Tobacco Use

Please answer honestly....your responses, but not your names, will be submitted and compiled.....Thanks in advance
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A red asterisk (*) indicates required questions.

  1. During the past 30 days, on how many days did you smoke cigarettes?*
    0 days
    1 or 2 days
    3 to 5 days
    6 to 9 days
    10 to 19 days
    20 to 29 days
    all 30 days


  1. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?*
    I did not smoke cigarettes during the past 30 days
    Less than 1 cigarette per day
    1 cigarette per day
    2 to 5 cigarettes per day
    6 to 10 cigarettes per day
    11 to 20 cigarettes per day
    More than 20 cigarettes per day


  1. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?*
    0 days
    1 or 2 days
    3 to 5 days
    6 to 9 days
    10 to 19 days
    20 to 29 days
    all 30 days





Mrs. G
Health Education
Port Byron School District
Port Byron, NY