This cigarette smoking survey is a neutrally worded questionnaire for health researchers, cessation programs, and public health teams who need to understand smoking behavior on paper. It gathers smoking habits, attitudes, quit attempts, vaping, and views on smoke-free places across 26 questions on three printable pages.
What this survey measures
The questionnaire opens with a short profile, including age, gender, education and general health, and asks whether the respondent smokes now, used to smoke, or has never smoked. Smokers then record what they smoke, how many cigarettes they have on a typical day, when they started, how soon after waking they light up, and where and when they usually smoke. A rating grid covers personal attitudes such as enjoyment, cost, routine, and health. The health and quitting section asks about advice from a doctor or nurse, quit attempts and the methods used, readiness to quit, how important quitting is to them, confidence, and what support would help most. A short vaping section and a grid on smoke-free places, including homes, cars carrying children, and playgrounds, complete the form, followed by a comment box.
How to use it on paper
Hand out the printed form in a clinic, cessation program session, community health event, or research study intake. Ask respondents to use a blue or black pen and fill the checkboxes completely. 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.