* 1. Please answer the below questions.

  Yes No
Do you smoke?
Have you smoked in the last 30 days?
Does anyone in your family smoke?
If you currently do not smoke tobacco, have you ever smoked?
In the home in which you grew up, did anyone smoke tobacco?
If indoor air quality was regulated in the county would it affect your patronage at local businesses?
If placed on a ballot, would you support an ordinance to allow for the regulation of indoor air quality?

* 2. How many tobacco products do you smoke a day?

* 3. How many members in your household currently smoke tobacco?

* 4. Do you know the health risks of smoking tobacco?

* 5. Do you plan to quit smoking tobaacco within the next 5 years?

* 6. How many times have you tried to quit smoking?

* 7. If you have quit using tobacco, how long has it been?

* 8. If you are around second hand smoke, where do you encounter it?

  Yes No
Public Place
I do not encounter second hand smoke

* 9. Please chose what best describes your opinion on the following statments.

  Agree No Opinion Disagree
Second hand smoking is harmful to your health.
Second hand smoke is unpleasant indoors.
People should not smoke indoors out of courtesy for others.
Not smoking indoors would make for a healthier enviroment for all.
Business owners should not allow smoking indoors.
You are more likely to do business where smoking is not allwed indoors.
Local government should regulate indoor air quality.
The county as a whole would be healthier if indoor air quality was regulated.
If indoor air quality was regulated in county, it should be inforced with a fine.
If indoor air quality was regulated in the county, it should be regulated voluntarily.

* 10. If you would like more information on tobacco use, its effects, and cessation information please fill out the below and we will contact you.