The following survey is designed to explore your perception and attitudes towards

smoking cessation aids (these are aids to help someone stop smoking).

1.

2. Which of the following statements best describes your experience with cigarette smoking?

 You never smoked

 You used to smoke, but have completely quit
 You currently smoke even though you have tried to quit
 You are a social smoker who does not smoke every day
 You currently smoke and have never tried to quit

3.

4. What age did you begin smoking?

 Before 18
 18-25
 26-30
 31-36
 36-40
 41-45
 46-50
 50+
 N/A

5. How long have you been smoking?

 Less than 1 year

 1-3 years
 4-7 years
 8-10 years
 10+ years
 N/A

6. How frequently do you smoke?

 A few times per week (1-4)

 At least once a day
 Five cigarettes a day
 Half a pack a day
 Pack a day
 More than pack a day
 N/A
7. Do you ever worry about the effects of tobacco use on your health?

 Yes
 No
 N/A

8. Have you ever tried to quit smoking?

 Yes
 No
 N/A

9. If YES, what method(s) did you try? (Check all that apply).

 Nicotine Patch
 Cold-turkey (Stopping immediately without aids)
 Gradual Reduction
 Nicotine Gum
 Counseling
 Self-Help Books
 Hypnosis
 Other, please specify ______________________________
 10. Please indicate how strongly you agree or disagree with the following statements regarding
smoking cessation aids?

11.

Neither
Strongly Agree nor Strongly
Disagree Disagree Agree
I would use a smoking cessation
aid to help me quit 1 2 3 4 5 6 7
I wouldn’t use an aid because they
cost to much 1 2 3 4 5 6 7
I wouldn’t use an aid because I’m
worried about the side effects 1 2 3 4 5 6 7
I wouldn’t use an aid because I’m
not sure which one to try 1 2 3 4 5 6 7
I wouldn’t use an aid because I
don’t think they work 1 2 3 4 5 6 7
12. On a scale of 1-10, how badly do you want to quit?

Please circle the number that corresponds to the level of the intensity that describes your
attitude
Do not want Desperately
to quit want to quit

N/A 1 2 3 4 5 6 7 8 9
10

13. How many times have you tried to quit?

 Never
 Once
 Twice
 Three times
 Four times
 More than four times




14. You are basing your assessment on smoking cessation aids from which of the following
sources: (Check all that apply)

 TV ads
 Newspaper
 Internet
 Healthcare professionals
 Employer
 Friends
 Family Members
 Other, please specify_____________________________

15.

16. Please rank the methods on your perception of their effectiveness. This can be based on
experience or what you have heard. Circle the number that corresponds to your opinion
(1=Completely Ineffective, 7=Completely Effective

17. )
18.

Neither
Completely Effective nor Completely
Ineffective Ineffective Effective

1 2 3 4 5 6 7

Nicotine Patch
1 2 3 4 5 6 7
Cold-turkey
1 2 3 4 5 6 7
Gradual Reduction
1 2 3 4 5 6 7
Nicotine Gum
1 2 3 4 5 6 7
Counseling
1 2 3 4 5 6 7
Self-Help Books
1 2 3 4 5 6 7

Hypnosis

19.



20.


21. Rank these attributes in order of important they are to in a smoking cessation aid? Circle
the number that corresponds to your opinion (1= Not Important at all, 7= Extremely
Important).

Not Important Extremely

at All Important
Very
Effective
(How well it works) 1 2 3 4 5 6 7
Use only once a day 1 2 3 4 5 6 7
Can be taken orally
(placed in mouth) 1 2 3 4 5 6 7
Tastes good (if oral) 1 2 3 4 5 6 7
Can be hidden beneath
clothing 1 2 3 4 5 6 7
Includes self-help CD 1 2 3 4 5 6 7
Can be administered
by oneself 1 2 3 4 5 6 7
Does not involve nicotine
therapy 1 2 3 4 5 6 7
Is relatively inexpensive 1 2 3 4 5 6 7

22. Rank these side effects in order of how much they would prevent you from purchasing a
smoking cessation aid? Circle the number that corresponds to your opinion (7= Definitely
Would Not Prevent You, 1= Definitely Would Prevent You).

Definitely May or May Definitely

Would Not Not Prevent Would Prevent
Prevent You You You
Mild irritation at the
Patch adherence site 1 2 3 4 5 6 7
Dizziness 1 2 3 4 5 6 7
Nausea 1 2 3 4 5 6 7
Perspiration 1 2 3 4 5 6 7
Awful Taste 1 2 3 4 5 6 7
Moodiness/Irritability 1 2 3 4 5 6 7
Duration of treatment
exceeding two months 1 2 3 4 5 6 7
Higher chances of
weight gain 1 2 3 4 5 6 7
23. What is the main reason you want to quit smoking? (Check all that apply).

 Heath
 Social
 Economic
 Family
 Other, please specify ______________________
 Not interested in quitting

24. Currently, there are Smoking Cessation Aids that are gums and lozenges –oral products
rather nicotine patches. Are these products more preferable to you?

 Yes, I prefer gums/lozenges

 No, I would prefer Patch
 I wouldn’t care/ no preference.

25. Currently, there are clear and flesh colored transdermal patches available, would you have a
preference for either?

 Clear
 Flesh colored
 No preference
 Other, please specify ________________________

The following questions are for classification purposes only








26. What is your age?

 18-22
 23-25
 26-30
 31-35
 36-40
 41-45
 46-50
 50+
27. What is your race?

 American Indian
 Asian
 Black/African American
 Hispanic/Latino
 White/Caucasian
 Other, please specify____________________
28. What is your gender?

 Male
 Female

29.

30. What is the highest level of education completed?

 High School
 Associate’s degree
 Bachelor’s degree
 Master’s degree
 Doctorate
 Other, please specify ____________________

31. Which of the following groups does your total annual household income fall into?

 < $ 24,999
 $25,000-$44,999
 $45,000-$64,999
 $65,000-$84,999
 $85,000-$99,999
 $100,000-$149,999
 $150,000 or More