SURVEY QUESTIONNAIRE

Topic: The Effects of Students that Smoke Cigarettes in Don Andres Soriano
National High School

Name:__________________________Age:____Gender:______Date:_____________
Instruction: Kindly put a check in every column if you agree in every statement or not.
Legend:
4-Never 3-Sometimes 2-Often 1-Always
Never Sometimes Often Always
(4) (3) (2) (1)
1. At any time in your life, have you
smoked 1 or more cigarettes per
day for 30 days straight?
2. Do you currently use any of the
following tobacco or nicotine
products? Chewing tobacco or
snuff, cigars, tobacco pipes, clove
cigarettes or bidis, nicotine
replacement products such as
gum or patch, or any other
tobacco products besides
cigarettes?
3. Do you find it difficult to refrain
from smoking in places where it is
forbidden?
4. Do you smoke more frequently
during the first hours after waking
than during the rest of the day?
5. Do you smoke even if you are so
ill that you are in bed most of the
day?
6. Did you believe that smoking
cigarettes could be harmful to
your health?
7. How often did you see smoking
advertisements on television,
radio, billboards, posters,
newspapers, and magazines?
8. Do you believe that you could
become addicted to cigarettes?
9. Do you think that smoking is
"cool"?
10.How often did you see or hear
anti-smoking messages on
television, radio, billboards,
posters, newspapers, magazines,
or movies?
11. While you were growing up, did
any of your parents/guardians
smoke inside your home?
12. While you were growing up, did
your parents/guardians allow
visitors and guests to smoke
inside your home?
13. While you were growing up, did
your parents/guardians allow you
to smoke inside your home?
14. While you were growing up, did
your parents/guardians ever talk
to you about the dangers of
smoking?
15. While you were growing up, did
your parents/guardians tell you
that you were not allowed to
smoke?
16. While you were growing up, did
you have a close relationship with
your parents/guardians?
17. While you were growing up, did
your parents/guardians ever ask
nearby smokers to stop smoking?
18. When you were in school, were
you taught about the dangers of
smoking (for example, lung
cancer, heart disease, fire
hazards)?
19. When you were in school, did you
discuss the reasons why people
smoke in any of your classes?
 20. When you were in school, were
you taught about the side effects
of smoking, such as making teeth
yellow, causing wrinkles, or
making smokers smell bad?
21. When you were in high school,
were there designated smoking
areas for students?
22. When you were in high school,
were adults such as teachers and
administrators allowed to smoke
at the school?
23.how often did you see or hear
anti-smoking messages on
television, radio, billboards,
posters, newspapers, magazines,
or movies?
24. Was there a minimum legal age
for buying cigarettes?

25. Was it easy for you to get

cigarettes?

26. Did anyone refuse to sell you

cigarettes because of your age?

27.How often did you see actors

smoking when you watched TV,
movies, or videos?
28. Do you think you had a healthy
lifestyle?

29. Did a doctor or dentist ever talk to

you about the dangers of
smoking?
30. Do you think you received
adequate information about
smoking and its risks?

URL: https://gsoutreach.gs.washington.edu/database/questionnaire.html