Professional Survey regarding Smoking Cessation Interventions

Question Title

* 1. Please provide your ACS Membership # or ACS Member ID:

Question Title

* 2. About your practice, within the last month:

	Never	Sometimes (1-25% of the time)	Frequently (26-75% of the time)	Almost always (>75% of the time)	Always (100% of the time)
I ask my patients if they smoke cigarettes?	I ask my patients if they smoke cigarettes? Never	I ask my patients if they smoke cigarettes? Sometimes (1-25% of the time)	I ask my patients if they smoke cigarettes? Frequently (26-75% of the time)	I ask my patients if they smoke cigarettes? Almost always (>75% of the time)	I ask my patients if they smoke cigarettes? Always (100% of the time)
I advise my patients about the health risks of tobacco use.	I advise my patients about the health risks of tobacco use. Never	I advise my patients about the health risks of tobacco use. Sometimes (1-25% of the time)	I advise my patients about the health risks of tobacco use. Frequently (26-75% of the time)	I advise my patients about the health risks of tobacco use. Almost always (>75% of the time)	I advise my patients about the health risks of tobacco use. Always (100% of the time)
I provide counseling for my patients who use tobacco on how to quit.	I provide counseling for my patients who use tobacco on how to quit. Never	I provide counseling for my patients who use tobacco on how to quit. Sometimes (1-25% of the time)	I provide counseling for my patients who use tobacco on how to quit. Frequently (26-75% of the time)	I provide counseling for my patients who use tobacco on how to quit. Almost always (>75% of the time)	I provide counseling for my patients who use tobacco on how to quit. Always (100% of the time)
I provide resource materials and referrals to help my patients quit.	I provide resource materials and referrals to help my patients quit. Never	I provide resource materials and referrals to help my patients quit. Sometimes (1-25% of the time)	I provide resource materials and referrals to help my patients quit. Frequently (26-75% of the time)	I provide resource materials and referrals to help my patients quit. Almost always (>75% of the time)	I provide resource materials and referrals to help my patients quit. Always (100% of the time)
I follow up with my patients after surgery about their smoking status.	I follow up with my patients after surgery about their smoking status. Never	I follow up with my patients after surgery about their smoking status. Sometimes (1-25% of the time)	I follow up with my patients after surgery about their smoking status. Frequently (26-75% of the time)	I follow up with my patients after surgery about their smoking status. Almost always (>75% of the time)	I follow up with my patients after surgery about their smoking status. Always (100% of the time)
Do you code for smoking cessation reimbursement?	Do you code for smoking cessation reimbursement? Never	Do you code for smoking cessation reimbursement? Sometimes (1-25% of the time)	Do you code for smoking cessation reimbursement? Frequently (26-75% of the time)	Do you code for smoking cessation reimbursement? Almost always (>75% of the time)	Do you code for smoking cessation reimbursement? Always (100% of the time)

Question Title

* 3. About your practice, within the last month:

	Don’t know	Strongly Disagree	Disagree	Agree	Strongly Agree
I believe that quitting smoking for 1 to 30 days before surgery will reduce the rate of postoperative complications.	I believe that quitting smoking for 1 to 30 days before surgery will reduce the rate of postoperative complications. Don’t know	I believe that quitting smoking for 1 to 30 days before surgery will reduce the rate of postoperative complications. Strongly Disagree	I believe that quitting smoking for 1 to 30 days before surgery will reduce the rate of postoperative complications. Disagree	I believe that quitting smoking for 1 to 30 days before surgery will reduce the rate of postoperative complications. Agree	I believe that quitting smoking for 1 to 30 days before surgery will reduce the rate of postoperative complications. Strongly Agree
Nicotine replacement therapies such as gum or patches are safe for patients to use during surgery.	Nicotine replacement therapies such as gum or patches are safe for patients to use during surgery. Don’t know	Nicotine replacement therapies such as gum or patches are safe for patients to use during surgery. Strongly Disagree	Nicotine replacement therapies such as gum or patches are safe for patients to use during surgery. Disagree	Nicotine replacement therapies such as gum or patches are safe for patients to use during surgery. Agree	Nicotine replacement therapies such as gum or patches are safe for patients to use during surgery. Strongly Agree
Non-nicotine medications are effective in helping patients quit?	Non-nicotine medications are effective in helping patients quit? Don’t know	Non-nicotine medications are effective in helping patients quit? Strongly Disagree	Non-nicotine medications are effective in helping patients quit? Disagree	Non-nicotine medications are effective in helping patients quit? Agree	Non-nicotine medications are effective in helping patients quit? Strongly Agree
Reimbursement is available for tobacco use interventions for my patients.	Reimbursement is available for tobacco use interventions for my patients. Don’t know	Reimbursement is available for tobacco use interventions for my patients. Strongly Disagree	Reimbursement is available for tobacco use interventions for my patients. Disagree	Reimbursement is available for tobacco use interventions for my patients. Agree	Reimbursement is available for tobacco use interventions for my patients. Strongly Agree