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By order of the commander

BY ORDER OF THE COMMANDER
MEDICAL GROUP INSTRUCTION 40-4
16th Medical Group
1 March 2003
Medical Command
HEALTH PROMOTION TOBACCO PREVENTION AND CESSATION PROGRAM
COMPLIANCE WITH THIS INSTRUCTION IS MANDATORY

Supersedes: MDGI 40-4, 11 Jan 01
OPR: 16 MDOS/SGOAZ
Certified by: 16 MDG/SGA (Lt Col Felins)
Pages: 13
Distribution: F

This instruction outlines the Hurlburt Field Health Promotion Tobacco Prevention and Cessation
Program. This program directly supports the Air Force and Air Force Special Operations
Command's emphasis on wellness in order to improve military readiness and effectiveness. This
policy applies to 16th Medical Group (16 MDG) personnel and others assisting with the
program.
SUMMARY OF REVISIONS: Para 4.1.6, deleted "Integrated Delivery System (IDS)."
Changed to read, "Commando Agencies Reaching Everyone (CARE)." Para 4.4.5.2 changed
"(attachment 2)" to "(attachment 2,4, or 5)." Para 4.4.8, deleted "IDS," replace with "CARE."
Para 5.5.1, "PCM teams may schedule members for the 4-week tobacco cessation program
and/or intake appointment at the HAWC through CHCS or central appointments." Changed to
read, "PCM teams may contact the HAWC at 884-4292 to schedule members for the 4-week
tobacco cessation program." Added attachments 4 and 5. Attachment 4 "Sample AF Form 781,
Multiple Item Prescription Habitrol (1PPD or more)," and Attachment 5 "Sample AF Form 781,
Multiple Item Prescription Habitrol (Less than 1DDP)."
1. REFERENCES.

1.1. DoD Directive 1010.10, Health Promotion.
1.2. DoD Directive 1010.15, Smoke-Free Workplace.
1.3. AFPD 40-1, Health Promotion.
1.4. AFI 40-101, Air Force Health Promotion Program.
1.5. AFI 40-102, Tobacco Use in the Air Force.
MDGI 40-4 1 March 2003 2

2. GENERAL. Tobacco cessation and prevention is one of seven major areas emphasized in
Health Promotion. Tobacco use is linked to cancer, cardiovascular disease, lung disease,
periodontal disease, fetal abnormalities, and death. Tobacco cessation is a critical program for
maintaining a healthy, mission-ready military community.
3. OBJECTIVES.

3.1. Educate the Hurlburt Field population of the dangers related to tobacco use and benefits of
cessation.
3.2. Deglamorize the use of tobacco in a positive manner and promote non-smoking as the
norm.
3.3. Create an environment that supports abstinence, discourages use of tobacco products, and
promotes a healthy working environment.
3.4. Provide tobacco users with encouragement and professional assistance in giving up the
tobacco habit.
3.5. Offer a variety of tobacco cessation programs to encompass all the needs of our military
beneficiaries.
4. RESPONSIBILITIES.

4.1. 16 MDG personnel will:
4.1.1. Set the example and encourage tobacco cessation among patients and 16 MDG personnel
as well as enforce the ban of all tobacco products anywhere in the vicinity of ingress/egress areas
of the medical group.
4.1.2. Abstain from using tobacco products to include smokeless tobacco within the medical
group facility (workplace) IAW AFI 40-102.
4.1.2.1. Points of ingress/egress (doors and entryways), windows, and air intake units/vents shall
be considered part of the workplace, and therefore must be kept free of tobacco use. Likewise,
tobacco use areas must be enough distance away from points of ingress/egress to prevent smoke
from being drawn into the building. Furthermore, butt cans and receptacles are NOT to be
located in doorways or vestibules, but only in designated smoking areas.
4.1.3. Use of tobacco products is permitted only in designated tobacco use areas. For the
16 MDG the designated area is the northwest corner of the building (91020/main clinic) and
egress to and from the smoking area shall be from the front door of the clinic. Use of the dental
work egress doors or rear door of the clinic is not permitted.

MDGI 40-4 1 March 2003 3
4.1.3.1. Each ancillary building of the medical campus (buildings 91041, 91042, 91049, 99998,
99999, 90315, 90316, and 90319) shall have a designated smoking area that complies with the
distance requirement, posting requirements, and ingress/egress areas free from the effects of
tobacco use.
4.1.4. Support and assist with anti-tobacco initiatives offered by the Health Promotion Program.
4.1.5. Keep the Health Promotion Manager (HPM) and Health Care Integrator informed of any
programs or resources related to tobacco cessation.
4.1.6. Report tobacco metrics to the Commando Agencies Reaching Everyone (CARE),
Community Action Information Board (CAIB), wing stand-up, and AFSOC through established
reporting mechanisms such as cycle ergometry, health enrollment assessment report, behavioral
risk factor surveillance, and dental population health measure report.
4.2. Providers will:
4.2.1. Ensure all patients are referred to the HAWC before prescribing nicotine replacement
therapy (NRT) or Zyban.
4.2.2. Perform a record screen, telephone consult, or physical screening as deemed necessary
prior to prescribing NRT or Zyban.
4.2.3. Review and sign completed SF 600, Chronological Record of Care, with the tobacco
overprint (attachment 1).
4.2.4. Refer personnel on flight status to Flight Medicine for completion of AF Form 1042,
Medical Recommendation for Flying or Special Operational Duty, for NRT. Members on flying
status will be DNIF for 72 hours when they initiate nicotine patch use.
4.2.5. Providers will not prescribe Zyban to personnel on flight status without clearance from the
unit commander. Refer personnel on flight status to Flight Medicine for completion of AF Form
1042, Medical Recommendation for Flying or Special Operational Duty, for Zyban. Members
will be DNIF for the duration of the 8-week Zyban therapy.
4.3. Pharmacy staff will:
4.3.1. Support the Tobacco Cessation Program with NRT and Zyban.
4.3.2. Dispense NRT or Zyban at the pharmacy to HAWC class participants enrolled in the
Tobacco Cessation Program with 1-week doses. Class members will identify themselves with a
HAWC prescription card.
4.3.3. Provide refills each week to class members while the class is in session.
MDGI 40-4 1 March 2003 4
4.3.4. Dispense enough medications after the last class to complete therapy. Duration of NRT or
Zyban therapy may be extended for up to 12 weeks upon evaluation by and recommendation of
the individual's Primary Care Manager (PCM) as long as there are no significant breaks in
treatment.
4.4. Health Promotion Manager will:
4.4.1. Assist in planning, development, and publicity of anti-tobacco initiatives.
4.4.2. Schedule daytime and evening tobacco cessation classes as needed to accommodate all
eligible beneficiaries in the Hurlburt Field community.
4.4.3. Assist the tobacco cessation facilitators by promoting the program, referring individuals to
the program, and relaying educational materials and higher headquarters information in relation
to tobacco use.
4.4.4. Ensure all individuals are screened at the initial intake appointment at the HAWC for
medical contraindications for the use of the nicotine patch and Zyban and evaluate readiness for
change.
4.4.4.1. Only prescribe NRT to members enrolled in a correspondence tobacco cessation course.
Individuals may enroll in a tobacco cessation correspondence course by contacting the HAWC.
4.4.4.2. Ensure a SF 600, Chronological Record of Care, with tobacco overprint, SGOAZ Form
2 (attachment 1) is completed on each individual prior to tobacco cessation program enrollment.
4.4.4.3. Forward SGOAZ Form 2 to the individual's Primary Care Manager (PCM), or other
medical provider if PCM is not available for review and prescription as needed.
4.4.5. Forward list of class participants to Pharmacy at least 48 hours in advance prior to the
tobacco cessation class start date.
4.4.5.1. Notify class participants enrolled within 48 hours of program start date that they may
pick up their initial prescription up to 48 hours after first class session.
4.4.5.2. Ensure an AF Form 781, Multiple Item Prescription (attachment 2,4, or 5) is attached to
civilian prescriptions for either NRT or Zyban for all eligible beneficiaries. This notifies the
pharmacy the individual has signed up for the tobacco cessation program.
4.4.6. Procure educational materials in relation to tobacco cessation and distribute appropriately.
4.4.7. Maintain list of available tobacco cessation programs/resources on base and local area.
Keep this list updated continuously.
4.4.8. Provide biannual report of tobacco use to the CARE and CAIB in conjunction with the
cycle ergometry updates.
MDGI 40-4 1 March 2003 5
4.4.9. Work with the 16th Medical Group Commander in keeping base commanders/supervisors
updated on issues related to tobacco cessation and the command anti-tobacco campaign.
4.4.10. Track program participants at 3-month and 6-month intervals after class completion to
evaluate program effectiveness. Results are compiled on a quarterly basis.

4.4.10.1. Make a reasonable effort to contact program attendees at the prescribed intervals to
determine long term success of the tobacco cessation program. After three unsuccessful
attempts, individuals will be considered not available for follow-up and no further action will be
required.
4.4.10.2. Contact may be accomplished via electronic mail or telephone.
4.4.10.3. Offer a weekly tobacco relapse class to participants returning to tobacco within 1 year
of 4-week program completion date. Participants may receive Zyban or NRT assistance, but
must purchase the products on their own.
5. POLICIES/PROCEDURES.

5.1. Tobacco cessation efforts will include emphasis on all smoking products (cigars, cigarettes,
pipes, and smokeless tobacco).
5.2. At least one of the monthly activities sponsored by the Health Promotion Program should
focus on tobacco cessation and prevention (i.e., November, Great American Smokeout). In case
you cannot attend, programs will be presented more often based on identified needs and requests
of the base population.
5.3. Tobacco Cessation Programs:
5.3.1. Classes are scheduled through the HAWC on an ongoing basis. All beneficiaries and
DoD civilians are eligible to enroll in the tobacco cessation program. A DD Form 2569, Third
Party Collection Program--Record of Other Health Insurance, (must be filled out at the beginning
of the cessation program for all non-active duty members. DoD civilians that do not have other
health insurance will still be eligible to attend the class and receive the prescription for the NRT
or Zyban; however, they will not be eligible to have them filled through the 16 MDG. DoD
contractors are eligible to attend the program. DoD contractors that have other health insurance
will be billed for the program as well as the NRT or Zyban. DoD contractors that do not have
other health insurance will not be eligible for the NRT or Zyban through the 16 MDG; however,
they will be eligible to attend the cessation program. Any of the two above categories that are
also dependents of an eligible sponsor can have their prescriptions filled by the 16 MDG.
5.3.2. Each class will consist of at least four sessions conducted over a 4-week period. Classes
are offered both during and after duty hours. There must be at least six participants enrolled in
order to conduct a class. Maximum number of participants is 25.
5.3.3. A weekly tobacco relapse class is offered for participants who have completed at least
three sessions of the 4-week tobacco cessation program within the prior 12-month period.
MDGI 40-4 1 March 2003 6
Participants must have abstained from using tobacco products for a minimum of 2 weeks during
the 4-week tobacco cessation program to enroll. Maximum number of participants is 20.
5.3.4. Deployed members wishing to break the tobacco habit may enroll in a tobacco cessation
correspondence course. Enrollment can be accomplished by contacting the HPM. The HPM
will screen/approve on a case-by-case basis any member desiring to enroll in the correspondence
course.
5.3.5. All class participants will sign a "contract to stop using tobacco" (attachment 3) at the
initial intake appointment conducted at the HAWC. Contracts will be kept on file for a
12-month period.
5.3.6. The base newspaper, marquee, and flyers will be used to advertise the tobacco cessation
classes.
5.3.7. Class facilitators must be trained as a tobacco cessation facilitator by the American Lung
Association, other national health agency, or have training in behavior modification.
5.4. NRT or Zyban Therapy:
5.4.1. Zyban is the primary treatment for tobacco cessation. Those members with
contraindications for using Zyban are treated with the nicotine patch. Members on flying status
will not be prescribed Zyban unless cleared through Flight Medicine and the unit commander.
5.4.2. The combined use of Zyban and nicotine patch will be limited to those members who are
not successful on Zyban alone and will be evaluated on a case-by-case basis.
5.4.3. Class facilitator will explain the use, side effects, and contraindications of NRT and
Zyban during the first class. Members reporting problems with the use of nicotine patch or
Zyban are referred to their PCM.
5.4.4. Individuals unable to tolerate Zyban or the nicotine patch may use alternate methods such
as 1 or 2 mg of nicotine gum or the nicotrol inhaler. Providers may write prescriptions for the
nicotine nasal spray or inhaler, but beneficiaries must purchase at their own expense.
5.4.5. Individuals unable to attend a class secondary to mission requirements or special
circumstances will be seen on an individual basis or scheduled for an alternate class. These
individuals will be able to pick up their medications at the pharmacy if cleared by the program
facilitator.
5.4.6. Participants are only allowed one tobacco cessation prescription during any 12-month
period. Prescriptions may combine Zyban and NRT if deemed appropriate by health care
provider.
5.4.6.1. Beneficiaries desiring tobacco cessation prescriptions within 12 months of initial
prescription may purchase the cessation aids on their own.
MDGI 40-4 1 March 2003 7
5.4.6.2. Exceptions to the limitation on tobacco cessation prescriptions such as a life-changing
event may be considered by HAWC staff or medical provider on a case-by-case basis.
5.5. Scheduling procedures:
5.5.1. PCM teams may contact the HAWC staff at 884-4292 to schedule members for the
4-week tobacco cessation program.
5.5.2. Providers wishing to write NRT or Zyban prescriptions during a routine appointment must
forward prescriptions to the HAWC. The HAWC will ensure members are scheduled for a
tobacco cessation program, compile all class prescriptions, and forward to the pharmacy.
Pharmacy will NOT fill Zyban or NRT prescriptions from any sources except those approved by
the HAWC.
5.5.3. Individuals are encouraged to self-refer to the HAWC tobacco cessation programs.
KEVIN A. POLLARD, Colonel, USAF, MSC, CHE Commander, 16th Medical Group Attachments: 1. SF 600, Chronological Record of Care with Overprint for Tobacco Cessation Classes 2. Sample AF Form 781, Multiple Item Prescription (Zyban) 3. Contract to Stop Using Tobacco 4. Sample AF Form 781, Multiple Item Prescription Habitrol (1PPD or More) 5. Sample AF Form 781, Multiple Item Prescription Habitrol (Less than 1PPD) MDGI 40-4 1 March 2003 10
Multiple Item Prescription Provider's Stamp/Signature/Date MULTIPLE ITEM PRESCRIPTION
(This form is subject to the Privacy Act of 1974-Use Blanket PAS - DD Form 2001 Rx Strength
Amount Directions

MDGI 40-4 1 March 2003 11
Contract to Stop Using Tobacco I, (print name), hereby promise myself that I will stop using tobacco on _(date). After this date I will remain tobacco free because (list three reasons) Because I want to succeed at stopping tobacco use and continue to fill my prescription for Tobacco
Cessation aids, I agree to:
_(initial) Attend all Tobacco Cessation sessions. If unable to attend, I will make arrangements
with the Health and Wellness Center (HAWC) to attend a make-up session.
_(initial) I understand that Zyban costs $102 (60 days) and the nicotine patch costs $109 (8
week) and the Hurlburt Medical Group Pharmacy will supply me with tobacco cessation aids once
during a 12-month period.
_(initial) I understand that if I am not successful, I may attend any HAWC tobacco cessation
programs in the following year, but will have to pay for any cessation aids on my own.
_(initial) When contacted by the HAWC at 3- and 6-months point after my class date, I agree
to provide information about my tobacco use status. I understand the future of this program
depends on the HAWC's ability to document progress via follow-up.
_
(signature

MDGI 40-4 1 March 2003 12
Multiple Item Prescription MULTIPLE ITEM PRESCRIPTION
(This form is subject to the Privacy Act of 1974-Use Blanket PAS - DD Form 2001 Rx Strength
Amount Directions
(* FOR PATIENTS 1PPD OR MORE)

MDGI 40-4 1 March 2003 13
Multiple Item Prescription MULTIPLE ITEM PRESCRIPTION
(This form is subject to the Privacy Act of 1974-Use Blanket PAS - DD Form 2001 Rx Strength
Amount Directions
(* FOR PATIENTS LESS THAN 1PPD)
Provider's Stamp/Signature/Date MDGI 40-4 1 March 2003 8
Attachment 1
MDGI 40-4 1 March 2003 9

Source: http://ndri.org/docs/Hurlburt%20Field%20AFB%20Medical%20Group%20Instruction%2040-2%20Health%20Pro.pdf