Smoker Survey

E-Mail to Dr. Tom Ferguson

Questions to Dr. Ferguson will be addressed only if the answers are not already provided under Smoking FAQ's (Frequently Asked Questions), and your "Smoker Survey" results are made available for Dr. Ferguson's confidential review.

If you agree with the above, please complete and send the following form to Dr. Ferguson. A copy of your survey results will be sent, and Dr. Ferguson will provide feedback via e-mail at the address you have listed below.

Smoker Survey

This is a survey of smokers -- including those smokers who are not yet ready to quit -- to learn more about their perspective. Please take a few minutes to complete and submit this Smoker Survey. This will entitle you to receive information on our comprehensive Stop Smoking Audio Program. Thank you for your participation.

1. Please rate each of the following possible benefits of smoking on the 1- to 10-point scale. (Please enter a number in each box corresponding to the rating scale provided.)

No benefit	Very major benefit
___________________________________
1 2 3 4 5 6 7 8 9 10

Helps me deal with stressful situations.
Provides a pleasant and enjoyable break from work.
Helps me unwind and relax.
Helps me deal with painful or unpleasant situations.
Prevents unpleasant withdrawal symptoms.
Helps me deal with an overstimulating environment.
I enjoy the physical sensation of lighting and handling a cigarette.
Keeps me from feeling bored.
Increases my enjoyment of pleasant experiences.
Helps me feel comfortable in social situations.
Helps me concentrate.

2. Please rate each of the following possible drawbacks of smoking on the 1- to 10-point scale. (Please enter a number in each box corresponding to the rating scale provided.)

No drawback	Very major drawback
___________________________________
1 2 3 4 5 6 7 8 9 10

Smoking makes my clothes, hair, home and office smell bad.
I have more frequent colds, coughs and sore throats.
I worry that it's bad for my health.
Some people don't want to be my friend because I smoke.
I feel that other people disapprove of my smoking.
I worry that my smoking might be a health risk for others.
I get out of breath more easily because of my smoking.
I feel that I am setting a bad example.

3. How have the attitudes of nonsmokers changed with respect to tolerating smoking in the last 5 to 10 years? (Click on the number on the scale that best describes your opinion.)

Much more
 tolerant

Somewhat
more tolerant


No change

Somewhat
less tolerant

Much less 
tolerant

___________________________________
1 2 3 4 5

4. Which of the following changes in nonsmokers' behavior have you noticed in the last few years? (Please click on the appropriate answer for each box.)

TRUE	FALSE	Statement
		I'm now more likely to ask permission to smoke when visiting a nonsmoking friend.
		Friends and family members are now more likely to express concerns about my smoking.
		I am now more likely to refrain from smoking when nonsmokers are present.
		Nonsmokers in restaurants are now more likely to say that my smoking bothers them.
		I now feel more guilty about my smoking than I did a few years ago.

5. Have you ever attempted to quit smoking? (Please select only one of the four possible answers.)

	I have never wanted to quit.
	I have wanted to quit but have never tried.
	I have tried to quit, but have not succeeded.
	I have tried and succeeded, but started smoking again.

6. What was the longest time you have gone without cigarettes since you started smoking? (Please select only one of the three possible answers.)

	Two days or more.
	One week or more.
	One year or more.

7. Do you think you will quit smoking? (Please select the best answer.)

I will quit.

No.

I'm a minimal smoker.

Not sure.

8. Would you like to take a greater measure of control of your smoking behavior?

True

False

9. Which of the following topics should be included in a comprehensive, self-help stop smoking program? (Please enter a rating in the box for each statement.)

Unimportant	Extremely important
___________________________________
1 2 3 4 5 6 7 8 9 10

How to tell whether you're a high- or low-risk smoker.
How to keep smoking from harming your family and friends.
How to get along with nonsmokers.
The most effective ways of cutting down.
The economic consequences of smoking.
Do smokers have special needs for vitamins.
How to cut your smoking through stress reduction.
What you need to know to get ready to quit.
How to stay a nonsmoker after you quit.
Dealing with weight gain after you quit.
What withdrawal symptoms you might encounter after you quit.
The most effective ways of quitting.
What smoking does to a smoker's body.

10. To Complete this Survey and receive information on our comprehensive Stop Smoking Audio Program, please enter your name and address in the space below. You may also include a comment or question for Dr. Ferguson.

Name:
E-mail Address:
Company:
Mailing Address:
City:
State:
Zip:
Sex:
Age:
Questions:

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