Smoking Support Preferences Survey Template
Interest in quitting and access to support are different questions. Learn what adults want to know, which formats suit them and what could keep them from using a service.
Interest in quitting and access to support are different questions. Learn what adults want to know, which formats suit them and what could keep them from using a service.
This smoking support preferences survey gives community teams seven optional questions for planning an offer people can actually access. It does not score dependence or prescribe a quit plan. Build the questionnaire in SurveyLegend, explain how responses will be used and keep participation separate from eligibility for other services.
When to Use This Template
Use this template before choosing the format of a voluntary smoking-support program or reviewing an existing offer. Invite adults who smoke, including people who do not want support now. A response of “not interested” is useful planning information, not a failure that needs correcting.
7 Smoking Support Preferences Survey Questions
This questionnaire asks adults who smoke about support preferences. You do not need to want to quit to answer. Every question is optional, and your answers do not request treatment or enroll you in a service. Do not include names, medical details or contact information.
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Explore this 7-question example at your own pace. Every question is optional.
Smoking Support Preferences Survey
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How to Adapt the Questionnaire
Name the organization, intended audience, planning period and actual person responsible for reviewing responses. Replace hypothetical formats with services the organization can realistically provide or refer to. Explain privacy accurately; do not promise anonymity if the collection setup can identify respondents. SurveyLegend’s discussion of sensitive survey questions is relevant when deciding what information is necessary. Keep support preferences separate from medical records and employment decisions.
When to Ask
Ask before finalizing service arrangements, with enough time to change the offer. Provide a private way to answer and a paper version for people without reliable internet. Do not ask someone to complete the form publicly while receiving another essential service, or imply that their answer affects access to that service.
How to Use the Responses
Summarize interest separately from format preferences. “No support now” does not mean someone needs no information later. Compare the most requested formats with cost, timing and privacy barriers before choosing an offer. For Question 5, report the number answering the question and allow totals above 100%. Read the final open-ended question for specific improvements, grouping comments manually without publishing identifying details. These responses describe the participating adults; they do not measure local smoking prevalence or predict quit rates.
What the Research Adds
Bryant and colleagues (2011) conducted six focus groups with 32 clients of community welfare organizations in New South Wales. Their abstract reports “a strong preference for personalised quit support.” This finding helps explain why the template separates preferred support, contact format and barriers. The study involved a specific disadvantaged service population and did not test this questionnaire or prove an intervention works. Current local availability must be checked separately. Read the community support study .
Frequently asked questions
Does this survey assess nicotine dependence?
No. It asks about interest, information and access preferences. It contains no diagnostic items, dependence score or treatment recommendation.
Should only people ready to quit answer?
No. Including adults who want information later or do not want support now helps avoid designing the entire offer around the most motivated participants.
Can the answers enroll someone in support?
No. Use a separate, clearly explained referral or enrollment process if someone later requests contact. This questionnaire collects no contact details.
Printable Smoking Support Preferences Survey
Print the respondent introduction and exactly seven questions, including all opt-out choices. Use squares for Question 5, circles for the other selection questions and ample lines for Question 7. Provide a private return method set by the organization; no name or smoking-history field. Paper responses need separate review or manual entry; they are not automatically added to online results.
Download the questionnaire AI Prompt: Smoking Support Preferences Survey
Copy this smoking support preferences survey prompt into an AI assistant to prepare the questionnaire. Review the result, then build and customize it in SurveyLegend. It does not automatically create or transfer a survey.
Smoking Support Preferences Survey Prompt
Copy the prompt into an AI assistant to draft the questions, then build your survey in SurveyLegend.
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