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 ____ 31 – 34 ____ 35 – older

Gender: ____ M, ____F Major: ______________________

1. Do one or more of your parent(s) or guardian(s) currently smoke? ____ yes ____no

2. In the home in which you grew up, did anyone else smoke? ____ yes ____ no

3. If yes in number 1 and 2, how many members of your immediate household (parents,
siblings, grandparents) smoke? ______

4. 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? ____

5. Do you smoke cigarettes? ____ yes ____no

If you responded with Yes, please continue with question 6.

If you responded with No, please skip to question 15.

Questions if you smoke

6. At what age did you begin smoking? ____

7. What were the three main reasons you started smoking?

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8. Approximately how much do your smoke?

_______ cigarettes per day or ________ cigarettes per week

9. What are the main reasons you continue to smoke?

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 10. Name the three places you smoke most often.
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11. What triggers your urge to smoke?

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(please continue on the back side)

Questions if you smoke

12. Do you anticipate health problems related to smoking? ____ yes ____no

13. Have you tried to stop smoking? ____ yes ____ no

If YES, how many times? ____
If YES, what methods did you try? __________________________________________

14. Do you feel you could stop smoking whenever you wanted to? ____ yes ____no

15. If you do not smoke now, did you ever smoke? ____ yes ____ no
Questions if you do not smoke.

16. 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?

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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.