This free survey is powered by
  1. Surveys
  2. 2014
  3. February
  4. S
  5. Smoking
0%
Exit Survey
 
 
1. Are you a current smoker
 
yes
 
no
 
 
 
2. Do you smoke daily
 
yes
 
no
 
 
 
3.On average how many cigarettes do you smoke
 
> 25 cigs/day
 
10-25 cigs/day
 
<10 cigs/day
 
 
 
No. of years smoked?
 
<10 years
 
10-20 years
 
20-30 years
 
30-40 years
 
>40 years
 
 
 
5. How many attempts have you made to quit smoking? ( quitting defined as not smoking for at least 7 days with an intention to quit)
 
0
 
1-2
 
3-4
 
>4
 
 
 
6. Does your doctor ask you about your smoking status on each visit?
 
Yes
 
No
 
 
 
7.Does your doctor advice you about quitting smoking on each visit?
 
Yes
 
No
 
 
 
8. What methods have you used to help you quit? (Select all that apply)
 
Physician counselling including explaining health risks of smoking, various options available for quitting, providing support),
 
Nurse counselling
 
Counselling session with psychologist available at clinic
 
Smoking quitline
 
Self- help/motivation
 
Warning on tv/websites
 
Chantix
 
Bupropion
 
Nicotine patches/gums
 
Medications plus counselling at the same time
 
Financial reasons
 
Family support
 
None

 
 
 
9. Out of the strategies you used which one led to a successful quit attempt? (Select all that apply)
 
Physician counselling (including explaining health risks of smoking, various options available for quitting, providing support)
 
Nurse counseling
 
Counselling session with psychologist available at clinic
 
Smoking Quitline
 
Self- help/motivation
 
Warning on tv/websites
 
Chantix
 
Bupropion
 
Nicotine patches/gums
 
Medications plus counselling at the same time
 
Financial reasons
 
Family support
 
None.

 
 
 
10. What are the barriers to quitting? (Select all that apply)
 
Stress/anxiety
 
Lack of follow up from PCP
 
Weight gain
 
Lack of support
 
Depression
 
Dependence
 
Loss of control
 
Inability to afford smoking cessation medications
 
Substance abuse
 
Old age