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2012
May
S
Smoking Cessation University of West London BSc Su
Smoking Cessation University of West London BSc Su
0%
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How many Cigarettes do you smoke per day please tick to confirm daily rate
5
10
15
20
30
What is your annual income please tick the correct range?
£ 5000- 10000
£10000- 15000
£15000- 20000
£20000- 25000
£25000- 30000
£30000 -Above
What is your age range choose select one below?
10 -15
15 -20
20 -25
25 -30
40 -45
45 -50
55 -60
65 -70
How do you describe the neighbourhood in which you come come from?
Ghetto
Middle Class
Secluded Affluent Suburbs
Homeless Shelter
Please rank (1-3) the following in order of effectiveness to smoking Cessation
NRT
-- Select --
1
2
3
4
5
Bupropion
-- Select --
1
2
3
4
5
Nicorettes
-- Select --
1
2
3
4
5
Gum
-- Select --
1
2
3
4
5
Counselling
-- Select --
1
2
3
4
5
How long have you been have you been smoking please fill the answer box?
How satisfied are you with professional services that you get in relation to cessation services available?
Very Dissatisfied
-- Select --
1
2
3
4
5
Not Satisfied
-- Select --
1
2
3
4
5
Neutral
-- Select --
1
2
3
4
5
Satisfied
-- Select --
1
2
3
4
5
Very Satisfied
-- Select --
1
2
3
4
5
What barriers to smoking cessation have you experienced when trying to quit? Tick the appropriate barrier item.
Socio economic
Lack of Advice
Lack of Motivation
Peer Group Friends
Fear of Stress and withdrawal symptoms
Are you aware of the dangers of smoking?
Yes
No
Do you suffer from any of the following illness? Please select one that applies to you.
Lung Cancer
Severe Mental Illness
COPD
Astma
Respiratory distress
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