Make it happen!

Sample smoke-free employee surveys

The following surveys can be used to assess how adopting a smoke-free workplace policy might effect your business.  They can also be downloaded in MS Word format (77kb) so that you can edit them for your own use.

bulletSecondhand Smoke: Business Report Card
bulletCustomer Survey
bulletEmployee Opinion Survey

Secondhand Smoke: Business Report Card
Curious about your policy on smoking in the workplace? Take a quick test and see how you score!

Category

Grade Determinants   

Possible Scores

Your Score

Policy

Smoke free on entire business campus, in business owned vehicles and at business sponsored events.

40

 

 

 

 

 

 

 

 

 

Smoke free inside business but smokers are allowed to smoke outside, away from windows and entrances.

35

Smoke free in most of the building with separately ventilated rooms for smokers.

30

Smoke free in most of the building; smoking sections in lounges and lobbies.

20

Smokers are allowed to smoke anywhere in building.

0

Partners in the Policy

Everyone, including employees, managers, owners, customers and guests, are prohibited from smoking. 

10

 

Employees are prohibited from smoking but guests are allowed to smoke in prohibited areas.

5

Employees and guests allowed to smoke anywhere.

0

Enforcement

Policy is strictly enforced by both employees and managers who respect the policy.

20

 

Policy is reluctantly enforced by managers, leaving the work to employees who feel strongly about the policy.

10

The policy is not enforced by employee or managers.

0

Cessation Resources

Any employee who expresses an interest in quitting is provided with cessation resources, positive incentives to quit and breaks on the costs of quitting.

20

 

 

 

 

 

 

Employees who are smokers and who want to quit have access to cessation pamphlets and are compensated by their insurance for cessation aides.

15

Employees who are smokers are encouraged to quit through education as well as by peers.

10

Employees who want to quit are encouraged to look for cessation resources when they’re not at work.

5

There are no cessation resources offered.

0

Community Involvement

Business sponsors community events that educate people about secondhand smoke and smoking, and offers advice to businesses which are changing their smoking policy.

10

 

Sponsors some community events as long as they are tax deductible and promote the business’ logo.

5

Does not sponsor community events and is not willing to talk to other businesses about smoking policies

0

 

Tally your score for a final grade _______

bulletA: Outstanding          
85 to 100 points
bulletB: Above Average      
71 to 84 points
bulletC: Average                     
56 to 70 points
bulletD: Below Average       
41 to 55 points
bulletF: Failing                       
40 or less

 

Customer Survey
Here is a set of easy questions about secondhand smoke you can ask customers and visitors as they leave your business.  You can then tally these results to determine whether your customers would support a smoke-free policy.  

Assessing Secondhand Smoke:

Customer Survey

 

Question

Very True

Somewhat True

Not Very True

False

Don’t Know

Knowledge of secondhand smoke

Exposure to secondhand smoke is dangerous for adults.

 

 

 

 

 

Exposure to secondhand smoke is dangerous for children.

 

 

 

 

 

Secondhand smoke causes lung cancer.

 

 

 

 

 

Secondhand smoke causes heart disease.

 

 

 

 

 

Secondhand smoke causes asthma and bronchitis.

 

 

 

 

 

Secondhand smoke irritates asthma and bronchitis

 

 

 

 

 

Preference

A smoke-free environment is the only way to protect yourself from secondhand smoke.

 

 

 

 

 

It is ok to be exposed to some secondhand smoke.

 

 

 

 

 

Affect on Patronage

I would be more likely to eat/shop at a smoke-free restaurant/store.

 

 

 

 

 

I would tell my friends if a restaurant/store was smoke-free.

 

 

 

 

 

 

Employee Opinion Survey

The following worksite survey is a two-part survey to determine whether employees would appreciate and benefit from a smoke-free policy in the workplace.

 

Worksite Survey

  1. Please indicate the extent to which you are bothered by secondhand smoke at work.
    bulletFrequently bothered
    bulletOccasionally bothered
    bulletSeldom bothered
    bulletNever bothered
  2. If you are bothered by secondhand smoke at work, in what way are you bothered? (check all that apply)
    bulletEye, nose and throat irritation
    bulletConcern for your long-term health
    bulletInterference with work performances
    bulletHeadaches
    bulletPregnancy related concerns
    bulletOther, please specify_________________________________________
  3. What is your opinion of a smoking policy for the workplace?
    bulletCompany grounds should be entirely smoke-free
    bulletThe building should be entirely smoke-free
    bulletSmoking should be allowed in rooms with separate ventilation, dedicated only to smoking.
    Please specify the location_______________________
  4. Please indicate your current smoking status:
    bulletCurrently smoke cigarettes
    bulletCurrently smoke pipe/ cigar
    bulletUsed to smoke
    bulletNever smoked

For current smokers only:

  1. Would you attend a company-sponsored program to help you stop smoking?
    bulletYes
    bulletNo
    bulletMaybe
  2. If smoking were banned in the workplace, how would this affect the amount you currently smoke?
    bulletIt would not affect it
    bulletI would smoke less
    bulletI would smoke more at home
    bulletI would try to quit.

Thank you for your cooperation!

 

Worksite Follow-Up Survey

  1. Please indicate your current smoking status:
    bulletCurrently smoke cigarettes
    bulletCurrently smoke pipe/ cigar
    bulletFormer smoker (stopped before the smoking policy was adopted)
    bulletFormer smoker (stopped after the smoking policy was adopted)
    bulletNever smoked
  2. What is your opinion of the smoking policy at your workplace?
    bulletNot strict enough
    bulletReasonable
    bulletToo strict
  3. What is your opinion of secondhand smoke? Check one:
    bulletDefinitely harmful
    bulletProbably harmful
    bulletNot harmful
    bulletNot sure

For those who smoked at the time the smoking policy was implemented:

  1. Have you enrolled in a smoking cessation program?
    bulletYes, I have enrolled.
    bulletNo, I have not enrolled.
  2. How has the smoking policy affected your smoking? Check all that apply:
    bulletI smoke less overall.
    bulletI smoke less at work.
    bulletI smoke more overall.
    bulletI smoke more at work.
    bulletI smoke more at home.
    bulletIt has not affected me.
    bulletI quit smoking.
    bulletI am trying to quit.
    bulletI smoke less at home.
    bulletI only smoke outdoors.

 Thank you for your cooperation!

 


 

 


 

 

This page was last updated on May 28, 2003. Copyright © 2003 Tobacco Prevention and Control Branch, NC Department of Health and Human Services. All rights reserved. Click here for disclaimer.