Menthol Survey

The Champaign-Urbana Public Health District is collecting community opinions about menthol tobacco product use and its impact. Community responses and comments will remain confidential. They will be compiled to assist with policy creation efforts. Thank you for taking the time to complete this survey.

Part 1: General Information

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1. Age

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2. Zip Code

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3. Gender

Male

Female

Trans male/ transgender male

Trans female/ transgender female

Non-binary/ agender

Genderqueer/ genderfluid

Prefer not to answer/ unknown

Another gender, please write in:

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4. Race (Please select one)

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

More than one race

Prefer not to answer/ unknown

Additional race category, please write in:

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5. Ethnicity (Please select one)

Hispanic or Latinx

Not Hispanic or Latinx

Prefer not to answer/ unknown

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6. Household Income

Prefer not to answer

$15,000 - 24,999

$25,000 - 34,999

$35,000 - 49,999

$50,000 - 74,999

$75,000 - 99,999

$100,000 +

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7. What is the highest level of education you have completed?

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8. Have you ever or do you currently smoke cigarettes or use tobacco products?

Yes

If you do not smoke cigarettes or tobacco products, please continue to Part 3.

Part 2: Tobacco Use

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9. Have you smoked 100 cigarettes (approximately 5 packs) in your lifetime?

Yes

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10. Do you usually smoke menthol or non-menthol cigarettes?

Menthol Cigarettes

Non-menthol Cigarettes

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11. How long have you smoked menthol cigarettes?

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12. In the past 12 months, were you smoking every day, some days, or not at all?

Every day

Some days

Not at all

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13. In the past 3 months, were you smoking every day, some days, or not at all?

Every day

Some days

Not at all

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14. In the past, have you attempted to quit smoking?

Yes

Menthol Survey

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1. Age

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2. Zip Code

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3. Gender

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4. Race (Please select one)

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5. Ethnicity (Please select one)

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6. Household Income

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7. What is the highest level of education you have completed?

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8. Have you ever or do you currently smoke cigarettes or use tobacco products?

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9. Have you smoked 100 cigarettes (approximately 5 packs) in your lifetime?

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10. Do you usually smoke menthol or non-menthol cigarettes?

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11. How long have you smoked menthol cigarettes?

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12. In the past 12 months, were you smoking every day, some days, or not at all?

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13. In the past 3 months, were you smoking every day, some days, or not at all?

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14. In the past, have you attempted to quit smoking?

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15. If so, how many times have you attempted to quit smoking?