Empowered to Quit (ATL)

Tobacco Use and Quitting Habits Survey

The CVS Research Foundation has partnered with the National Urban League to assess the tobacco usage and quitting habits of African-Americans. The information from this survey will be used to gain an understanding of the specific and unique needs of African-Americans who use tobacco and may be interested in quitting.

No identifying information (i.e. name, address) will be shared and we appreciate you answering all of the questions.

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* 1. Have you used tobacco in the past 6 months?
(Tobacco = Bidis, chew, cigarettes, cigars, cigarillos, little cigars, dip, dissolvable tobacco, electronic cigarette or e-cig containing cartridge with nicotine, hookah, kreteks, snuff or other tobacco related product)

Yes

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* 2. Do you currently use tobacco?

Yes

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* 3. How often do you use tobacco?

Everyday

4 or 5 times a week

3 or fewer times a week

Not applicable

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* 4. Have you ever thought about quitting?

Yes

Not Applicable

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* 5. Have you ever tried to quit?

Yes

Not Applicable

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* 6. What strategies or medications did you use to quit tobacco use?
Select all that apply

Cold Turkey

Quit Smoking Group

Over the Counter Nicotine Replacement (patch, gum)

Prescription Nicotine Replacement (inhaler, spray)

Other Prescription Medication (Bupropion, Zyban, Chantix)

Not Applicable

Other (please specify)

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* 7. Are you interested in attending an Empowered to Quit informational Workshop?

Yes

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* 8. Are you interested in participating in a tobacco quit program?

Yes

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* 9. What race/ethnicity do you identify as?

Black/African-American

Other/Multi-Racial

Decline to Respond

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* 10. About You
Optional if you would like to be contacted about workshops or our quit program.

Name

Email Address

Phone Number

Question Title

* 1. Have you used tobacco in the past 6 months? (Tobacco = Bidis, chew, cigarettes, cigars, cigarillos, little cigars, dip, dissolvable tobacco, electronic cigarette or e-cig containing cartridge with nicotine, hookah, kreteks, snuff or other tobacco related product)

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* 2. Do you currently use tobacco?

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* 3. How often do you use tobacco?

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* 4. Have you ever thought about quitting?

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* 5. Have you ever tried to quit?

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* 6. What strategies or medications did you use to quit tobacco use?Select all that apply

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* 7. Are you interested in attending an Empowered to Quit informational Workshop?

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* 8. Are you interested in participating in a tobacco quit program?

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* 9. What race/ethnicity do you identify as?

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* 10. About You Optional if you would like to be contacted about workshops or our quit program.

* 1. Have you used tobacco in the past 6 months?
(Tobacco = Bidis, chew, cigarettes, cigars, cigarillos, little cigars, dip, dissolvable tobacco, electronic cigarette or e-cig containing cartridge with nicotine, hookah, kreteks, snuff or other tobacco related product)

* 6. What strategies or medications did you use to quit tobacco use?
Select all that apply

* 10. About You
Optional if you would like to be contacted about workshops or our quit program.