| Section 1: Demographics | |||
1 | What is your gender? 1. Female 2. Male | |||
2 | What is your age? Age _______ | |||
3 | Which year of student you are: | |||
| Section 2: Shisha use | |||
4 | Which of the following best describes your smoking behaviour? ( Please circle your answer) 1. I have never smoked shisha Go to question 13 2. I have quit shisha Go to question 10 3. I currently smoke occasionally (Some days) Go to question 5 4 i smoke both cigarettes and Shisha Go to question 5 5.i use only Shisha Go to question 5 6. I currently smoke every day Go to question 5 | |||
| If you CURRENTLY smoke | |||
5 | How old were you when you first started to smoke on a regular basis? Age _____ | |||
6 | On the days that you smoke, (how much time use Shisha?) average time for Shisha ( ) | |||
7 | Have you ever stopped smoking for at least one week? 1. Yes 2. No | |||
8 | Which of the following best describes how you feel about your shisha smoking? 1 Not ready to quit within the next 6 months 2 Thinking about quitting within 6 months 3. Ready to quit NOW | |||
| If you smoked shisha in the PAST (those who have quit) | |||
10 | When you smoked in the past, how often did you smoke shisha? 1. Daily (Every day) 2. Occasionally (Some days) | |||
11 | How old were you when you first started to smoke shisha on a regular basis? Age _____ | |||
12 | How old were you when you stopped smoking shisha completely? Age _____ | |||
| Section 3: Knowledge and attitudes | |||
| Check appropriate box | Agree | unsure | Disagree |
13 | Shisha smoking is harmful to your health. |
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14 | Health professionals serve as role models for their patients and the public. |
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15 | Health professionals should set a good example by not smoking shisha |
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16 | Patient’s chances of quitting shisha smoking are increased if a health professional advises him or her to quit. |
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19 | Health professionals who smoke are less likely to advise people to stop smoking. |
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20 | Health professionals should get specific training on shisha cessation techniques. |
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21 | Health professionals should speak to community groups about shisha smoking. |
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22 | Shisha smoking in enclosed public places should be prohibited. |
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23 | There should be Health warnings in shisha cafes. |
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24 | Tobacco sales to children and adolescents should be banned. |
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25 | Sport sponsorships by tobacco industry should be banned. |
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