West Virginia Covenant House Lesbian, Gay, and Bisexual Tobacco Survey
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1 West Virginia Covenant House Lesbian, Gay, and Bisexual Tobacco Survey You are invited to participate in a short survey about tobacco use in the West Virginia lesbian, gay, and bisexual community. Taking the survey is up to you. Participation is voluntary. The survey is anonymous. The survey should take you five minutes or less. You can stop answering questions at any time or skip any questions you do not want to answer. This survey will help us learn new information about tobacco use in the community and may help people in the future. You will receive a small gift of a tea bag or lollipop, but you may not receive any other benefit from being in the survey. This survey has no or little risk (people nearby might see you answering and identify you as gay or lesbian). About this survey: Title of Study: West Virginia Lesbian, Gay, and Bisexual Tobacco Survey Principal Investigator: Adam O. Goldstein UNC-Chapel Hill Department: Family Medicine Funding Source: West Virginia Covenant House, Charleston, WV Study Contact: Joseph Lee Study Contact telephone number: Study Contact jose.lee@unc.edu IRB # We will combine answers in a report so no one can identify your responses. Page 0 WV Covenant House / UNC Survey
2 1. Which of the following best applies to you? I live in West Virginia I currently live in West Virginia because I go to a West Virginia school I do not live in West Virginia Stop! You re not eligible for this survey. 2. What is your age? Under Prefer not to answer (18+) Stop! You re not eligible for this survey. 3. What best describes your gender? Female Male Other 4. Do you identify as transgender? I don t know 5. What best describes your sexual orientation? Bisexual Gay Lesbian Straight Continue to next page Page 1 WV Covenant House / UNC Survey
3 6. What is the highest grade or year of school you completed? Some high school High school 2 year college 4 year college Graduate school 7. Have you smoked at least 100 cigarettes in your entire life? te: 5 packs = about 100 cigarettes. 8. Do you now smoke cigarettes every day, some days, or not at all? Every day Some days t at all 9. Do you currently smoke cigars every day, some days, or not at all? Every day Some days t at all 10. Do you currently use chewing tobacco or snuff every day, some days, or not at all? Every day Some days t at all Continue to next page Page 2 WV Covenant House / UNC Survey
4 11. On average how many cigarettes do you smoke a day? ne/i don t smoke Less than one half pack One half pack One pack One and a half packs Two packs or more 12. On average how many pouches or cans of chewing or dipping tobacco do you use per week? ne/i don t use More than During the past 12 months, have you stopped using tobacco (cigarettes, chew/dip/snuff, or cigars) for one day or longer because you were trying to quit using tobacco? I don t use tobacco 14. If you decide to quit, would a program run for gay, lesbian, and bisexual people make you feel more confident about quitting? I don t use tobacco I don t care I don t want to quit Continue to next page Page 3 WV Covenant House / UNC Survey
5 15. How would you like to find out about LGBT friendly programs to help you quit? I don t use tobacco I don t want to find out about quitting Facebook WV Queer News web site WV Pride web site Posters at bar or club Yellow pages Friends Other: End of survey Thanks! Page 4 WV Covenant House / UNC Survey
6 WE HAVE THE SOLUTION FOR YOUR NEW YEAR S RESOLUTION GET THE NEW YEAR OFF TO A HEALTHY START SMOKING CESSATION CLASSES TUESDAY, JANUARY 5, :00 PM 7:30 PM ASBURY UNITED METHOD CHURCH FREE SEVEN-WEEK CLASS FREE & DINNER PATCHES, GUM, LOZENGES FREE FOLLOW-UP SUPPORT GROUP SIGN UP AT THE BAR OR CONTACT JEFF CRIST: EXT. 18 / JCRIST@WVCOVENANTHOUSE.ORG
7 SMOKING CESSATION CLASSES GAY-FRIENDLY ATMOSPHERE SIGN UP ON THE BACK OR CONTACT JEFF CRIST EXT. 18 NAME PHONE NUMBER PLEASE FILL-OUT THIS CARD AND RETURN IT TO THE BARTENDER.
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