Smoke Screen 2

1. How old are you?

(years of age)

2. Are you male or female?

Male

Female

3. Were you born in Canada?

Yes

No, I was born in (country)

4. How many years you have lived in Canada?

(years)

5. Which ethnic/cultural group do you identify with?

6. Please tell us a little bit about the people you live with?

	Relationship to you (e.g. mother, father, sister, brother, etc.)	Does the person smoke tobacco?	Does the person smoke inside the house?
1.		Yes No	Yes No
2.		Yes No	Yes No
3.		Yes No	Yes No
4.		Yes No	Yes No
5.		Yes No	Yes No
6.		Yes No	Yes No
7.		Yes No	Yes No

7. What is the highest level of education you completed?

I am still in High School

High School

Some College/university

Trade Certificate/Diploma

University degree

Other, please specify

8. In the past 6 months how often have you:

	Please select one response only	Never	Sometimes	Often	Always
a.	Been physically active (i.e. walking, sports, gym, etc.)?
b.	Felt happy with your weight?
c.	Had alcoholic beverages?
d.	Felt good about yourself?
e.	Felt that you do things as well as most other people you know?
f.	Socialized with friends from your ethnic/cultural group?
g.	Felt accepted by other people your age?
h.	Felt that it is important to do things that meet with you friend’s approval?
i.	Felt that it is important to do things that meet with you family’s approval?
j.	Felt sad or isolated?
k.	Felt stressed?
l.	Missed family/friends from your home country?

9. During the past 30 days, have you smoked part or all of a cigarette?

Yes

No

10. Please read all of the statements and check the one that best describes you.

I would describe myself as a(n):

Non-smoker

(check this box if you have NEVER smoked)

Experimental smoker

(check this box if you have tried smoking, but don't plan on smoking regularly)

Social smoker

(check this box if you smoke with others only)

Smoker

(check this box if you regularly smoke cigarettes)

Former smoker

(check this box if you used to smoke, but have quit for at least 12 months)

Recent quitter

(check this box if you have quit within the past 12 months)

11. If you have ever smoked, at what age did you have your first cigarette?

(years of age)

12. Why did you smoke your first cigarette?

If you have never smoked or have quit for longer than 12 months, please skip to question 15.

13. Why do you smoke now? (Please check as many categories as you like).

To cope with stress

To fit in with friends/other smokers

To look cool

To look more grown up

To be more popular

To control my weight

To be rebellious

Out of boredom

It makes me feel good

In my culture I am expected to smoke

Because I am addicted to cigarettes

Other. Please describe:

14. How do you feel about your smoking?

I enjoy it

I would like to quit

Other. Please describe:

15. What are some of the factors that might encourage you to stop smoking?

(e.g. health concerns, price of cigarettes, parent's disapproval). Please list the reason that is most important to you first. Try to list additional reasons in order of priority.

1.

2.

3.

4.

5.

16. This is a question for non-smokers only. What are your reasons for NOT smoking?

Check as many categories as you like.

It is bad for my health

My family would not approve

In my culture I am expected not to smoke

My friends would not approve

My religious beliefs prevent me from smoking

Other. Please describe:

17. Your close friends are friends you like to spend the most time with.

How many of your close friends smoke cigarettes? (Enter 0 if none of your close friends smoke).

of my close friends smoke.

18. If one of your closest friends were to offer you a cigarette, would you smoke it?

Yes

No

19. In the last month have you heard, seen or read any messages that either promote

or discourage smoking? If you can recall any, please note the number of these messages you have seen/heard/read in the past month. Select Yes or No and enter the number of times, if possible.

	Promote Smoking	Discourage Smoking
Television ads or shows	Yes, times No	Yes, times No
Radio ads or programs	Yes, times No	Yes, times No
Billboards/Posters	Yes, times No	Yes, times No
Newspaper or magazine advertisements	Yes, times No	Yes, times No
Movies	Yes, times No	Yes, times No
Online (Internet)	Yes, times No	Yes, times No

20. Which of the messages that discouraged smoking stood out most for you?

What was the message (give a brief description) and why did it stand out?

21. Which of the messages that promoted smoking stood out most for you

(eg. Movie characters that make smoking look attractive; internet ads)? What was the message (give a brief description) and why did it stand out?

22. Do you think that smoking tobacco could be harmful to your health?

Yes

No. Please, go to question 24

23. Please state the harmful effects of smoking tobacco that you have

heard/read about:

24. Do you think that being exposed to second-hand smoke could be

harmful to your health?

Yes

No. Please, go to question 26

25. Please state the harmful effects of being exposed to second-hand

smoke that you have heard/read about

26. Please tell us where you heard/read about the harmful effects of

smoking / being exposed to second hand smoke (you can check more than one response):

At school

At home

Through the media (TV, radio etc.).

Other. Please describe:

27. Please tell us what your 5 favourite television shows, programs or stations

are and how many hours per week you watch each of them?

	Name of television show, program or station	Hours watched per week
1.
2.
3.
4.
5.

28. Now tell us About what your 5 favourite newspapers/magazines are:

	Name of newspaper or magazine
1.
2.
3.
4.
5.

29. Do you watch television and/or read newspapers in a language other than English?

Yes

No. Please, go to question 32

30. What kind of television programs / stations do you watch (and in which language)?

	Television programs / stations	Language
1.
2.
3.
4.
5.

31. What kind of newspapers/magazines you read (and in which language).

	Newspaper/Magazine	Language
1.
2.
3.
4.
5.

32. Since coming to Canada, have you changed your attitudes about smoking tobacco?

Yes

No. Please don't answer the last two questions.

33. How have your attitudes changed?

34. Why do you think your attitudes have changed?