Live Tobacco Free Participant Intake Pre-Survey

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1. How did you hear about the Tobacco Cessation Program? (check all that apply)

Healthcare provider or nurse

Tarrant County Public Health

Friend or family member

Community Center or Faith-based Organization

Employer/Work

Online Search

Social Media

Event attended

Other (please specify)

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2. What class format are you registering for? (Required.)

Virtual

In-person

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3. Why did you choose to participate in this program? (check all that apply)

better manage my current health condition (i.e. COPD, heart disease, etc.)

prevent a chronic health condition

save money

required to attend

Other (please specify)

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4. What is your First and Last name? (Required.)

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5. What is today's date?

Today's Date

Date

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6. Approximately how long have you been a tobacco user? (please specify in years)

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7. Do you currently smoke cigarettes?

Yes, how much on average per day? (please provide a number, not a range)

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8. If you smoke cigarettes, but not daily, how much do you currently smoke on average per week? (please provide a number, not a range)

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9. Do you currently smoke cigars or cigarillos?

Yes, how much on average per day? (please provide a number, not a range)

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10. If you smoke cigars or cigarillos, but not daily, how much do you currently smoke on average per week?

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11. Do you currently use an electronic nicotine delivery device (vape, e-cig, Juul, etc.)?

Yes, approximately how many milliliters per day?

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12. If you use an electronic nicotine delivery device (like a vape or e-cig), but don't use daily, approximately how many milliliters do you currently use per week?

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13. Do you currently use smokeless tobacco (dip, chew, etc.)?

Yes, approximately how much per day? (please provide a specific amount, not a range)

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14. If you use smokeless tobacco (dip or chew), but don't use daily, approximately how much do you currently use per week? (please provide a specific amount, not a range)

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15. How soon after you wake up do you usually have your first cigarette/cigar/dip/chew/vape?

Within 5 minutes

6 to 30 minutes

31 to 60 minutes

More than 60 minutes

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16. Have you ever completed a tobacco cessation program?

Yes, When and where?

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17. Have you tried to quit tobacco in the past 6 months?

Yes, when and for how long did you quit?

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18. How have you tried to quit tobacco in the past? (check all that apply)

Cold Turkey (completely stop use on quit date)

Taper Down (cut back until cessation is reached)

Postponing (delay smoking and increase time between them)

Nicotine Replacement Therapy (patch, gum, etc.)

Prescription Medications (Chantix, Zyban, etc.)

Never tried to quit

Other (please specify)

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19. Which of the following best describes your thoughts about quitting? I am planning to quit.....

Within the next month

Within the next 6 months

Between 6 to 12 months

Someday, but not within the next 12 months

Not interested in completely quitting

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20. How much support do you expect to receive in your quit attempt from family?

A lot

Some

Not much

None

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21. How much support do you expect to receive in your quit attempt from friends?

A lot

Some

Not much

None

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22. On a scale of 1 to 5, with 1 being not at all confident and 5 being extremely confident, how confident are you that you can quit tobacco now?

Clear

i We adjusted the number you entered based on the slider’s scale.

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23. Has a doctor ever told you that you have any of the following health conditions? (check all that apply)

Breathing/Lung Disease (e.g. COPD, Emphysema, Asthma)

Diabetes

Heart Disease/Congestive Heart Failure

Hypertension (High Blood Pressure)

Stroke

Depression or Anxiety Disorder/s

Cancer

Chronic skin ulcers/long term skin sore

History of falls

Other (please specify)

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24. On a scale of 1 to 5, with 1 being not very important and 5 being extremely important, how important is it that you quit tobacco now?

Clear

i We adjusted the number you entered based on the slider’s scale.

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25. Based on what you know or believe, does tobacco use cause chronic disease/illness?

Yes

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26. How often do you allow smoking inside your home?

Regularly (daily)

Occasionally (weekly)

Seldom (monthly)

Rarely (less than monthly)

Never

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27. What is your DATE OF BIRTH?

Date

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28. What is your gender?

Male

Female

Other (please specify)

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29. What is your race/ethnicity? (select all that apply)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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30. What is your contact information?

Address

City

State

ZIP/Postal Code

Email Address

Phone Number

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31. What type of health insurance do you currently have? (check all that apply)

Medicaid

Medicare

VA Benefits

Private Insurance (includes JPS Network)

None

Other (please specify)

Live Tobacco Free Participant Intake Pre-Survey

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* 1. How did you hear about the Tobacco Cessation Program? (check all that apply)

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* 2. What class format are you registering for? (Required.)

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* 3. Why did you choose to participate in this program? (check all that apply)

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* 4. What is your First and Last name? (Required.)

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* 5. What is today's date?

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* 6. Approximately how long have you been a tobacco user? (please specify in years)

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* 7. Do you currently smoke cigarettes?

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* 8. If you smoke cigarettes, but not daily, how much do you currently smoke on average per week? (please provide a number, not a range)

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* 9. Do you currently smoke cigars or cigarillos?

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* 10. If you smoke cigars or cigarillos, but not daily, how much do you currently smoke on average per week?

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* 11. Do you currently use an electronic nicotine delivery device (vape, e-cig, Juul, etc.)?

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* 12. If you use an electronic nicotine delivery device (like a vape or e-cig), but don't use daily, approximately how many milliliters do you currently use per week?

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* 13. Do you currently use smokeless tobacco (dip, chew, etc.)?

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* 14. If you use smokeless tobacco (dip or chew), but don't use daily, approximately how much do you currently use per week? (please provide a specific amount, not a range)

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* 15. How soon after you wake up do you usually have your first cigarette/cigar/dip/chew/vape?

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* 16. Have you ever completed a tobacco cessation program?

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* 17. Have you tried to quit tobacco in the past 6 months?

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* 18. How have you tried to quit tobacco in the past? (check all that apply)

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* 19. Which of the following best describes your thoughts about quitting? I am planning to quit.....

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* 20. How much support do you expect to receive in your quit attempt from family?

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* 21. How much support do you expect to receive in your quit attempt from friends?

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* 22. On a scale of 1 to 5, with 1 being not at all confident and 5 being extremely confident, how confident are you that you can quit tobacco now?

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* 23. Has a doctor ever told you that you have any of the following health conditions? (check all that apply)

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* 24. On a scale of 1 to 5, with 1 being not very important and 5 being extremely important, how important is it that you quit tobacco now?

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* 25. Based on what you know or believe, does tobacco use cause chronic disease/illness?

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* 26. How often do you allow smoking inside your home?

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* 27. What is your DATE OF BIRTH?

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* 28. What is your gender?

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* 29. What is your race/ethnicity? (select all that apply)

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* 30. What is your contact information?

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* 31. What type of health insurance do you currently have? (check all that apply)

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* 32. How many people currently live in your home?

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* 33. What is your current annual gross income for your household?

1. How did you hear about the Tobacco Cessation Program? (check all that apply)

2. What class format are you registering for? (Required.)

3. Why did you choose to participate in this program? (check all that apply)

4. What is your First and Last name? (Required.)

5. What is today's date?

6. Approximately how long have you been a tobacco user? (please specify in years)

7. Do you currently smoke cigarettes?

8. If you smoke cigarettes, but not daily, how much do you currently smoke on average per week? (please provide a number, not a range)

9. Do you currently smoke cigars or cigarillos?

10. If you smoke cigars or cigarillos, but not daily, how much do you currently smoke on average per week?

11. Do you currently use an electronic nicotine delivery device (vape, e-cig, Juul, etc.)?

12. If you use an electronic nicotine delivery device (like a vape or e-cig), but don't use daily, approximately how many milliliters do you currently use per week?

13. Do you currently use smokeless tobacco (dip, chew, etc.)?

14. If you use smokeless tobacco (dip or chew), but don't use daily, approximately how much do you currently use per week? (please provide a specific amount, not a range)

15. How soon after you wake up do you usually have your first cigarette/cigar/dip/chew/vape?

16. Have you ever completed a tobacco cessation program?

17. Have you tried to quit tobacco in the past 6 months?

18. How have you tried to quit tobacco in the past? (check all that apply)

19. Which of the following best describes your thoughts about quitting? I am planning to quit.....

20. How much support do you expect to receive in your quit attempt from family?

21. How much support do you expect to receive in your quit attempt from friends?

22. On a scale of 1 to 5, with 1 being not at all confident and 5 being extremely confident, how confident are you that you can quit tobacco now?

23. Has a doctor ever told you that you have any of the following health conditions? (check all that apply)

24. On a scale of 1 to 5, with 1 being not very important and 5 being extremely important, how important is it that you quit tobacco now?

25. Based on what you know or believe, does tobacco use cause chronic disease/illness?

26. How often do you allow smoking inside your home?

27. What is your DATE OF BIRTH?

28. What is your gender?

29. What is your race/ethnicity? (select all that apply)

30. What is your contact information?

31. What type of health insurance do you currently have? (check all that apply)

32. How many people currently live in your home?

33. What is your current annual gross income for your household?