Smoking Habits Survey

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Name
0

Date of birth
0

Gender
0

Occupation
0

Do you smoke?
Yes

No
0

What type of smoker are you?
Serial smoker

Heavy smoker

Binge smoker

Casual smoker

Social smoker
0

How much do you smoke?
< 1 cigarette a day

1-5 cigarettes a day

6-10 cigarettes a day

11-20 cigarettes a day

> 20 cigarettes a day
0

How much do you spend a month on smoking?
0

What cigarettes do you smoke? Check all that apply.
Reds

Golds

Silvers

Blacks

Smooths

72's

No. 27's edge

Southern cut

NXT

Menthols

Other (Please specify)
0

At what age did you start smoking?
0

Is there family history of smoking?
Yes

No
0

Please elaborate

0 / 5000
0

Does anyone close to you smoke?
Yes

No
0

Please elaborate

0 / 5000
0

Are you aware of the dangers and health problems that come from smoking?
Yes

No
0

Why do you smoke?
Peer pressure

Socialization

“Cool” factor

Parental influence

Advertising and media

Self-medication

Stress relief

Other (Please specify)