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Questionnaire For Tobacco Smokers (S.T.E.P.)

This questionnaire is for tobacco smokers interested in joining the purplebox S.T.E.P. 

Please print off the questionnaire and email your completed form back to steve@purplebox.ie

Please answer as honestly as you can.

  

Name: 

Address:

Email:

Telephone:

Just to repeat to make sure it’s clear:
  1. What are your vaping goals: (for example):

    • Stop smoking completely
    • Reduce the number of cigarettes you smoke each day
    • Only smoke tobacco cigarettes at weekends

 ____________________________________________________________

 ____________________________________________________________

  1. Why do you feel you smoke on a daily basis?

  ___________________________________________________________

  ___________________________________________________________

  1. How many cigarettes do you smoke during the day?

  ___________________________________________________________

  1. How many cigarettes do you smoke in the evening?

  ___________________________________________________________

  1. How many cigarettes do you smoke during the weekend?

  ___________________________________________________________

  1. Do you have a particular favourite brand?

  ___________________________________________________________

  1. Have you tried to stop before? What methods have you tried?

    • Gum
    • Patches
    • Cold turkey
    • E-cigarettes
    • Hypnosis
    • Other

 ___________________________________________________________

  1. If you stopped:

    • How long for?
    • What made you start again?

 ___________________________________________________________

  1. When do you feel most like a cigarette?

    • At work
    • After a meal
    • Socialising with friends
    • When under stress
    • I associate having a cigarette with a pint/glass of wine etc.

  ___________________________________________________________

   10. What do you like or dislike about smoking?

  ___________________________________________________________

  ___________________________________________________________

  11. Do you have any fears regarding smoking?

  ___________________________________________________________

  12. Are you suffering from any smoking related illnesses?

  ___________________________________________________________

  13. Do you suffer from shortness of breath when, for example, running for the train / climbing stairs / playing with the children / doing exercise?

  ___________________________________________________________

  14. Does your partner or close friends smoke?

  ___________________________________________________________

  15. Have you ever tried an electronic cigarette or vaping device before?

  ___________________________________________________________

  16.  Would you like to try other flavours of e-juice besides tobacco flavours?

  ___________________________________________________________  

 Well Done! We'll be in touch once we receive your completed form.