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Surveys
2014
February
S
Smoking
Smoking
0%
Exit Survey
1. Are you a current smoker
yes
no
2. Do you smoke daily
yes
no
3.On average how many cigarettes do you smoke
> 25 cigs/day
10-25 cigs/day
<10 cigs/day
No. of years smoked?
<10 years
10-20 years
20-30 years
30-40 years
>40 years
5. How many attempts have you made to quit smoking? ( quitting defined as not smoking for at least 7 days with an intention to quit)
0
1-2
3-4
>4
6. Does your doctor ask you about your smoking status on each visit?
Yes
No
7.Does your doctor advice you about quitting smoking on each visit?
Yes
No
8. What methods have you used to help you quit? (Select all that apply)
Physician counselling including explaining health risks of smoking, various options available for quitting, providing support),
Nurse counselling
Counselling session with psychologist available at clinic
Smoking quitline
Self- help/motivation
Warning on tv/websites
Chantix
Bupropion
Nicotine patches/gums
Medications plus counselling at the same time
Financial reasons
Family support
None
9. Out of the strategies you used which one led to a successful quit attempt? (Select all that apply)
Physician counselling (including explaining health risks of smoking, various options available for quitting, providing support)
Nurse counseling
Counselling session with psychologist available at clinic
Smoking Quitline
Self- help/motivation
Warning on tv/websites
Chantix
Bupropion
Nicotine patches/gums
Medications plus counselling at the same time
Financial reasons
Family support
None.
10. What are the barriers to quitting? (Select all that apply)
Stress/anxiety
Lack of follow up from PCP
Weight gain
Lack of support
Depression
Dependence
Loss of control
Inability to afford smoking cessation medications
Substance abuse
Old age
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