This cigarette smoking survey is a short, neutrally worded questionnaire for health researchers, cessation programs, and public health teams who need to understand smoking behavior on paper. It gathers product preferences, daily consumption, and attitudes toward smoking and quitting across 6 questions on a single printable page.
What this survey measures
The questionnaire opens by asking what respondents prefer to smoke, from cigarettes and cigars to water pipes and electronic cigarettes, and whether they have tried an e-cigarette. It then records how many cigarettes are smoked per day. Two rating grids follow: one on personal smoking experience, covering enjoyment, cost, health, and plans to quit, and one on opinions about smoking in restaurants, public transport stops, public places, and the workplace. A final question captures whether the respondent wants to quit.
How to use it on paper
Hand out the printed form in a clinic, cessation clinic session, community health event, or research study intake. Ask respondents to use a blue or black pen and mark one box per line. Collect the completed pages, then scan or photograph them and upload to PaperSurvey, which reads the marked checkboxes automatically and compiles the results for you.
Customize this template
Most teams add their organization logo, adjust the consumption ranges or agreement scale wording, and add or remove statements in the rating grids to match their protocol. You can also translate the form or drop questions you do not need, and the layout reflows automatically when you change the content.
Preview the PDF above, or use this template to start collecting responses today.