Name: Sex: M/F

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
No Neutra Huge
effect l effect effect
Family
(other family
members smoking)
Friends
(peer pressure)

Media
(anti-smoking ad
campaigns)
Body Image
(weight loss)

Education
(your knowledge
about smoking)
Medical Issues
(medical issues
that could act as a
barrier)
Rebellion/Ima
ge
(wanting to look
cool/ be
independent)
Mentality
(your mental
state / your current
situation)

2. Justify your selections from above.

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3. Have you ever tried a smoke? Y/N
If yes, continue to Question 4 and 5. If no, skip to
Question 6.

4. What influenced your decision to smoke?

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5. Do you regret your decision to smoke? Y/N
Why/Why not?
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6. Rank the following strategies from most effective to
least effective to help an individuals decision to
not smoke.
(1 being the most effective and 5 being the least effective.)

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