Survey for Smokers

Survey for Smokers

Please take a moment to complete this short survey. Thank you!
How old were you when you began smoking?*
How do you prefer to smoke?*

CigarettesCigarsPipeWater PipeOther
Have you ever tried an electronic cigarette?*

YesNo
How often do you smoke?*

Several times per dayOnce per daySeveral times per weekLess Often
How many cigarettes do you smoke per day?*

1-55-1010-2020-3030-40Other
How much money do you spend on tobacco products per months?*

Less than $25$25-$50$50-$100$100-$150$150-$200More than $200

Please answer the following according to your personal smoking experience.*

	True	Somewhat True	False
I enjoy smoking
Smoking calms me down
Smoking is really expensive
Smoking is a huge part of my life

To what extent do you agree with the following statements?*

	Agree	Somewhat Agree	Somewhat Disagree	I Disagree
It is okay to smoke around family and friends
It is okay to smoke around children
There should not be smoking in restaurants
There should not be smoking at bus/train stops
Smoking should not be in the workplace

How would you consider the following challenges if you were to quit smoking? *

	Not Likley	Somewhat Likely	Likley	Very Likely
I would have more control over my life
I would have more money to do other things
I would gain weight
I would be more stressed
I would be short-tempered, cranky, or moody
I would be more productive
I would be more sociable
My friends and family would be happy
My cravings would be more than I can handle
My health would improve

This survey is anonymous. If you would like Future Builders to send you information about quitting, please enter your information below. You do not have to enter your information if you would not like to receive any information.
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Should be Empty: