--- generated_by: surveylegend-page-markdown title: Smoking Support Survey Template | SurveyLegend description: Ask adults what smoking support they want and what makes it hard to access. Adapt seven optional questions and practical guidance in SurveyLegend. canonical: https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/smoking-template/ --- # 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. [Try this template ](https://app.surveylegend.com/register/)[Preview template](https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/smoking-template/#try-template) Preview on a device Show the desktop survey layout Show the tablet survey layout Show the mobile survey layout ![](https://www.surveylegend.com/survey-template-media/demo-backgrounds/smoking-template-background.avif) **SurveyLegend** 1 / 7 Smoking Support Preferences Survey Which statement best describes your interest in smoking support right now? I would like support soon I would like information before deciding I may want support later +3 more answer choices Next → Smoking Support Preferences Survey [Preview](https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/smoking-template/#try-template) Share [Facebook ](https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fsmoking-template%2F)[LinkedIn ](https://www.linkedin.com/sharing/share-offsite/?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fsmoking-template%2F)[X ](https://x.com/intent/tweet?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fsmoking-template%2F\&text=Smoking%20Support%20Preferences%20Survey%20Template)[Reddit](https://www.reddit.com/submit?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fsmoking-template%2F\&title=Smoking%20Support%20Preferences%20Survey%20Template) 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. **Create your smoking support preferences survey in SurveyLegend** 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. ## 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. Try the survey ## A little feedback. A clearer picture. Explore this 7-question example at your own pace. Every question is optional. Preview on a device Show the survey at full desktop width Resize the survey to a tablet-width preview Resize the survey to a mobile preview with scrolling inside the frame Choose a look Use Classic: a white survey card over the background photo Use Light: dark text over a light tint covering the background photo Use Dark: light text over a dark tint covering the background photo SurveyLegend demo Question 1 of 7 ### Smoking Support Preferences Survey 01 Which statement best describes your interest in smoking support right now? Choose one answer, or skip this question. I would like support soon I would like information before deciding I may want support later I do not want support now Not sure Prefer not to say 02 How easy would it be for you to find out what smoking support is available locally? Choose one answer, or skip this question. Very difficult Somewhat difficult Neither easy nor difficult Somewhat easy Very easy I have not looked Prefer not to say 03 Which kind of support would you most like an organization to offer? Choose one answer, or skip this question. A private conversation with a trained support worker A group with other adults Information I can review on my own Help finding an existing service No support at present Another kind Not sure Prefer not to say 04 Which contact format would work best if you chose to use support? Choose one answer, or skip this question. In person Phone conversation Video conversation Written messages Printed information without a conversation No format would suit me now Another format Not sure Prefer not to say 05 What could make it difficult for you to use smoking support? Choose the options that apply, or skip this question. Cost Appointment times Travel Finding a private space Internet or phone access Concern about being judged Not knowing what will happen No difficulty comes to mind Another difficulty Prefer not to say 06 What would you most want explained before deciding whether to use support? Choose one answer, or skip this question. What happens in a session Any costs Who will see my information Whether I can stop attending What options are available I do not need more information Something else Prefer not to say 07 What would make a smoking-support offer more useful or welcoming to you? Share your answer, or skip this question. #### One last look Review your answers before submitting this demo. 0 answered #### Thank you for trying the survey! You’ve tried the template from the respondent’s side. Make it your own with SurveyLegend. [Create your own survey](https://www.surveylegend.com/register/) Checking submission availability… This is a demo. We count starts and submissions only. Your answers stay in your browser and are never sent or saved. **—**Starts **—**Submissions Activity is temporarily unavailable. ## 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 ](https://www.surveylegend.com/survey-questions/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 ](https://www.surveylegend.com/customer-insight/open-ended-survey-questions/)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 ](https://link.springer.com/article/10.1186/1471-2458-11-493). ## 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. ![First page of the printable Smoking Support Preferences Survey Template with questions and answer spaces](https://www.surveylegend.com/survey-template-media/pdf-previews/smoking-template-pdf-preview.avif) [![](https://www.surveylegend.com/user-guide-media/icons/download-pdf.svg) Download the questionnaire](https://www.surveylegend.com/downloads/survey-templates/smoking-support-preferences-survey-template.pdf) Export Smoking Support Preferences Survey as PDF ## 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 AI Prompt: Smoking Support Preferences Survey [Create this survey in SurveyLegend](https://www.surveylegend.com/register/) Copy the prompt into an AI assistant to draft the questions, then build your survey in SurveyLegend. [Sign in](https://app.surveylegend.com/) to SurveyLegend to build your smoking support preferences survey Healthcare and Hospital Survey Templates 1. [![Preview of the Healthcare CAHPS® Visit Survey 2.0 Survey Template](https://www.surveylegend.com/survey-template-media/previews/template-healthcare-cahps-visit-survey-template-survey-preview.avif) Healthcare CAHPS® Visit v2.0 Survey Template Healthcare When a patient chooses to enter your hospital, the quality of the treatment they are going to receive is the most important thing. To reach a high quality in the treatment, several aspects have to be taken into consideration. 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