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NAME: _________________________________
AGE: ____ GENDER: ____ 1. Do you smoke?
__YES __NO 2. If yes, at what age did you start smoking?
__less than 11 y/o
__between 11-15 y/o
__between 16-19 y/o
__between 20-25 y/o
__over 26 y/o 3. Who or what influence you to smoke?
__ Family/Relatives
__Friends
__Oneself
__It gives you confidence
__It makes you rebellious
__Social Media 4. How often do you smoke, in one day?
__Chain smoker __Once
__Twice __Thrice
__5 to 10 times __higher than 10x 5. Are you aware of some effects of smoking using tobacco cigarette?
__YES __NO 6. If yes, which among these affect you?
__Stain you’re Teeth
__Difficulty in breathing
__Cough
__Body odor
__Lung illness/ pulmonary illness
__Others, please specify: ___________ 7. How much you spend money in buying tobacco cigarette per day?
______________________________________
8. Do you want/have plans to quit smoking?
__YES __NO 9. If yes, why?
__Health issues
__It cost too much money
__Influenced by anti-smoking campaigns
__Influenced by family and friends 10. Are you familiar with E-cigarette?
__YES __NO 11. If yes, what do you know about e-cigarette?
__ Smokeless
__cheaper
__less harmful
__it helps to end nicotine addiction
__no odor
__no stain in teeth
__others, please specify: _________________ 12. Have you ever try to use e-cigg?
___YES __NO 13. If yes, do you think it has the similar sensation to tobacco cigarette?
__YES __NO 14. To whom do you get information about e-cigg?
__social media
__friends
__family/relatives
__reference person 15. Do you think e-cigg could be a good substitute for traditional cigarette?
__YES __NO 16. How likely are you to recommend e-cig to a friend or colleage?

1 2 3 4 5 6 7 8 9 10 17. What brand do

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