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  1. Surveys
  2. 2013
  3. November
  4. T
  5. Trial 1
0%
Exit Survey
 
 
[INSERT TEXT INTRODUCING THE SURVEY]
 
 
 
* Have you ever used any of the following products:
Cigarettes, Cigars/Little Cigars/Cigarillos, Chewing Tobacco/Snuff/Dip/Snus, E-cigarettes/Electronic, or Vapor Cigarettes (like Ruyan, Blue, or NJoy), Tobacco Pipes, Tobacco smoked from a hookah or waterpipe, or some other tobacco product not listed above?
 
 
During the past 30 days, on how many days did you use the following products:
None 1-5 6-10 11-15 16-20 21-25 26-30
Cigarettes
Cigars/Little Cigars/Cigarillos
Chewing Tobacco/Snuff/Dip/Snus
E-cigarettes, Electronic or Vapor Cigarettes (like Ruyan, Blue, or NJoy)
Tobacco Pipes
Tobacco smoked from a Hookah or Waterpipe
Roll-your-own cigarettes
Some other tobacco product not listed above
 
 
In the last 12 months have you:
Yes No N/A
Tried to stop smoking?
Tried to stop using tobacco products of any and all kinds?
Wanted to try to quit tobacco products but have not attempted to do so?
 
 
 
Thinking back to the last time you tried to quit smoking cigarettes, did you use any of the following to help you (select all that apply or none)?
 
Counseling from a health care provider, a class, a program, or a telephone-based quitline or helpline
 
Used any type of quit smoking medications, including nicotine replacement product or prescription from a physician
 
Switched to a smokeless tobacco product such as chewing tobacco, snuff, or snus
 
Switched to a different combustible tobacco product
 
Switched to an electronic or vapor cigarette
 
None
 
Other
 

 
 
Do you:
Yes No Maybe
* Currently use tobacco while in uniform?
* Know about the tobacco cessation benefits from Tricare?
 
 
 
If you currently use tobacco products, how motivated are you to try to quit tobacco knowing that you will not be able to use tobacco products in uniform starting January 1, 2014?
 
Extremely motivated
 
Somewhat motivated
 
Neutral
 
Not very motivated
 
Not at all motivated
 
Don’t know/not sure
 
Refused/NA
 
 
What is your
18-24 25-44 45-64 65 or older Male Female Other Refused
Age
Gender
 
 
 
What is your current Agency?
 
 
 
What is your category?
 
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