Union Anonymous Tobacco Survey

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This is anonymous, so please be honest, you will not get in trouble. -TriCounty Health Dept. Skip a question if it does not apply to you.

Have you ever tried any of the following? (mark all that apply)

Cigarettes

Cigars

Smokeless tobacco (chew)

Hookah or waterpipe

Vaping/ E cigs? (mods, vape pens, Juuls, etc.)

I have never tried any of these.

Please mark the tobacco products that you are currently using

Cigarettes

Cigars

Smokeless tobacco (chew)

Hookah or waterpipe

Vaping/ E cigs? ( mods, vape pens, Juuls,etc.)

How often are you using this product?

Every day

Multiple times a week

Only occasionally

Clear selection

How old were you when you first tried it?

Younger than 10

11 or 12

13 or 14

15 or 16

17 or 18

Why do you use it? please mark all that apply

Friends use it

Peer pressure

Tried a family members

Stress

Boredom

Because of the flavors

Because its cool & trendy

To make the tricks

I tried it and got addicted

Other:

Have you had any side effects from vaping?

Coughing

Shortness of breath/ Breathing difficulty

Irritation of eyes or mouth

Fevers

Fatigue

Nausea/ vomiting

Loss of endurance (not being able to perform your best in sports)

Respiratory symptoms

Chest Pains

Seizures

I have had to go to the hospital

Other:

How harmful do you think vaping is? 1-10, 10= very bad 1= its healthy (answer even if you have never tried it)

Clear selection

How do you obtain your device? (mark all that apply)

Friend/family member older than 19

Friend/family member under 19

Online

Convenience store, supermarket, discount store, or gas station.

Tobacco specialty store/ smoke shop

Other:

How do your parents feel about you vaping?

They don't know

They don't like it

They don't care

Clear selection

Do your parents or family members smoke/vape?

Yes

Clear selection

What would help you stop using this product?

Would you be interested in getting help quitting?(remember this is anonymous, just want to know how many people)

Yes

Maybe

Clear selection

Submit

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