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Gender
Male
Female
Age
15-18
19-24
25-34
35-54
55+
Amount smoked daily
Less than 10 a day
More than 10 a day, less than 30
Over 30 a day
Have you ever tried to stop smoking?
Never tried
Tried before
How long has your best attempt to stop lasted?
Not sure/Can't remember/Don't know
Less than 3 months
More than 3 months
Do you believe smoking helps to relax you?
Agree strongly
Agree
Neither agree nor disagree
Disagree
Disagree Strongly
Do you believe that smoking helps you concentrate?
Agree strongly
Agree
Neither agree nor disagree
Disagree
Disagree Strongly
Do you believe that smoking relieves stress or cope with anxiety?
Agree strongly
Agree
Neither agree nor disagree
Disagree
Disagree Strongly
Smoking keeps me thin / Quitting makes me put on weight
Agree strongly
Agree
Neither agree nor disagree
Disagree
Disagree Strongly
Do you believe that it takes willpower to quit smoking
Agree Strongly
Agree
Neither agree nor disagree
Disagree
Disagree Strongly
Do you believe that nicotine withdrawal is difficult?
Agree Strongly
Agree
Neither agree nor disagree
Disagree
Disagree Strongly
When you quit smoking, you are nicotine-free after:
3 days
3 weeks
3 months
 
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