Thank you for your support of SMART About Tobacco:  Smile SMART as we seek to make Tennessee tobacco-free.  By completing this commitment form, you agree to counsel ten patients about tobacco cessation and living smoke-free.   No follow-up or additional steps are needed and you will not be contacted unless you choose to participate in the  SMART About Tobacco:  Smile SMART research project and have indicated interest on this form.

As a dental professional, are you committed to counseling at least ten tobacco-using * patients on the risks of tobacco and secondhand smoke and to utilizing best-practices counseling for cessation with these patients?  *NOTE:  Patients who use electronic nicotine delivery devices (ENDS) such as e-cigs, e-pipes, vaporizers are considered tobacco users as are those who use cigarettes, cigars, pipes, chewing tobacco, etc.

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* 1. As a dental professional, are you committed to counseling at least ten tobacco-using * patients on the risks of tobacco and secondhand smoke and to utilizing best-practices counseling for cessation with these patients?  *NOTE:  Patients who use electronic nicotine delivery devices (ENDS) such as e-cigs, e-pipes, vaporizers are considered tobacco users as are those who use cigarettes, cigars, pipes, chewing tobacco, etc.

What is your job or role at your facility or practice?

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* 2. What is your job or role at your facility or practice?

Would you be willing to share outcomes from your counseling efforts?

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* 3. Would you be willing to share outcomes from your counseling efforts?

Please share the county (ies) in which you practice.

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* 4. Please share the county (ies) in which you practice.

Please list your name and e-mail address if you have questions and would like to be reached about SMART About Tobacco: Smile SMART or  SMART Moms  (for pregnant smokers).

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* 5. Please list your name and e-mail address if you have questions and would like to be reached about SMART About Tobacco: Smile SMART or  SMART Moms  (for pregnant smokers).

Are you interested in participating in the SMART About Tobacco:  Smile SMART research project?  The research project provides training on best-practices tobacco cessation counseling techniques for dental professionals.  If you are interested, please provide your contact information in the comments section so that project staff can get in touch with you about information on the study.  If you are not interested, leave the box blank.

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* 6. Are you interested in participating in the SMART About Tobacco:  Smile SMART research project?  The research project provides training on best-practices tobacco cessation counseling techniques for dental professionals.  If you are interested, please provide your contact information in the comments section so that project staff can get in touch with you about information on the study.  If you are not interested, leave the box blank.

Please enter your name and e-mail address if you would like to be entered into a drawing for participating in this online survey:

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* 7. Please enter your name and e-mail address if you would like to be entered into a drawing for participating in this online survey:

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