TFHS Tobacco Use Survey
Directions: Please answer all questions honestly. Do not put your name on this survey.
Background Information:
1. How old are you?
12 or younger ___ 13 ___ 14___ 15___ 16___ 17___ 18 or older___
2. What is your sex?
Female ____ Male _____
3. What grade are you in?
9th____ 10th____ 11th____ 12th____
4. How do you describe yourself (select one or more)?
American Indian or Alaskan Native____
Asian ___
Black or African American _____
Hispanic or Latino _____
Native Hawaiian or other Pacific Islander _____
White___
5. During the last 12 months, how would you describe your grades in school?
Mostly A’s___, Mostly B’s___, Mostly C’s___, Mostly D’s____, Mostly F’s____
Tobacco-Use Behavior:
1. Have you ever tried cigarette smoking, even one or two puffs?
Yes____ No_____
2. How old were you when you smoked a whole cigarette for the first time?
I have never smoked a cigarette___, 8 yrs or younger____, 9-10 yrs____,
11-12 yrs____, 13-14 yrs____, 15-16 yrs____, 17 yrs or older____.
3. During the past 30 days, on how many days did you smoke cigarettes?
0___, 1-2___, 3-5___, 6-9___, 10-19___, 20-29___, all 30 days___
4. During the past 30 days, on the days you smoked, how many cigs did you smoke per day?
I did not smoke cigarettes during the last 30 days___, < 1 cig/day ___, 1 cig/day __,
2-5cigs/day___, 6-10 cigs/day___, 11-20 cigs/day ___, more than 20 cigs/day___.
5. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip such as Redman, Levi Garrett, Skoal, Skoal Bandits, or Copenhagen?
0___, 1-2___, 3-5___, 6-9___, 10-19___, 20-29___, all 30___.
6. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
0___, 1-2___, 3-5___, 6-9___, 10-19___, 20-29___, all 30___.
7. Within the next three months, do you think that you will try or use tobacco?
Definitely___, probably___, not sure___, probably not___, definitely not___
8. How likely are you to try to quit smoking in the next three months?
Don’t smoke___, definitely___, probably___, not sure___, probably not___, definitely not__
Tobacco Correlates:
1. How many people at your home smoke?
0___ 1___ 2___ 3___ 4___ 5 or more___
2. How many of your five closest friends smoke?
0___ 1___ 2___ 3___ 4___ 5___
3. What would happen if your friends found out you were smoking?
Nothing___, a little upset____, a lot upset____
4. How many times have you been offered a cigarette?
Never___, a few times___, a lot___
5. Out of every 10 students your age, how many do you think smoke cigarettes?
0___, 1___, 2___, 3___, 4___, 5___, 6___, 7___, 8___, 9___, 10___
6. How strongly do you agree with the following (1 = Strongly Disagree, 5 = Strongly Agree):
Smoking helps you relax. 1 2 3 4 5
Smoking makes you alert. 1 2 3 4 5
It’s safe to smoke for only a year or two. 1 2 3 4 5
Smoking helps you lose weight. 1 2 3 4 5
You can smoke a few cigarettes without becoming addicted. 1 2 3 4 5
7. How important are the following for you to not use tobacco (1 = Not important, 5= Very important)?
Concern about health damage 1 2 3 4 5
Concern about losing control of self 1 2 3 4 5
Concern it could lead to stronger drugs 1 2 3 4 5
Concern about becoming addicted to cigarettes 1 2 3 4 5
Wouldn’t be enjoyable 1 2 3 4 5
Parents would disapprove 1 2 3 4 5
Friends would disapprove 1 2 3 4 5
Too expensive 1 2 3 4 5
Illegal to use if under age 18 1 2 3 4 5