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.

14

Health professionals serve as role models for their patients and the public.

15

Health professionals should set a good example by not smoking shisha

16

Patient’s chances of quitting shisha smoking are increased if a health professional advises him or her to quit.

19

Health professionals who smoke are less likely to advise people to stop smoking.

20

Health professionals should get specific training on shisha cessation techniques.

21

Health professionals should speak to community groups about shisha smoking.

22

Shisha smoking in enclosed public places should be prohibited.

23

There should be Health warnings in shisha cafes.

24

Tobacco sales to children and adolescents should be banned.

25

Sport sponsorships by tobacco industry should be banned.