Tobacco Use And Awareness Survey

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Tobacco Use and Awareness Survey

The Saint Charles County Department of Community Health and the Environment is partnering with Missouri’s Maternal Child Health Services to assess community tobacco use and awareness.
Your completion of this survey will help us address tobacco use and develop targeted interventions that meet community need.

Behavior/Exposure
1.	What is your age?
2.	What is your gender? Male Female
3.	What is your highest level of education completed?
4.	What county do you live in? What is your zipcode:
5.	Do you use tobacco? Yes No If yes does that concern you? Yes No
6.	What age did you start smoking? Please indicate your age or NA if not aplicable.
7.	I smoke cigarettes:
8.	Are you seriously considering stopping smoking within the next six months? Yes No
9.	Within the past 12 months has your employer offered any stop smoking programs or any other help to employees who want to quit smoking? Yes No Not Applicable
10.	Exposed to tobacco smoke at home:
11.	I use chewing tobacco:
Knowledge
12.	Is smoking in the community a:
13.	Is secondhand smoke a :
14.	Do you believe secondhand smoke is a cause of any of the following conditions? Heart Disease: Yes No Colon cancer: Yes No respiratory problems in children: Yes No sudden infant death syndrome: Yes No
15.	Is smokeless tobacco a:
16.	Nicotine replacement products (patches, gum, and lozenge) are safer than smoking.:
17.	It is safer for pregnant women to cut back on smoking rather than using nicotine replacement products (patches, gum, or lozenge to quit):
Beliefs/attitude
18.	I am more likely to go to a restaurant that is smoke free:
19.	I would support legislation to eliminate all smoking in restaurants:
20.	I would support legislation to eliminate all smoking in bars:
21.	I believe that smoke-free laws in restaurants hurt business:
22.	I believe that smoke-free laws in bars hurt business:
23.	Do you believe that tobacco use leads to the use of other drugs and or alcohol? Yes No