Clinical Practice Resources
Provider Handout: How Health Care Professionals Can Help Pregnant Smokers Quit
A one-page handout that describes the 5 A’s intervention for pregnant women.
Order Form: ACOG Clinician’s Guide
The American College of Obstetricians and Gynecologists (ACOG) has produced a training manual called "Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking." This educational program provides the background and tool necessary for clinicians to implement evidence-based interventions in the office setting.
Documentation Forms: Five A’s Intervention Record
Provider Administered | Client Administered
Patient chart forms used by state demonstration projects to collect information on provider delivery of the 5 A’s. There are prenatal and postnatal versions, and provider-administered and patient-administered versions.
Postpartum Quitline Protocol
A detailed counseling protocol designed for quit coaches and other providers who want to address post-partum relapse. Consists of scripts and a worksheet on basic counseling principles.
Practice Guideline Manual: San Diego Partnership for Smoke-Free Families
A manual containing valuable lessons learned, recommendations for program implementation, and samples of program materials from a successful comprehensive tobacco treatment project.
Curriculum: Second Wind, First Breath
Facilitator Guide | Participants Guide
A support group curriculum designed by American Indians for American Indian pregnant women who want to quit smoking. Contains a facilitator guide and patient materials.
Planning Guide: Treating Tobacco Use and Dependence
A planning guide for obstetric health care practice sites to assist them in implementing office systems for smoking cessation services.
Documentation Forms: Assessing Tobacco Use
Forms used by SFF research project grantees to obtain standardized measures of smoking status and other information on study subjects. The series includes a core baseline assessment form, a core screening form, an end-of-pregnancy assessment form, and a core postpartum assessment form.
Documentation Form: Smoking History Survey for Pregnant Women
A standardized form containing a short, three section survey on a pregnant woman’s smoking status, history of tobacco use, and second-hand smoke exposure.
Tobacco Treatment Database
A sample Access database from the Maine Prenatal Collaborative that contains screens for documenting delivery of the 5 A’s and additional patient / provider information.
Office Poster: With Help From Your Doctor
This poster was created for provider offices with the tagline “With help from your doctor, you could quit smoking by your next visit”.
Helping Families Thrive: Key Policies to Promote Tobacco Free Environments for Families
This report presents facts on second-hand smoke, evidence-based solutions for creating tobacco-free environments, and policy action recommendations that affect families with young children.