Smoker Survey

This is a survey of smokers -- including those smokers who are not yet ready to quit -- to learn more about their perspective. Please take a few minutes to complete and submit this Smoker Survey. This will entitle you to receive our comprehensive Stop Smoking Audio Program on loan for up to 3 months. Our experts are also available to respond to your questions related to smoking, after you complete and submit the smoker survey. Thank you for your participation.

This is a demo Only.  Form Will not submit.  

1. Please rate each of the following possible benefits of smoking on the 1- to 10-point scale. (Please enter a number in each box corresponding to the rating scale provided.)
No benefit Very major
benefit
___________________________________
1       2       3       4       5       6       7      8      9      10

Helps me deal with stressful situations.
Provides a pleasant and enjoyable break from work.
Helps me unwind and relax.
Helps me deal with painful or unpleasant situations.
Prevents unpleasant withdrawal symptoms.
Helps me deal with an overstimulating environment.
I enjoy the physical sensation of lighting and handling a cigarette.
Keeps me from feeling bored.
Increases my enjoyment of pleasant experiences.
Helps me feel comfortable in social situations.
Helps me concentrate.

2. Please rate each of the following possible drawbacks of smoking on the 1- to 10-point scale. (Please enter a number in each box corresponding to the rating scale provided.)
No drawback Very major
drawback
___________________________________
1       2       3       4       5       6       7      8      9      10

Smoking makes my clothes, hair, home and office smell bad.
I have more frequent colds, coughs and sore throats.
I worry that it's bad for my health.
Some people don't want to be my friend because I smoke.
I feel that other people disapprove of my smoking.
I worry that my smoking might be a health risk for others.
I get out of breath more easily because of my smoking.
I feel that I am setting a bad example.

3. How have the attitudes of nonsmokers changed with respect to tolerating smoking in the last 5 to 10 years? (Click on the number on the scale that best describes your opinion.)
Much more
 tolerant
Somewhat
more tolerant

No change
Somewhat
less tolerant
Much less 
tolerant
___________________________________
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4. Which of the following changes in nonsmokers' behavior have you noticed in the last few years? (Please click on the appropriate answer for each box.)
TRUE FALSE Statement
I'm now more likely to ask permission to smoke when visiting a nonsmoking friend.
Friends and family members are now more likely to express concerns about my smoking.
I am now more likely to refrain from smoking when nonsmokers are present.
Nonsmokers in restaurants are now more likely to say that my smoking bothers them.
I now feel more guilty about my smoking than I did a few years ago.


5. Have you ever attempted to quit smoking? (Please select only one of the four possible answers.)
I have never wanted to quit.
I have wanted to quit but have never tried.
I have tried to quit, but have not succeeded.
I have tried and succeeded, but started smoking again.


6. What was the longest time you have gone without cigarettes since you started smoking? (Please select only one of the three possible answers.)

Two days or more.
One week or more.
One year or more.
7. Do you think you will quit smoking? (Please select the best answer.)
I will quit.
No.
I'm a minimal smoker.
Not sure.


8. Would you like to take a greater measure of control of your smoking behavior?

True False
9. Which of the following topics should be included in a comprehensive, self-help stop smoking program? (Please enter a rating in the box for each statement.)
Unimportant Extremely
important
___________________________________
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How to tell whether you're a high- or low-risk smoker.
How to keep smoking from harming your family and friends.
How to get along with nonsmokers.
The most effective ways of cutting down.
The economic consequences of smoking.
Do smokers have special needs for vitamins.
How to cut your smoking through stress reduction.
What you need to know to get ready to quit.
How to stay a nonsmoker after you quit.
Dealing with weight gain after you quit.
What withdrawal symptoms you might encounter after you quit.
The most effective ways of quitting.
What smoking does to a smoker's body.

10. As a final step in completing this survey and receiving our comprehensive Stop Smoking Audio Program on loan for up to 3 months, please enter your name and address in the space below. You may also include a comment or question for our Stop Smoking Expert.
Name:
E-mail Address:
Company:
Mailing Address:
City:
State:
Zip:
Sex:
Age:
Questions:

Stop Smoking Survey is available to Members Only.  Click here to Join.

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