Survey

Name: Sex:
Age: Regular Smoker: Y/N

1. How would you describe the effect the following factors have on a
person choosing to smoke?
Place a tick in the correct column.

1 2 3 4 5 6 7 8 9 10
No Hug
effe e
ct effe
ct
Family

Friends (peer
pressure)
Media / anti-
smoking ads
Body Image
(Weight Loss)
Education /
Knowledge
Under
pressure /
Stressed
Personal
Issues /
Emotions
Medical
Issues

Medical
Research

2. Justify your selection from above.

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3. Have you ever tried a cigarette before?

Yes / No

4. What influences you from Question 1 to smoke / not to smoke?

- - -

- - -

- - -

5. Do you pay attention to anti-smoking advertisements? Circle your

answer

Yes / No

Why / Why not?

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6. Are you a frequent smoker? Circle your answer (If yes proceed to
question 7. If no skip question 7 and proceed to question 8.)

Yes / No

7. Do you feel the need to quit? What pressures you to quit (use
question one)?

Yes / No

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8. In your opinion, rank the following (1 is most effective, 5 is least

effective) strategies in their effectiveness to increase healthy
decision making in relation to smoking in young people.

_____ Educate young people more on the consequences of smoking in an

interactive, fun way

_____ Create more anti-smoking advertisements aimed towards teenagers

_____ Make cigarettes more expensive so teenagers cant afford them

_____ Create quit lines specifically for teenagers to give them targeted support

_____ Make cigarettes less accessible by selling them at fewer places