1. Do you currently use one or more tobacco products? Yes No
2. Which tobacco products do you currently use? (check all that apply)Not applicable (Do not use tobacco products) Cigarettes Smokeless tobacco (spit/chew/snus/dip) Cigars, cigarillos, or little cigars Pipes
3. At what age did you first use tobacco products? Not applicable (Never tried tobacco products) 10 and under 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 and older
4. Have you smoked at least 100 cigarettes in your entire life? (5 packs = 100 cigarettes) Not applicable (Do not use tobacco) Yes No
5. At what age were you when you tried cigarette smoking, even one or two puffs? Not applicable (never tried cigarette smoking) 10 and younger 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 and older
6. At what age did you first use tobacco products? Not applicable (Never tried tobacco products) 10 and younger 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 and older
7. At what age were you when you smoked more than 10 cigarettes in a week? Not applicable (I never smoked) 10 and younger 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 and older
8. The brand of tobacco product that you regularly smoke or use is... Not applicable (Do not smoke or use tobacco products) Not mentholated Mentholated Mentholated with the capsulated ball in the filter “Black n’ mild” (cigar without filter) Other
9. During the past 30 days, on how many days did you smoke or use tobacco products? Not applicable (I do not smoke cigarettes) Did not use in the last 30 days 1-2 Days 3-5 Days 6-9 Days 10-19 Days 20-29 days Used daily
10. During the past 30 days, on the days you smoked, how many cigarettes did yo smoke per day? (a pack is 20 cigarettes) Not applicable (I do not smoke) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 A park or more
11. Do you smoke or use other tobacco products while you are on HT's campus? Not applicable (I do not smoke or use tobacco products) Yes No
12. Have you ever quit or tried to quit smoking or using other tobacco products? Not applicable (I never tried to smoke) Yes No
13. What types of products or other services have you tried in your attempts to quit tobacco? (Check all that apply) Not applicable (I was never a tobacco user) Not applicable (I was a regular tobacco user but I never tried to quit) Will power or to stop on own Nicotine replacement therapy (nicotine gum, patch, lozenges) Zyban (Bupropian, Wellbutrin) Chantix (Varenicline) Group counseling (ex. Freedom from Smoking) Nicotine Anonymous Quitline or other telephone counseling Internet counseling Hypnosis Acupuncture Self help books, pamphlets, or videos Prayer or meditation Stopped smoking along with friends or relatives who were also trying to quit Support groups Other
14. Are you aware of tobacco cessation services that are available? Yes No
15. Would you or your family members be interested in tobacco cessation assistance from the Huston-Tillotson University (HT) Student Health Center? Not applicable (Neither my family nor I use tobacco product) Yes No
16. If tobacco use were prohibited at HT (including outdoor areas), how would this affect the amount of tobacco you currently use? Not applicable (I do not use tobacco products) My tobacco use would not be affected; I would use the same) I would use less tobacco I would use more at home or other places I would try to quit using tobacco I don't know
17. Do you think time off from classes or work to attend cessation classes would help you to quit using tobacoo products? Not applicable (I do not use tobacco products) Won't help at all Will help a little Will help a lot
18. Do you think free cessation services on HT's campus during the day would help you to quit using tobacco products? Not applicable (I do not use tobacco products) Won't help at all Will help a little Will help a lot
19. Would free cessation services on HT's campus in the evening help you to quit using tobacco products? Not applicable (I do not use tobacco products) Won't help at all Will help a little Will help a lot
20. Would free Nicotine, Replacement Therapy, or Other medications help you to quit using tobacco products? Not applicable (I do not use tobacco products) Won't help at all Will help a little Will help a lot
21. How bothered are you when you are exposed to cigarette smoke at HT in the following places: Outside areas, including entrances to buildings, building grounds, courtyards and patios, parking lots (around the dorms, cafeteria, security guard booth)? Not bothered Somewhat bothered Very bothered
22. How important is it for you to work, attend classes at, or live in a tobacco-free campus worksite or campus? Not important at all Somewhat important Very important
23. Do you support the transition of HT to a tobacco-free campus or worksite? Yes No
24. Are you interested in serving on a committee to plan and implement a tobacco-free campus or worksite at HT? Yes No Maybe
25. What is your current age? 18 and under 19-24 25-34 35-44 45-54 55-64 65 and over
26. Gender? Male Female
27. Academic year of study? Freshman Sophmore Junior Senior Not applicable (I am not a student)
28. What is your ethnicity? Hispanic or Latino or Spanish Origin Non-Hispanic or Latino or Spanish Origin
29. What is your race? (Please choose all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other
30. Which campus organizations are you a member of? (Check all that apply) Greek (fraternity or sorority) Social club Honor society Club associated with major None (I do not belong to a campus organization) Other
31. What is your housing status? On campus dorm Off-campus group house Off-campus apartment Off-campus house Off-campus house
32. How much do your beliefs about a higher power (whether it be religious or spiritual) influence what you do? Not applicable (no belief in a higher power) Not at all A little bit Somewhat Very much Don't know/Unsure
33. Think of the family, friends, and/or partners who are closest to you. How many of them smoke or use tobacco products? All of them smoke or use tobacco Most of them smoke or use tobacco Some of them smoke or use tobacco None of them smoke or use tobacco
34. How likely do you think it is that you will have serious health problems from smoking if you continue to smoke? Not applicable (I do not smoke) Very likely Somewhat likely Somewhat unlikely Very unlikely
35. Would you say that tobacco use for African Americans is... A very serious problem Fairly serious problem Not a serious problem
36. Within the last 6 months, how would you rate the overall level of stress you have experienced? No stress Less than average stress Average stress More than average stress Tremendous stress
37. Smoking helps one to feel less anxious... I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
38. How likely is it that you will be a non-smoker six months from now? Not at all likely A little likely Fairly likely Very likely
39. In general, how satisfied are you with your life? Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied
40. Staying healthy is mostly a matter of luck... I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
41. There is very little I can do to keep myself from getting sick... I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
42. There is a lot I can do to keep myself from getting cancer.. I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
43. Smoking helps to control weight I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
44. It's lower class to smoke; people who don't smoke appear to have a higher social status... I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
45. Cigarette smoking is part of a plan to wipe out African Americans... I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
46. Cigarette smoking is an individual's choice; it has nothing special to do with being African American... I disagree a lot with this statement I disagree a little with this statement I agree a little with this statement I agree a lot with this statement
