to your patients (>3 minutes), how often do you BILL for it? |
Never |
| Rarely |
| Sometimes |
| Usually |
| Always |
| Please describe your COMFORT PRESCRIBING: |
| Nicotine replacement (gum, patches, etc) |
Very comfortable |
| Somewhat comfortable |
| Neutral |
| Uncomfortable |
| Very uncomfortable |
| Chantix (Varenicline) or Wellbutrin (Bupropion) |
Very comfortable |
| Somewhat comfortable |
| Neutral |
| Uncomfortable |
| Very uncomfortable |
| QuitLine |
Very comfortable |
| Somewhat comfortable |
| Neutral |
| Uncomfortable |
| Very uncomfortable |
| Smoking Cessation Clinic or Inpatient Consult Service |
Very comfortable |
| Somewhat comfortable |
| Neutral |
| Uncomfortable |
| Very uncomfortable |
| Please describe your FAMILIARITY with the following: |
| Nicotine replacement (gum, patches, etc.) |
Very familiar |
| Somewhat familiar |
| Unfamiliar |
| Very unfamiliar |
| Chantix (Varenicline) or Wellbutrin (Bupropion) |
Very familiar |
| Somewhat familiar |
| Unfamiliar |
| Very unfamiliar |
| QuitLine |
Very familiar |
| Somewhat familiar |
| Unfamiliar |
| Very unfamiliar |
| Smoking Cessation Clinic or Inpatient Consult Service |
Very familiar |
| Somewhat familiar |
| Unfamiliar |
| Very unfamiliar |
