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Tobacco use is the number one public health threat in Kentucky. The state’s adult and youth
smoking rates, annual deaths related to smoking, and lung cancer death rates are among the
highest in the country.

According to the 2004 BRFSS, 27.5% of adults (over the age of 18) currently smoke compared
to the national average, 20.8%. Approximately one out of every four pregnant women smokes –
twice the national average. This behavior places their children at risk for low birth weight,
SIDS, respiratory problems, and various other health conditions.

The single most important step in addressing tobacco use and dependence is screening for
tobacco use. After the clinician has asked about tobacco use and has assessed the willingness to
quit, he or she shall then provide the appropriate intervention, either by assisting the patient in
quitting, by providing a motivational intervention, or referring to the Cooper/Clayton Method to
Stop Smoking, Make Yours a Fresh Start Family, or Kentucky’s Tobacco Quit Line 1-800-QUIT

The “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) are designed to be used with the
smoker who is willing to quit. (“Treating Tobacco Use and Dependence”, U.S. Department of
Health and Human Services, Public Health Service)

“2 A’s Plus 1 R” (Ask, Advise, Refer) can be used with all patients who use tobacco products.

   1. All Health Departments shall ensure that tobacco use status identification is visible in
      the patient’s file. Documentation should include status, referrals, progress and follow-up.
   2. Tobacco use status questions should be asked and recorded for every visit. Tobacco
      status, in addition to cigarette use, includes smokeless or spit tobacco and exposure to
      secondhand smoke.
   3. Every patient identified as a smoker should be advised to quit at every visit. This advice
      shall be clear, strong, and personalized to the patient. Brief interventions of 3–5 minutes
      shall be developed and presented in an empathetic and nonjudgmental matter and be
      culturally appropriate. For WIC patients, refer to the WIC Section for additional
      counseling guidelines.
   4. Each patient identified as a smoker should be assessed as to willingness to quit.
      Clinicians shall ask questions at each visit that prompt the patient to identify reasons to
      quit and barriers to quitting. Document the assessment of the patient’s readiness to quit.
      Assure the patient that when he/she is ready to quit, assistance shall be provided.
   5. Assist every smoker who wants to quit by providing educational materials, referrals to
      cessation classes and cessation lines, and to the Tobacco Program Coordinator for
      additional referrals and programs.
   6. Patients, parents of small children exposed to secondhand smoke, and pregnant women
      shall be informed of the dangers associated with secondhand smoke and advised to make
      environmental changes when possible.

                                                Page 1 of 5
                                  Kentucky Public Health Practice Reference
                                             Section: Tobacco
                                              January 1, 2008
7. Smokeless or spit tobacco users shall be advised to quit and provided information and
   referrals to assist them either in making a decision to quit or pursuing methods to quit.

At the minimum, each visit should include the 2 A’s Plus 1 R:

    Ask. Find out about your client’s smoking status.
    Advise. Explain the benefits of being smoke-free, and let them know they need to stop.
    Refer. Verbally refer the patient to group counseling, one-on-one counseling, or the quit
    line. (Example: “Here is a phone number. Calling the quit line will more than double
    your chance of being smoke-free” 1-800-QUIT NOW [1-800-784-8669])

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                               Kentucky Public Health Practice Reference
                                          Section: Tobacco
                                           January 1, 2008
Recommended programs include the Make Yours A Fresh Start Family program for pregnant
women and mothers/guardians of young children and the Cooper/Clayton Method for Becoming
a Nonsmoker for those who have determined that they want to quit. (See below for details on
these two programs.) Both of these programs are targeted primarily toward adults.

Youth cessation programs are often coupled with prevention efforts and are available through
schools, family resources and youth services centers, and other community partners or from your
local health department tobacco program coordinator.

Contact your Tobacco Coordinator/Health Educator staff for recommendation of additional
programs and resources.

1. Make Yours A Fresh Start Family (MYFSF)
   MYFSF is a comprehensive program for health care providers to help them counsel pregnant
   women and mothers to stop smoking. This innovative program teaches providers to give their
   smoking patients one-on-one counseling using a 5-step "STAGE" intervention. The program
   is based on the Agency for Health Care Policy and Research (AHCPR) Clinical Practice
   Guidelines on Smoking Cessation.

2. Cooper/Clayton Method to Stop Smoking
   The Cooper/Clayton Method to Stop Smoking is a twelve-session cessation intervention
   developed by Drs. Thomas M. Cooper & Richard R. Clayton of The Institute for
   Comprehensive Behavioral Smoking Cessation. The program combines counseling with
   nicotine replacement therapy and social support to maximize success with minimal relapse.
   A trained facilitator, primarily in a group setting, provides the intervention, which addresses
   all aspects of smoking––physical, psychological, and behavioral.

3. Kentucky Cancer Program Provider Practice Prevention Tool Kit for Public Health Nurses

4. Tool Kits: Contact your local Tobacco Program Coordinator for kits
    “Dispelling the Myths About Tobacco, A Community Toolkit for Reducing Tobacco Use
      Among Women” – CDC
    “Got A Minute? Prevention Through Parenting kit to tackle teen tobacco use” – CDC

5. Quit Lines:
    800–QUIT NOW

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                                   Kentucky Public Health Practice Reference
                                              Section: Tobacco
                                               January 1, 2008
                       A Twelve Week Comprehensive Program
        The Cooper-Clayton Method to Stop Smoking is an effective smoking cessation method
which addresses all aspects of smoking. The method uses the nicotine patch, nicotine gum, and
the nicotine lozenge and it also provides twelve-intensive education sessions and weekly support
group meetings.

       This method is successful because there is a long-term support group; the training is
designed to achieve and maintain abstinence; and it uses proven nicotine replacement products.

       The facilitators are trained in evaluating individual smoking patterns, understanding
behavior modification techniques, how to lead group discussions, and how to minimize relapse.

        Cooper-Clayton Classes may be provided in group settings in clinic or at another site as a
means to provide a common message in a cost effective manner. With the new coding options
for preventive health and group classes, the format and content of these classes are very critical.

Target Audience: Anyone (over the age of 18) who desires to make the journey from smoker to

Curriculum: The Cooper-Clayton Method to Stop Smoking – A Twelve-Week Comprehensive

Week One            Understanding Addiction
                    Advantages/Disadvantages of Nicotine Replacement products
                    Recommendation for Patches or Number of pieces of gum or lozenges
Week Two            How the Body Metabolizes Nicotine
                    Physiological Dependence
Week Three          Dealing with Stress as a Nonsmoker
                    LARK Approach to deal with Stress
Week Four           Exercise for the New Nonsmoker
                    Making the Transition from Smoker to Nonsmoker
Week Five           Nutrition/Eating as a Nonsmoker
                    Tom’s Model for Caloric Needs
                    “The Target Diet” by Covert Bailey
Week Six            Life’s Pleasures as a Nonsmoker
                    A Chance for Good Health
Week Seven          Understanding Behavior Modification
                    Relapse Prevention
Week Eight          Dealing with Depression as a Nonsmoker
                    The Stages of Grief
Week Nine           Living with Smaller Amounts of Nicotine
                    Weight Gain as a Nonsmoker

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                                  Kentucky Public Health Practice Reference
                                             Section: Tobacco
                                              January 1, 2008
Week Ten            Positive/Negative Effects Related to Being a Nonsmoker
                    Alcohol and Caffeine and the Nonsmoker
Week Eleven         Behavioral Aspects of Remaining a Nonsmoker
                    Maslow’s Research – Changing needs throughout Your Lifetime
Week Twelve         Celebration Time
                    Benefits of Remaining a Nonsmoker

Requirements for Billing Medicaid:
Staff/Training Requirements -- Instructors must be a professional or allied-health professional.
Instructors must complete a one-day Cooper-Clayton Facilitator Training (under the direction of
Drs. Cooper and Clayton and the KY Cancer Program)
Billing/Coding -- If the health department chooses to bill Medicaid for the service, a Patient
Encounter Form (PEF) should be completed on each date of class attendance for each attendee.
CPT codes 99411or 99412 (preventive medicine codes for counseling and risk factor
interventions in group settings) are to be used for reporting on the PEF, 99411 for classes
lasting up to 49 minutes and 99412 for classes lasting 50 minutes or more.

Cost of Service – If the health department chooses to bill for the service, all attendees (unless
they have Medicaid), will be required to pay a nominal fee of $1.00 for each class. Attendees
who have Medicaid should be instructed that Medicaid will be billed for the class. Health
departments may decide to collect the nominal fees on site or bill attendees at a later date.
Inform attendees that no person will be denied services because of an inability to pay.
Record Keeping – A class roster including all participants and their contact information shall be
maintained in a locked file by the primary coordinator of the class series (follow HIPAA
In addition, offsite health department patient registration guidelines will apply to Cooper-Clayton
classes for all individuals who attend the classes. A modified chart will be required including:
      CH 5B (WITHOUT the completion of #20 -- the salary and income section)
      CH 3A - service progress note identifying the content that was included in each class
      HIPAA form
      PEF
The completed forms/chart shall be stored in the health department of the county where the class
was conducted.
                         Record-Keeping/Reporting Summary

                               Billing Medicaid                          Not Billing Third
Chart (HIPAA, Ch5B,            X
PEF                            X
Pre/Post Assessment            X                                         X
Class Roster                   X                                         X
Reporting                      PSRS (via PEF)                            Catalyst Reporting System

                                                 Page 5 of 5
                                   Kentucky Public Health Practice Reference
                                              Section: Tobacco
                                               January 1, 2008