Smoking Cessation Health Awareness Survey
Help us understand your smoking habits and awareness to support better health initiatives.
Your Full Name
*
First Name
Last Name
Your Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
What is your current smoking status?
*
Current smoker
Former smoker
Never smoked
How many cigarettes do you smoke per day?
*
Please Select
I do not smoke
1-5
6-10
11-20
More than 20
Have you ever tried to quit smoking?
*
Yes, once
Yes, multiple times
No, never tried
How motivated are you to quit smoking?
*
Not motivated
1
2
3
4
5
6
7
8
9
Highly motivated
10
1 is Not motivated, 10 is Highly motivated
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Smoking increases the risk of lung cancer
1
2
3
4
5
I am aware of resources to help me quit smoking
6
7
8
9
10
Quitting smoking improves overall health
11
12
13
14
15
I feel supported by family or friends to quit
16
17
18
19
20
What resources would you consider using to help quit smoking? (Select all that apply)
*
Nicotine replacement therapy (patches, gum, etc.)
Counseling or support groups
Prescription medication
Mobile apps or online programs
I do not plan to use any resources
Other
If you have any additional comments or suggestions regarding smoking cessation or health awareness, please share them below:
Submit Survey
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