Hollandale PTSA Simmons High

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Community-Based Needs Assessment

Tobacco Prevention Campaign

Sponsored by The Campaign for Tobacco-Free Kids

Basic Demographic Questions- Age

25 - or less

26 - 39

40- 54

55 - 64

65 or over

I prefer not to answer

Option 7

Option 8

Clear selection

Sex

Male

Female

Other (please specify)

I prefer not to answer

Clear selection

What best describes your racial/ethnic background? Choose all that apply).

African-American/Black

Asian

Hispanic/Latino

Caucasian/White

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

I prefer not to answer

Community Tobacco Use and Behavior Assessment

How often do you currently use tobacco, e-cigarettes or other tobacco-related products?

Every day

Some days

Not at all

Clear selection

Have you ever observed students within our school community using tobacco, e-cigarettes or other tobacco-related products?

Yes

I don't know

Clear selection

How do you suspect students are accessing tobacco product?

Purchase from store

Stole from others

Bought from others

I don't know

Received from an adult

Peer provided

On the internet

Other

Clear selection

Have you ever observed parents or caregivers within our school community using tobacco, e-cigarettes or other tobacco-related products?

Yes

I don't know

Clear selection

Have you ever observed any of our school officials using tobacco, e-cigarettes or other tobacco-related products?

Yes

I don't know

Clear selection

What kind of tobacco is being used most frequently in our school community?

Pipe, hookah/narghile(Water pipe)

Chewed tobacco

Snuff

Cigar/cigarillo

Electronic cigarettes(eCigs)

Vape pipes

Cigarettes

Other (specify)

I don't know

Clear selection

How much do you think people harm themselves when they use tobacco products?

No harm

Little harm

Some harm

A lot of harm

Clear selection

How strongly do you agree with the statement "All tobacco products are dangerous"?

Strongly agree

Agree

Disagree

Strongly disagree

Clear selection

If you currently use tobacco, do you want to quit?

Yes

I don't use tobacco

Clear selection

What do you perceive as the most common barrier to tobacco cessation within our school community?

Stress management

Lack of support

Acceptability of smoking

I don't know

Clear selection

Based on your opinion, do students within our school district receive adequate education on tobacco prevention?

Yes

I don't know

Clear selection

Can you name at least one tobacco prevention within your school community?

Yes

I don't know

Clear selection

Have you ever helped promote tobacco prevention within your school community?

Yes

I don't know

Clear selection

Does your school district have a tobacco-free or smoke-free policy?

Yes

I don't know

Clear selection

What type of tobacco prevention programs would you like to see implemented within your school community?

In your opinion what is the best way to provide tobacco prevention education to our community?

Social media platforms newsletter

In person/virtual education sessions

Activities within the classroom

Monthly "tobacco prevention"

Tobacco prevention handout

Other (please specify):

Clear selection

Would you be interested in joining your school's PTSA or becoming involved in programs that help prevent tobacco use?

Yes

I don't know

Clear selection

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