Questionnaire notes

Thank you for entering the Smoke Free Working website. To provide ongoing motivational support to help you quit smoking, we need some essential information from you.

Please complete this questionnaire (it should not take more than 10 minutes) and return it to us by clicking on SUBMIT below.

Make sure you have read the Terms of Use

Support services

Sign up questionnaire

Your email address: Postcode:

Tell us a little bit about yourself

How old are you?

Gender Male Female

Which of the following best describes your ethnic origin?

Tell us about your smoking

How long have you smoked for?

What do you think are the main reasons that you smoke? (please tick one or more of the following)

Habit Addiction Pleasure Comfort To relax Social

Other (please describe)

How many do you smoke on an average day?

How soon after waking up do you have your first cigarette? Please tick one of the following:

Within the first 30 minutes Between 30 minutes and 1 hour Over an hour

Do you do any of the following:

Smoke regularly throughout the day Find it difficult to go for long periods without smoking Smoke, even when feeling ill Get up at night to smoke

Q9.a

Have you managed to give up smoking before? Yes No

Q9.b

If yes, for how long?

Q9.c

If yes, what was the main reason that you started smoking again? Partner smokes Stress No reason Holiday Alcohol Other reason:

Tell us about what you think about giving up smoking

Q10

What is the main reason that you want to stop now? Please tick one of the following:

Health and fitness Finances Affects on appearance

Q11

What would you really look forward to as a non smoker?

Q12

What worries you about quitting?

Setting a Quit Date

A good start is to set a date to quit in the near future. Give yourself a Quit Day within the next four weeks:

My quitting date:

What happens to this information?

The information you have provided is strictly confidential and will be used by our staff to help us provide you with regular tailor made motivational support that will help you quit smoking. We are required to provide information back to your employer or organisation on the numbers, age and gender of users of this service and numbers committed to quit smoking. This information does not allow for identification of individuals. In addition, we may provide this statistical information to you local NHS stop smoking service so they can see how many people are going smoke free in their location- again this information does not allow for individual identification. The information you have provided is not passed on to any other organisation. If you choose to make contact with your local NHS stop smoking service via the link on the website you are responsible for any personal information you provide. The NHS stop smoking service is responsible for informing you about how they intend to use any personal data you provide them. Should you wish to withdraw from the programme at any time, you can do so by simply clicking on this link: I wish to withdraw from the programme.