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Tobacco Use Survey – Example
Updates Based on STOPS MEETING
*These are suggested questions and should be modified to fit your program’s needs* 1. Are you currently a tobacco user? (Select all that apply; if YES to any, skip to question #4)
a. Yes, I currently smoke cigarettes b. Yes, I currently smoke cigars (e.g., Black „n Mild, Swisher Sweets, Phillies blunt, little c. Yes, I currently use smokeless tobacco (snus, snuff, dip, chew, etc) d. Yes, I currently use other tobacco products (please specify): e. No, I do not currently use any tobacco products 2. If you do not currently smoke and/or chew, have you smoked and/or chewed tobacco
products in the past?
a. Yes; it has been over 30 days since I last used tobacco products b. Yes; it has been over 3 months since I last used tobacco products c. Yes; it has been over 6 months since I last used tobacco products d. Yes; it has been over 12 months since I last used tobacco products e. No, I never smoked and/or chewed tobacco products (Skip to question #15) 3. If you stopped smoking and/or chewing, what method(s) did you use to successfully
quit tobacco use? (Select all that apply)
a. Cold Turkey b. Gradually decreased the amount until quit c. Nicotine patch, gum, or lozenge d. Prescription nicotine therapy such as the inhaler or nasal spray e. Prescription medication such as Chantix or Zyban f. Tobacco Quitline, 1-800 QUIT-NOW (784-8669) g. Group or individual cessation counseling h. Other: Please Specify_________________________ 4. When did you begin using tobacco?
a. I began using tobacco when I was younger than 13 years old b. I began using tobacco when I was between 13-17 years old c. I began using tobacco when I was a Freshman undergraduate student d. I began using tobacco when I was a Sophomore undergraduate student e. I began using tobacco when I was a Junior undergraduate student f. I began using tobacco when I was a Senior undergraduate student g. I began using tobacco after my 4th year, as an undergraduate student h. I began using tobacco when I was a Graduate student 5. How has your tobacco use changed since you have been in college?
a. Increased b. Decreased c. Stayed the same d. I no longer use tobacco (Skip to #15) 6. How often do you smoke and/or chew tobacco products?
a. I smoke and/or chew tobacco products regularly (at least once everyday) b. I smoke and/or chew tobacco products mostly in social situations c. I smoke and/or chew tobacco products occasionally (less than once a day)
7. On how many of the past 30 days did you use tobacco?
a. 0 b. 1-5 c. 6-10 d. 11-15 e. 16-20 f. 21-29 g. Everyday 8. In what situations do you smoke and/or chew tobacco products? (Select all that apply)
a. When I first wake up b. When I‟m stressed out c. When with friends/during social situations d. When drinking alcohol e. After meals/with coffee f. When I realize I haven‟t smoked/chewed for a while g. When with my significant other or close friend who is smoking/chewing h. When I‟m bored i. When I need a “pick me up” j. While driving k. While studying l. Before going to bed m. Other: ____________________________________________ 9. When do you have your first cigarette/cigar/chew of the day?
a. Within 30 minutes of waking up b. Within one hour of waking up c. After being awake for over an hour 10. Are you planning to quit using tobacco in the near future?
a. No b. Yes, within the next 30 days c. Yes, within the next 6 months d. Yes, within the next year e. Yes, when I graduate (if graduation is more than a year from now) 11. Have you ever tried to quit using tobacco?
a. Yes, within the last 30 days b. Yes, within the last 6 months c. Yes, within the last year d. No, I have never tried to quit (skip to question #14) 12. How many times in the past year have you tried to stop using tobacco?
a. 1 time b. 2 times c. 3 times d. 4 times e. 5 or more times 13. What method(s) did you use to try to stop using tobacco? (Select all that apply)
a. Cold turkey b. Nicotine patch, gum, or lozenge c. Gradually decreased the amount until quit d. Prescription nicotine replacement therapy such as nasal spray or inhaler e. Prescription medication such as Chantix or Zyban f. Tobacco Quitline, 1-800 QUIT-NOW (784-8669) g. Group or individual cessation counseling h. Other. Please specify:____________________ 14. Do you ever tell yourself you can stop using tobacco whenever you want to?
15. Do you think that using tobacco is physically addictive?
16. Do you think a cessation program using modern technology such as text messaging or
podcasting would be useful in supporting tobacco users attempting to quit?
17. Do you think that secondhand smoke is harmful to the health of nonsmokers?
18. What is the current tobacco use/smoking policy on your campus?
a. Tobacco smoking is prohibited everywhere on campus
b. Tobacco use of any variety is prohibited everywhere on campus
c. Tobacco use/smoking is restricted to designated smoking areas only
d. Tobacco use/smoking is restricted to a specific distance from all building and dorm
e. Tobacco use/smoking is allowed anywhere outdoors, except on outdoor sports fields and f. Tobacco use/smoking is allowed anywhere on campus outdoors
g. There is no tobacco use policy on my campus
h. I don‟t know (Skip to question #20)
19. Do you feel that tobacco users adhere to the campus tobacco use policy?
a. Yes, at all time b. Yes, but only some of the time c. No, I feel that tobacco users do not follow the policy 20. What campus tobacco control policies would you/do you support?
a. Tobacco smoking prohibited everywhere on campus
b. Tobacco use of any variety is prohibited everywhere on campus
c. Tobacco use/smoking restricted to designated smoking areas only
d. Tobacco use/smoking restricted to a specific distance from all building and dorm entrances
e. Tobacco use/smoking allowed anywhere outdoors, except on outdoor sports fields and
f. Tobacco use/smoking allowed anywhere on campus outdoors 21. Indicate your primary role on campus
a. Part-time Student b. Full-time Student c. Faculty d. Staff e. Facilities/Maintenance Employee f. Campus Visitor 22. If you are a student, which best describes your enrollment status?
a. 1st year undergraduate (freshman) b. 2nd year undergraduate (sophomore) c. 3rd year undergraduate (junior) d. 4th year undergraduate (senior) e. Past 4th year undergraduate f. Graduate student 23. Select your age group
a. under 18 b. 18-25 c. 26-30 d. 31-35 e. 36-40 f. 41-50 g. 51-60 h. Over 60 24. Indicate your gender

Source: http://www.marylandstops.org/resources/Tobacco_Use_on_Campus_Survey.pdf

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