QUIT SMOKING PROGRAM QUESTIONNAIRE

1. NAME 2. PHONE 3. GENDER 4. AGE 18-25 5. ARE YOU A SMOKER? IF YOU ARE NON SMOKER THE FOLLOWING QUESTIONS ARE NOT APLICABLE FOR YOU 6. AGE WHEN YOU STARTED TO SMOKE? <14 15-18 19-25 26-35 36-45 46-55 56-65 26-35 36-45 46-55 56-65 YES NO SURNAME EMAIL M F

7. FOR HOW MANY YEARS YOU HAVE BEEN SMOKING ? <1 1-5 6-10 11-15 16-20 21-30 > 31

8. THE NUMBER OF CIGARETTES YOU SMOKE DAILY? 1-5 6-10 11-15 16-20 21-30 > 31 YES YES NO NO

9. HAVE YOU EVER TRIED TO QUIT SMOKING? 10. DO YOU INTEND TO QUIT SMOKING? IF YES, BECAUSE OF: a) health b) new regulations c) to save money e) other

d) friends and/or family want me to quit

11. DO YOU CONSIDER SMOKING DANGEROUS FOR YOUR HEALTH? 12. DO YOU CONSIDER SMOKING DANGEROUS FOR THE HEALTH OF PEOPLE AROUND YOU? 13. WHICH BENEFIT OF NON-SMOKING YOU VALUE THE MOST? a) your health c) not spending extra money b) other people's health d) none e) other

YES YES

NO NO

14. ACCORDING TO YOU, WHICH ARE THE MOST COMMON HEALTH PROBLEMS RELATED TO SMOKING? a) respiratory problems c) cancer 15. HAVE YOU EVER BEEN OFFERED TO BE ENROLLED IN A QUIT SMOKING PROGRAM? 16. WOULD YOU JOIN A PROGRAM THAT CAN HELP YOU TO QUIT SMOKING? IF NOT, WHY: a) I like to smoke d) I'm not interested b) I'm healthy e) other YES NO c) the program won't help me YES NO b) cardiovascular problems d) none e) other YES NO

17. IN YOUR OPINION, TAKING IN CONSIDERATION GENERAL POLLUTION, DOES SMOKING DO AN EXTRA DAMAGE TO YOUR HEALTH?