Smoking Survey

What is your gender?

What is your age?

Where do you live?

1. What is your current smoking status?

Smoke regularlySmoke occasionallyUsed to smoke but quittedNever smoked

2. What type of tobacco products do/did you smoke?

3. How old were you when you first smoked?

4. How would you describe yourself as a smoker?

A light smokerA moderate smokerA fairly heavy smokerA heavy smoker

5. How often do you currently smoke?

EverydayFew times a weekFew times a monthLess than once a month

6. Have you ever tried to quit smoking?

Yes, onceYes, more than onceNo, never

7. What are the main reasons that made you try to quit smoking?

8. What made your attempts to quit smoking fail?

9. Are you addicted to smoking?

Not at allYes, somewhat addictedYes, very addictedNot sure

10. Are you planning to quit smoking?

YesNoNot sure