NH DHHS Promotes On-Demand Professional Development for Healthcare Professionals

To ensure healthcare professionals have access to evidence-driven tobacco treatment strategies, the DHHS Tobacco Prevention and Cessation Program has created a free online training curriculum.  The QuitWorks-NH on-demand professional development modules help health care professionals refer and assist their patients in quitting tobacco and utilizing the services through QuitNow-NH.

DHHS has completed 5 modules. Topics include: Fundamentals of QuitNow-NH, Ask, Assist, Refer: Treating Tobacco Use for Dependence, Pharmacotherapy, Motivational Interviewing, and Supporting Pregnant and Postpartum Women to Quit Tobacco. The modules can be found at The modules accommodate hectic clinical schedules and offer free continuing education credits for each module completed.

Tobacco treatment professional development on-demand modules

 DHHS Awards Four New Hampshire Health Systems
for Treating Tobacco Use and Dependence (October 2017)

The New Hampshire Department of Health and Human Services (DHHS), Division of Public Health Services (DPHS) recently recognized four health systems for their ongoing commitment to excellence in treating patients with tobacco use dependence.

The four health systems recognized are:

Dartmouth Hitchcock, Lebanon

Mid-State Health Center, Plymouth

Riverbend Community Mental Health, Inc.,Integrated Center for Health, Concord

Greater Nashua Mental Health Center, Nashua


Visit the NH Department of Health and Human Services for the full press release on this event.



 Electronic cigarettes (e-cigarettes) are devices, often resembling cigarettes, cigars or pipes, designed to deliver nicotine or related substances to users through inhalation or smoking.

Learn more at the New Hampshire Department of Health and Human Services.

Read the DHHS Public Health Advisories on e-cigarettes for Pediatricians and Providers:



Smoking Hits All-Time Low… But Not For These 3 Groups

Largest non-profit quitline in the U.S. hires Native counselors, looks to help LGBT smokers and those with mental health issues. While the overall number of people who smoke in the United States is at an all-time low, not everyone in Denver, Colorado is quite ready to celebrate.

Helping Smokers Quit – Opportunities in the Affordable Care Act

Affordable Care Act Guidance on Coverage of Tobacco-Cessation
Treatment – New England Journal of Medicine Perspective.

E-Cigarettes:  A Public Health and Clinical Update

What is an E-Cigarette?

An electronic cigarette (E-cigarette) is a device that heats and vaporizes liquid that contains nicotine designed to mimic the experience of smoking a conventional cigarette (commonly known as vaping). It is a new product – less than 10 years old, there are more than 250 brands. The Ingredients, flavorants (chemicals and natural flavors used to flavor the products), and amount of nicotine delivered vary widely across brands.

As of April 24, 2014, the US Food and Drug Administration (FDA), Center for Tobacco Products (CTP) issued a proposed rule that would extend the agency’s authorities to cover additional products that include: electronic cigarettes, cigars, pipe tobacco, certain dissolvables that are not “smokeless tobacco,” nicotine gels, and waterpipe (hookah) tobacco. E-Cigarettes are entirely unregulated at this time which means the FDA has not yet evaluated the safety of e-cigarettes.

Are E-Cigarettes Safe?

  • There is no scientific information on long-term health effects
  • Most people agree that an individual who totally switches from conventional (burnt) cigarettes to e-cigarettes probably reduces his/her health risks
  • At least one study has documented acute pulmonary dysfunction among a sample of e-cigarette users[i]
  • Poison Center Calls have increased as a result of exposure to liquid nicotine by infants/toddlers. This occurs when adults purchase the ‘refillable vaping’ pen and or refillable electronic cigarette.

Are E-Cigarettes Effective as an Aid for Tobacco Cessation?

  • Studies on e-cigarettes as a cessation aid for nicotine addiction and cigarette use are few, with mixed and modest results. Some show cessation effectiveness about equal to nicotine replacement therapies (NRT)
  • Due to very limited cessation data, neither the United States Public Health Service nor the Preventive Service Clinical Task Force has recommended e-cigarettes as a cessation aid
  • Current guidelines recommend: Asking a patient about tobacco use in every encounter, Assisting the patient with the recommendation to quit and information about help in quitting, and Referring them to the NH Quitline (1-800-QUIT-NOW) as best practice for treating tobacco and nicotine use and dependence.[ii]

Recommended Clinical Approach for 2014 When Patients Ask About E-Cigarettes

  • Clearly communicate that use of any tobacco product (combustible (burnt) or smokeless tobacco) can be harmful, but that combustible tobacco use is by far the most harmful
  • Strongly encourage the patient to stop using any combustible or smokeless tobacco product
  • If the smoker is willing to make a quit attempt, offer the evidence-based cessation treatments (e.g., physician advice, quit line counseling, FDA-approved medications). Refer the smoker to the NH Quitline via QuitWorks-NH fax or e-referral[iii]
  • If the patient is not willing to make a quit attempt at this time, urge the smoker to smoke combustibles as little as possible
  • When discussing cigarette substitutes, many patients may propose using e-cigarettes.  Inform the patient that:
  • The health effects of e-cigarette use are not known, but that e-cigarettes are likely safer than combustible tobacco products
  • Emphasize that the ultimate goal must be complete cessation of all tobacco products and electronic cigarettes
  • Note that dual use is not a good long-term goal

Key Public Health Issues

Risk to Children: Poison centers are reporting a recent uptick in calls about exposures to e-cigarette devices and liquid nicotine. Slightly more than half of these reported exposures have occurred in young children under the age of six. Some children and toddlers who come in contact with e-cigarette devices or liquid nicotine have become very ill; some even requiring Emergency Room (ER) visits with nausea and vomiting being the most significant symptoms. Adults should use care to protect their skin when handling the products, and they should be out of sight and out of the reach of children. Additionally, those using these products should dispose of them properly to prevent exposure to pets and children from the residue or liquid left in the container.

The American Association of Poison Control Centers recommends the following steps:

  • Protect your skin when handling the products
  • Keep e-cigarettes and liquid nicotine out of reach of children
  • Follow disposal instructions
  • If you believe someone has been exposed call The Northern New England Poison Center:  1-800-222-1222

Risk to Youth: The United States Centers for Disease Control reported a doubling of e-cigarette use among both middle and high school students between 2011 and 2012.[iv]

  • An additional concern is that e-cigarettes may be readily available to youth via the internet. Many of the flavors of e-cigarettes (e.g., bubble gum), intentionally or otherwise, may appeal to youth

Dual Use: While much of the marketing and many of the news stories regarding e-cigarettes promote their potential to aid smoking cessation, most e-cigarette users report that they also smoke conventional cigarettes.[v]

Second-Hand Exposure to E-cig Vapor: Little is known about second-hand exposure.

  • Some toxicology studies have documented ingestion of nicotine, volatile organic components, and other chemicals in individuals exposed to second-hand vapor[vi][vii]

How to Refer a Patient to the NH Quitline via QuitWorks-NH

Use the fax referral forms or call Teresa M. Brown, Certified Tobacco Treatment Specialist for the NH Division of Public Health Services at 603-271-8949 to set up systems change for treating tobacco use and dependence in your office setting.

i Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V; Connolly GN, Behrakis PK. Short-term Pulmonary Effects of Using an Electronic Cigarette: Impact on Respiratory Flow Resistance, Impedance, and Exhaled Nitric Oxide. Chest. 2012;141(6):1400-1406.

ii Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

iii or call Teresa M. Brown, CTS, NH Tobacco Prevention and Control Program: 603-271-8949
iv CDC Morbidity and Mortality Report, September 6, 2013 / 62(35);729-730.

v FDA Tobacco Products Scientific Advisory Committee. Presentation of Dr. Robert C. McMillen, American Academy of Pediatrics, April 30, 2013.

vi Schrip T, Markewitz D, Uhde E, Salthammer T. Does e-cigarette consumption cause passive vaping? Indoor Air. 2013;23:25-31.
vii Schober, W., et al., Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int. J. Hyg. Environ. Health (2013),

50th anniversary of the first Surgeon General’s Report on Smoking and Health

2014 Surgeon General's Report on Smoking and Health - Coming soon

How Can Providers Implement Meaningful Use and Tobacco Cessation

Q: What is Meaningful Use?
Meaningful Use is an incentive plan that eligible health care professionals and hospitals can qualify for through Medicare and/or Medicaid when they adopt certified Electronic Health Record (EHR) technology and use it to achieve specified objectives. The Recovery and Reinvestment Act of 2009 (ARRA) established the Health Information Technology for Economic and Clinical Health (HITECH) Act. Meaningful Use came out of regulations from the HITECH Act.

Meaningful use is using certified electronic health record (EHR) technology to:

  • Improve quality, safety, efficiency, and reduce health disparities
  • Engage patients and family
  • Improve care coordination
  • Improve population and public health
  • Maintain privacy and security of patient health information

Ultimately, it is hoped that the meaningful use compliance will result in: Long-term outcomes from Meaningful Use compliance:

  • Better clinical outcomes
  • Improved population health outcomes
  • Increased treatment transparency and efficiency
  • Empowered individuals Empowered patients and patient families
  • Robust tobacco treatment data collection within health systems

More details about Meaningful Use core and clinical quality measures (CQM) can be found here:

Q: What is the impact on quitlines when implementing Tobacco Treatment with Meaningful Use?
There are 3 Stages to the CMS Medicaid and Medicare EHR Incentive Programs:
Stage 1 Data Capture and Sharing – 2011-2012
Stage 2 Advanced Clinical Processes – 2014
Stage 3 Improved Outcomes – 2016

In each Stage tobacco dependence should be routinely screened for and consistently treated with referrals to quitlines plus medication. Documenting this process will be fully integrated in the health system’s EHR. By using the EHR meaningfully, tobacco screening and treatment may be delivered consistently and follow best practice recommendations (per the Public Health Service Guidelines).

More details about Meaningful Use can be found on this Fact Sheet from the University of Wisconsin Center for Tobacco Research and Intervention

And this Fact Sheet from the NH Tobacco Prevention and Control Program

While having an effective tobacco dependence screening and treatment template is critical to a comprehensive tobacco treatment system, it is not sufficient. Comprehensive tobacco treatment systems depend on the delivery of effective brief cessation interventions (e.g., 5A or 2AR) and the availability and utilization of community-based and statewide cessation resources. Meaningful Use is an opportunity to implement health systems change and can maximize tobacco cessation efforts.

Content adapted from University of Wisconsin Center for Tobacco Research and Intervention, Partnership for Prevention, Multi-State Collaborative for Health Systems Change, and Action to Quit. 2012

Families First Health and Support Center of the Greater Seacoast receives TREATING TOBACCO USE & DEPENDENCE INNOVATION AWARD

Treating tobacco use innovation award

The aim of this clinical quality improvement project was to increase the capacity of Families First Health and Support Center to effectively provide a brief tobacco use and dependence intervention with clients who use tobacco. Interventions were incorporated by making modifications to their electronic health/medical records and clinical workflow using evidence-based US Public Health Service Taskforce recommendations for providing clinical brief interventions for Treating Tobacco Use and Dependence.

The result of this clinical quality improvement project was a unique, paperless communication loop between Families First clinicians, and the NH Quitline, the proactive tobacco cessation counseling service offered via the clinician portal QuitWorks-NH. Today, clients who are seen at Families First that use tobacco and want to quit are referred by clinicians to a Certified Tobacco Treatment Specialist with the touch of a button. The Specialist will call the patient and offer up to five no cost counseling sessions over the phone. The referring clinician then receives a confidential report from the Specialist about what treatment services were accepted by the patient, referred to as the patient status report. The patient status report is then downloaded into the patient’s electronic medical record.

This project fulfills activities for Meaningful Use and Medical Home requirements.

This project is the first of its kind in the State to complete all the steps mentioned above and is one of the first being achieved in the Nation.

To implement this paperless referal and feedback loop into your practice, contact Teresa Brown at the NH Tobacco Prevention & Control Program at 603.271.8949 or

Read coverage about the event here:
Portsmouth-NH Patch

Why 2As and 1R?

The alternative protocol to the gold standard 5As (Ask, Advise, Assess, Assist, Arrange).

The U.S. Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence 2008 Update calls for systems level tobacco intervention efforts using the 5As. However, working the 5As into the practice’s current workflow may be overwhelming, particularly if providers are not connected to state quitline resources. As Meaningful Use rolls out, QuitWorks-NH via the NH Tobacco Prevention and Control Program (TPCP), can provide training and technical assistance (TA) for practices integrating tobacco treatment into electronic medical records (EMR) using the 2A (Ask and Assist) and R (Refer to QW-NH) so that providers have a resource to refer patients that want to quit.

QuitWorks-NH TA Protocol:

  1. Create a team comprised of Senior Management, Technical Development, Clinical staff and Operational staff to address a process to adopt 2A and R.
  2. Examine current work flow and decide what the prompts for ASK will look like:
    • Current, Former, Never
    • Current every day, current some days, Former, Never
    • Other?
  3. Decide where in the EMR the ASK will be placed
    • Vital Signs
    • History
    • Problem List
    • Other?
  4. Changes in workflow due to changes in EMR
    • How will an ASSIST be made e.g., clear messages, prescriptions, OTC recommendations?
    • Will the REFER to QuitWorks-NH be paper or electronic: tailoring the fax form to the practice?
    • Generate reports based on provider loyalty to the EMR fields.
    • Disposition reports to providers from quitline on patient treatment status.
  5. Training in QW-NH logistics-getting staff together, changing job functions
  6. Institutionalizing responsibility for quitline materials to be present in waiting areas and exam rooms.
  7. All new staff will be trained in 2A and R upon hire.

To begin implementing 2As and 1R into your practice, contact Teresa Brown at the NH Tobacco Prevention & Control Program at 603.271.8949 or

2010 Surgeon General’s report Clinician Sheet

What to Tell Your Patients About Smoking

A new report from the Surgeon General contains important new information on how tobacco smoke causes disease and explains why it is crucial to stop smoking and avoid secondhand smoke.

This one-page fact sheet summarizes the findings from How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. This fact sheet features smoking-attributable chronic disease information as well as “how to quit” information from the Clinical Practice Guidelines (published by the U.S. Agency for Healthcare Research and Quality). The fact sheet provides simple talking points and key information to help medical providers talk to their patients about quitting tobacco use.

Click here to download the .pdf
Visit the CDC website to order copies
Click here to learn more about the full report

Text4baby is a free mobile information service designed to promote maternal and child health. An educational program of the National Healthy Mothers, Healthy Babies Coalition (HMHB), text4baby provides pregnant women and new moms with information they need to take care of their health and give their babies the best possible start in life. Women who sign up for the service by texting BABY (or BEBE for Spanish) to 511411 will receive free SMS text messages each week, timed to their due date or baby’s date of birth.

Visit for more information

Law Banning Flavored Tobacco Goes Into Effect

The FDA has released a notice regarding Tobacco products stating that effective September 22, 2009, cigarettes that contain certain characterizing flavors are considered adulterated under the Federal Food, Drug, and Cosmetic Act, as amended by the Family Smoking Prevention and Tobacco Control Act (FSPTCA). Menthol is not prohibited but rather flavors such as vanilla, mint and clove would be.

Read more on the FDA Web site »

Learn more about Health Risks Specific to Flavored Cigarettes