Smoking Questionnaire

Please respond to the following statements and questions: Place a check in front of your age group: ____ 18 20 ____ 21 24 ____ 25 30 Gender: ____ M, ____F 1. 2. 3.

____ 31 34

____ 35 older

Major: ______________________ ____ yes ____no

Do one or more of your parent(s) or guardian(s) currently smoke? In the home in which you grew up, did anyone else smoke?

____ yes

____ no

If yes in number 1 and 2, how many members of your immediate household (parents, siblings, grandparents) smoke? ______ How many times per day are you (not including yourself, if you are a smoker) in an environment where you can smell smoke or someone smoking? ____ Do you smoke cigarettes? ____ yes ____no If you responded with Yes, please continue with question 6.

4.

5.

Questions if you smoke

If you responded with No, please skip to question 15. 6. 7. At what age did you begin smoking? ____

What were the three main reasons you started smoking?

8.

Approximately how much do your smoke? _______ cigarettes per day or ________ cigarettes per week What are the main reasons you continue to smoke?

9.

10.

Name the three places you smoke most often.

11.

What triggers your urge to smoke?

(please continue on the back side)

Questions if you smoke

12. 13.

Do you anticipate health problems related to smoking? Have you tried to stop smoking? If YES, how many times? ____ If YES, what methods did you try? ____ yes ____ no

____ yes

____no

__________________________________________ ____ yes ____no

14.

Do you feel you could stop smoking whenever you wanted to?

15.

If you do not smoke now, did you ever smoke? 16.

____ yes

____ no

Questions if you do not smoke.

If you did smoke, what were the two most important factors that prompted you to quit smoking?

17. If you have never smoked, what factors have influenced you to not smoke?

 18. As a non-smoker how does a smoking environment affect you?

General comments regarding smoking:

Thank you for responding.

Research Sponsored by Toyota and the National Science Teachers Association and conducted in conjunction with students at Price Laboratory School. If you have questions, contact Jody Stone at PLS or Nadene Davidson at HPELS.