Survey for Smokers

Survey for Non-Smokers

Please take a moment to complete this short survey. Thank you!
Have you ever smoked?*

YesNo
Did any adult smoke at home during your childhood or adolescence (before you turned 20 years old)?*

YesNo
Are you living or have you lived with a habitual smoker since you turned 20 years old?*

YesNo
What do you see people smoking the most?*

CigarettesCigarsPipeWater Pipe
Are you currently exposed to second-hand smoke indoors, at home, or in the workplace?*

YesNo
Does second-hand smoke bother you?*

YesNo
How many times per week do you currently experience second-hand smoke indoors or at the workplace?*

1-23-45-6everyday

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 for people trying to quit smoking? Stopping smoking would...*

	Not Likley	Somewhat Likely	Likley	Very Likely
Give more control over ones life
Allow more money to be spent on other things
Make one gain weight
Cause one to be more stressed
Cause one to be short-tempered, cranky, or moody
Give more time for one to be productive
Create more social opportunities
Make ones friends and family happy
Cause cravings that one would not be able to handle
Help to improve health

This survey is anonymous. If you would like Future Builders to send you information about quitting for a friend or family member, 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:

Survey for Non-Smokers