Stop smoking service questionnaire

1. Have you ever smoked?

Y

If no, please go to question 9

2. Do you currently smoke?
Y

3. Do you currently chew tobacco?

Y

4. If the answer is yes to question 2 or 3 would you like to quit?

Y

Why would you like to quit?

.
.
.
5. Have you tried to quit in the past, if so how?
..
..
a) Did you get support

b) Did you succeed?

6. If you are wanting to quit what is stopping you from trying to quit right now?
..
..
7. Do you currently have any smoking/tobacco chewing related illnesses? If
so which (optional):
..
..
8. If you are thinking of quitting do you know who to contact for advice?
Y

YOU ARE FOUR TIMES MORE LIKELY TO QUIT WITH SUPPORT

(Please turn overleaf)

9. Is your home/car smoke free?

Y

10. Do you have any children under 5 living in your home?

Y

11. Do you know people that smoke i.e. friends or family?

Y

12. Have you given them any advice on quitting?

Y

13. If yes, what advice have you given them?

..
..
..
14. Do you think there is enough information available on how to quit
smoking?
Y

15. Where would you look for information on how to quit smoking?
GP

Internet

The NHS website

Library

Community centres

Internet other

Other (please state): ......

16. Do you have any other comments about smoking?
..
..
..
..
..
If you want advice on quitting please contact the stop smoking service
on: 01274 202793

Thank you for taking the time to fill in this questionnaire, your feedback is very
useful