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.

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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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
16. If you did smoke, what were the two most important factors that prompted you to quit
smoking?
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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?

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General comments regarding smoking:

Thank you for responding.