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Tobacco/E-Cigarette Prevention Campaign Survey
1.
Age:
25 or less
26 – 39
40 – 54
55 – 64
65 or over
I prefer not to answer
2.
Sex:
Male
Female
Other/I prefer not to answer
3.
What best describes your racial/ethnic background? (Choose all that apply)
African-American/Black
Asian
Hispanic/Latino
Caucasian/White
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
I prefer not to answer
4.
How often do you use tobacco, e-cigarettes, or other tobacco-related products?
Every day
Weekends/occasionally
Not at all
5.
How do you suspect students access tobacco products?
Purchase from store
Purchased from/provided by peers
Purchased from/provided by an adult
Provided or sold by a peer
Online/Social Media (Snap Chat, etc.)
Other (please specify)
6.
Have you ever seen adults within the Chantilly community using tobacco, e-cigarettes, or other tobacco-related products?
Yes
No
Not sure/don't know
7.
What kind of tobacco do you think is being used the most in our community? (Choose one)
Pipe, hookah/narghile (water pipe)
Chewing tobacco
Cigar/cigarillo
Electronic cigarettes (eCigs)
Vape pipes
Cigarettes
Other (please specify)
8.
What do you perceive as the most common barrier to
tobacco cessation within our school community?
Lack of stress-relieving outlets
Lack of material or social/emotional support
Use is acceptable or encouraged by peers
Cultural or social norms
Too easy to obtain
Other (please specify)
9.
In your opinion, do students within our school district receive adequate education on tobacco prevention?
Yes
No
I don't know
10.
In your opinion, what is the best way to provide tobacco and e-cigarette prevention education to our community?
Social media platforms
Monthly “tobacco prevention” newsletter
In person/virtual education sessions
Tobacco prevention handouts
Classroom instruction/activities
Other (please specify)
11.
Do you think vaping/tobacco use is a problem in the student population at Chantilly High School or another Chantilly Pyramid school?
Yes
No
I don't know