Date: ______City: ______
Section 1: Demographics1 / What is your gender?1. Female2. Male
2 / What is your age? Age ______
3 / Are you a: 1. Doctor 2. Nurse 3. Other
(specify)______
Section 2: Cigarette use
4 / Which of the following best describes your smoking behaviour? ( Please circle your answer)
1. I have never smoked cigarettesGo to question 12
2. I have quit smoking Go to question 9
3. I currently smoke occasionally (Some days)Go to question 5
4. I currently smoke every dayGo 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 many cigarettes do you smoke per day?
(Give average number) # ______
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 smoking?
1 Not ready to quit within the next 6 months Go to 12
2 Thinking about quitting within 6 monthsGo to 12
3. Ready to quit NOWGo to 12
If you smoked in the PAST
9 / When you smoked in the past, how often did you smoke?
1. Daily(Every day) 2. Occasionally (Some days)
10 / How old were you when you first started to smoke on a regular basis? Age _____
11 / How old were you when you stopped smoking completely? Age _____
Section 3: Knowledge and attitudes
Check appropriate box / 1. Stronglyagree / 2. Agree / 3. Unsure / 4. Disagree / 5. Strongly Disagree
12 / Smoking is harmful to your health.
13 / Health professionals serve as role models for their patients and the public.
14 / Health professionals should set a good example by not smoking.
15 / Patient's chances of quitting smoking are increased if a health professional advises him or her to quit.
Check appropriate box / 1. Stronglyagree / 2. Agree / 3. Unsure / 4. Disagree / 5. Strongly Disagree
16 / Health professionals should routinely ask about their patients smoking habits.
17 / Heath professionals should routinely advise their smoking patients to quit smoking.
18 / Health professionals who smoke are less likely to advise people to stop smoking.
19 / Health professionals should get specific training on cessation techniques.
20 / Health professionals should speak to community groups about smoking.
21 / Smoking in enclosed public places should be prohibited.
22 / Health warnings on cigarette packages should be in big print.
23 / Tobacco sales to children and adolescents should be banned .
24 / Sport sponsorships by tobacco industry should be banned.
25 / There should be a complete ban on the advertising of tobacco products.
26 / Hospitals and health care centres should be "smoke-free".
27 / The price of tobacco products should be increased sharply.
28 / Neonatal death is associated with passive smoking.
29 / Maternal smoking during pregnancy increases the risk of Sudden Infant Death Syndrome.
30 / Passive smoking increases the risk of lung disease in non-smoking adults.
31 / Passive smoking increases the risk of heart diseasein non-smoking adults.
32 / Paternal smoking increases the risk of lower respiratory tract illnesses such as pneumonia in exposed children.
33 / Health professionals should routinely advise patients who smoke to avoid smoking around children.
Section 4: Worksite practise
34 / Where is your workplace/practice located?
1. Urban 2. Rural 3. Suburban
35 / What sort of smoke-free policy is in place at your workplace?
1. No smoking policy in place GO TO 37
2. Smoking rooms availableGO TO 36
3. No smoking allowed at all on the premisesGO TO 36
36 / Is the smoke-free policy enforced?
1. Yes: always 2. Yes: sometimes 3.No 4. Don't Know
37 / Are the following interventions AVAILABLE to YOU to help your patients stop smoking?
aTraditional remedies? 1. Yes 2. No
bSelf- help materials1. Yes 2. No
cCounselling1. Yes 2. No
dMedication (Nicotine gum, patch, buproprion)1. Yes 2. No
eOther (specify) ______
38 / Which of the following interventions do you USE to help your patients stop smoking?
aTraditional remedies? 1. Yes 2. No
bSelf- help materials1. Yes 2. No
cCounselling1. Yes 2. No
dMedication (Nicotine gum, patch, buproprion)1. Yes 2. No
eOther (specify) ______
39 / How well prepared do you feel you are when counselling patients on how to stop cigarette smoking?
1. Very well prepared. 2. Somewhat prepared 3. Not at all prepared.
40 / Have you ever received any formal training in smoking cessation approaches to use with your patients ?
aFormal training during medical or nursing school1. Yes 2. No
bFormal training during specialization programs1. Yes 2. No
cSpecial conferences, symposia or workshops1. Yes 2. No
dOther explain ______
41 / What could Queen's University do to support your efforts to reduce smoking among your patients in your community?
Global Health Professional Survey
developed by the:
World Health Organization
modified by the
Queen's University Family Medicine
Development Program in the Balkans Region
You are being invited to participate in a research study that will investigate the smoking behaviours and knowledge and attitudes about smoking among family medicine physicians and nurses in Bosnia and Herzegovina. The study being conducted by members of the Queen's University Family Medicine Development Program in the Balkans Region will involve Family Medicine physicians and nurses in Bosnia and Herzegovina.
The questionnaire should only take about 15 minutes to complete. It is anonymous, meaning that we do not ask for your name on the questionnaires. Please also be assured that all responses are strictly confidential and will only be used by the research team for this study. To ensure that it remains confidential, please put your completed questionnaire in the closed box that we have provided for that purpose.
Your participation in completing this questionnaire is voluntary. If you decide not to take part, it will not affect your participation in the Queen’s University Family Medicine Development Program in any way.
Finally, when the study is completed, we will be sending the results to each ambulanta so that everyone has access to them. Also, depending on the results, we may organize a training day on smoking to discuss the implications of the study results on Family Medicine.
If you have any questions or would like more details on this study, you may contact Dr. Geoff Hodgetts, the Project Director, at (33) 215751, email: , Dr. Walter Rosser, Department Head, at +1 (613) 544-3400 ext. 3914, email: , or Dr. Albert Clark, Chair of the Research Ethics Board, at +1 (613) 533-6081.
Thank you for your cooperation