January 26-28, 2021
Zoom: https://us02web.zoom.us/meeting/register/
Efraim Lopez elopez@crihb.org
Register on zoom and complete form below
elopez@crihb.org or mmeza@crihb.org
Team Lead
Registration Form
For information contact
Basic Tobacco Intervention Skills
for Native Communities
1. Engage commercial tobacco users in a culturally relevant
and sensitive manner
2. Assess for commercial tobacco use and exposure to
secondhand/thirdhand smoke.
3. Conduct a culturally responsive integrated, state-specic
Five A Model brief intervention for health risk behavior
4. Demonstrate effective use of culturally adapted patient self-
management resources to evoke condence in a health risk
behavior change.
5. Describe pharmacotherapy options for commercial tobacco
dependence treatment.
6. Document details of interventions for treatment of
commercial tobacco dependence.
7. Follow-along and follow-up with individuals using a
disease management approach.
8. Refer patients/clients who use commercial tobacco to
relevant intensive treatment services.
9. Connect Native people who are dependent on
commercial tobacco with supportive resources.
10. Establish protocols to systematically prevent/treat
commercial tobacco use and dependence.
Program Objectives:
Basic Tobacco Intervention Skills
Registration Form
University of Arizona HealthCare Partnership
BS NAC Registration 04.2011
Copyright © 2011 The University of Arizona
Continued on back
Ocial Use ONLY
Instructor: _____________________________
Instructor Initials: _______________________
_ _____/_____/_____
Name Degree Todays Date
Employer Job Title
Are you a health or human service professional? Yes No
What type(s) of patients/clients do you work with and what percentage of each type?
Medicare Patients _____________ % Managed Care Patients ___________% Indian Health Service Patients _______%
Uninsured Patients
____________ % VA Patients _______________% Private Patients ________________%
(please specify) __________________________________
What tobacco dependence treatment practices currently exist in your healthcare system?
If yes, which one? Tribal aliation
Background Information
Total years of education completed
(circle one)
9 10 11 12 13 14 15 16 17 18+
High School College Post-Graduate
Major/area(s) of specialization: _______________________________________________________________________________________
List education, special training, licenses, or certications in substance abuse or behavioral health: ______________________________________
How long have you worked in tobacco control? _______ years _______ months less than 1 month
Purpose for registering for this program: _________________________________________________________________________________
Languages in which you are uent: _____________________________________________________________________________________
Contact Information
Home Address
Work Address
________________________________ _______ ____________
City State Zip
________________________________ _______ ______________
City State Zip
(_______) ____________________________________________
Home Telephone
(_______) ______________________________________________
Work Telephone
(_______) ____________________________________________
Cell Phone
(_______) ______________________________________________
Fax Number
Email Address
Demographic Information
(please specify)
American Indian/Alaska Native _______________________________ Multiethnic ____________________________________________
Asian ___________________________________________ Native Hawaiian or other Pacic Islander _____________________________
Black/African American ____________________________________ White _______________________________________________
Hispanic/Latino _____________________________________ Other _______________________________________________
Gender: Female Male Date of Birth: ______/______/_______
Do you require Continuing Education Credits to renew your professional license?
Yes No
If yes, what profession? Signature
Native Communities
January 26-28
, 202
Denitely Not
Undecided Condent Denitely
1. I can screen for and assess tobacco use 1 2 3 4 5
2. I can accurately assess my clients’ motivation to quit 1 2 3 4 5
3. I can perform a brief intervention for tobacco cessation 1 2 3 4 5
4. I can explore issues related to smoking and quitting, even with someone NOT
INTERESTED in quitting
1 2 3 4 5
5. I can accurately assess the dependence level of my clients 1 2 3 4 5
6. I can eectively use patient education materials for tobacco
1 2 3 4 5
7. I can provide clients with accurate information regarding the health benets of
1 2 3 4 5
8. I can personalize the benets of quitting with each individual client 1 2 3 4 5
9. I can create oce protocols to support tobacco cessation 1 2 3 4 5
10. I can provide clients with simple advice and instructions about nicotine
replacement therapy
1 2 3 4 5
11. I can describe rst-line pharmacotherapies for tobacco cessation 1 2 3 4 5
12. I can help clients develop a personalized plan for quitting 1 2 3 4 5
13. I can help clients identify community resources to help them quit 1 2 3 4 5
14. I can arrange for appropriate follow-up for my clients 1 2 3 4 5
Condence Self-Assessment
The following statements address competencies related to assisting people who are tobacco dependent to abstain from tobacco use. Please indicate your level of condence
in addressing these issues by circling the most appropriate number.
Knowledge Self-Assessment
The following questions are designed to assess your level of knowledge about tobacco issues before completing the Basic Tobacco Intervention Skills for Native Communities
certication. Your answers on these questions do not count for a grade. Please circle the one
response that provides the best answer.
1. Tobacco use should be brought up with the patient/client:
a. whenever the patient is presenting with a tobacco-related problem
because he or she will be more motivated to quit
d. only every few months, so that the patient does not feel that he or she is
being “nagged” about quitting
b. at every visit e. only by the physician
c. only during general check-up visits when the patient is more likely to
be focused on lifestyle issues
2. The highest risk for relapse from nicotine withdrawal is:
a. after the rst week of being tobacco free c. during the rst two weeks after quitting
b. during the rst 24 hours after quitting d. up to three months after quitting
3. Name the rst non-nicotine medication approved for use in treating tobacco dependence:
a. Claritin d. Valium
b. Dexatrim e. Zyban
c. Flonase
4. Name the Five As:
ask, advise, assess, arrange, act d. anticipate, advise, assess, arrange, act
b. ask, advise, admonish, assist, arrange e. approach, ask, advise, assist, arrange
c. ask, advise, assess, assist, arrange
Native Communities
BS NAC Registration 04.2011
Copyright © 2011 The University of Arizona
Tobacco Dependence Treatment Baseline
The University of Arizona HealthCare Partnership
Tobacco Dependence Treatment Certification Program
: __________________________
: ____/____/____
: _______________________
Which of the following tobacco control activities are routine procedures within your workplace setting?
(please check all that apply, N/A = Not Applicable)
Yes No N/A
Ask patients/clients/significant others about current commercial tobacco use at each visit.
Ask patients/clients/significant others about past commercial tobacco use at each visit.
Ask patients/clients/significant others about the potential of environmental tobacco smoke exposure within
Discuss the importance of quitting with patients/clients/family/friends unwilling to quit.
Distribute self-help materials to commercial tobacco users on a consistent basis.
Other (please specify) ________________________________________________________________
Yes No N/A
Implement the Five A model when conducting tobacco dependence treatment interventions with
Help patients/clients who are willing to make quit attempt, set a date and develop a quit plan.
Refer patients/clients/family/friends to suitable intensive services to support quit attempt.
Refer patients/clients/family/friends to intensive services provided by:___________________________
Provide follow-up support for commercial tobacco users during a quit attempt.
Other (please specify) ________________________________________________________________
Yes No N/A
Inform patients/clients about the use of pharmacotherapy for tobacco cessation.
Provide no cost or reduced cost medications to assist commercial tobacco users willing to set a quit date:
Check medications available.
Have physician standing orders to provide pharmacotherapy for individuals willing to set a quit date.
Other (please specify) ________________________________________________________________
Yes No N/A
Utilize a system (e.g. vital sign stamps, medical history form, progress note, problem list cover sheet,
computerized record system) to ask patients/clients about current and past commercial tobacco use, along
Document tobacco prevention/cessation intervention in the patient/client record.
Implement the Electronic Health Record to document/track tobacco prevention/cessation interventions.
Obtain treatment outcome information and verify abstinence using biochemical validation.
Other (please specify) ________________________________________________________________
Yes No N/A
Use billing codes to obtain reimbursement for Tobacco Dependence Treatment services.
Provide a setting that has instituted policies and procedures that ensure a tobacco-free campus.
Other (please specify) ________________________________________________________________