Tobacco-Free Policy Surveys

The following surveys were designed to assist organizations that are planning to or are in the process of implementing tobacco-free policies.

Attitudes, Knowledge, & Utilization Survey

An effective tobacco-free policy is expected to affect several areas, all of which are subject to evaluation. Use this survey to initially measure staff beliefs, attitudes, and knowledge regarding tobacco-free policies and tobacco treatment.

Community Health Agency Employee & Client Survey

The intent of a tobacco-free policy is straightforward – it provides a healthful environment for staff and clients. To this end, a baseline survey can be used to determine the prevalence, frequency, and intensity of tobacco use in the client community; the willingness and desire to quit; knowledge of tobacco’s harms; knowledge of and access to currently available cessation resources; and general attitudes about going tobacco-free. Similar surveys can be used for both staff and clients.

Community Partner & Coalition Member Survey

Your organization may also want to solicit input from community sites that you wish to engage as tobacco-free environment partners or coalition members. It is helpful to get a baseline from these partners on their attitudes and the status of their associated tobacco-free initiatives.

Workflow Assessment Tool

Use this tool to gather information about your organization’s patient demographics, utilization of the clinical guidelines for tobacco cessation, organizational supports, and status of tobacco-free policies. This assessment tool should be conducted by a key member of the organization with oversight of the organization’s practices.