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Are you Male or Female
 
Male
 
Female
 
 
 
Do you smoke cigarettes
 
Yes
 
No
 
No Answer

 
 
 
If yes, how often do you smoke
 
Every day
 
Every week
 
Every 2 - 3 weeks
 
Every month
 
Every 2 - 3 months
 
Every 4 - 6 months
 
Once or twice a year
 
 
 
Why do you smoke cigarettes?
 
Satisfaction
 
Relief Stress
 
Fitting In
 
Other
 
 
 
How do you feel when you smoke
   
 
 
 
Are you going to keep on smoking through out your life time
 
Very likely
 
Somewhat likely
 
Neutral
 
Somewhat unlikely
 
Very unlikely
 
 
 
How old are you?
 
15
 
16
 
17
 
18
 
19
 
other
 
 
 
Do you want to quit smoking ?
   
 
 
 
Do you parents smoke, or used to ?
 
Yes
 
No
 
Prefer not to answer
 
 
 
Do your parents/guardians know that you smoke
 
Yes
 
No
 
Prefer not to answer
 
 
 
Do you think smoking is cool ?
 
Yes
 
No
 
Prefer not to answer
 
Other
 
 
 
 
Are you aware of the side affects of smoking?
 
Yes
 
No
 
Prefer not to answer
 
Other
 
 
 
 
Do you regret smoking ?
 
Yes
 
No
 
Perfer not to answer
 
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