All the information you provide shall be kept confidential and at no stage your identity be disclosed.

Your Name

Address, City and other details you would like to provide. (Please provide your complete address if you want us to dispatch your gift)

Telephone No

Your E-Mail address

Age:

Years

Sex:

Male Female

Marital Status:

Married Unmarried Single for other reasons

Educational Qualification:

Illiterate Less than 12 years of schooling Under Graduate Graduate Post Graduate Doctorate

Approximate Family Income

Less than 10,000 10,000 to 30,000 Above 30,000

Please þ tick the appropriate

In your opinion are there hero/heroines who look good while smoking or consuming any tobacco product in movies?

Yes No

If yes name the hero/heroine and/or the movie.

Do you recollect any movie in which any tobacco brand name was visible in any scene?

Yes No

Name the movie.

Have you ever got impressed by the way film stars smoke, (For example the way Amitabh Bachchan lights a cigarette or Raj Kumar used to smoke pipe or Shahrukh Khan/Rajni Kant’s style, Shabana Azmi or Rani Mukherjee etc.)

Yes No

Have you ever felt a desire to smoke in their style?

Yes No

Even if you didn’t smoke, did you ever felt a desire to just hold a cigarette in your hand in a style?

Yes No

Have you ever in your life held any other article of the kind pencil/pen, etc. like a cigarette so as to emulate/copy a film star and pretended to smoke. Even jokingly.

Yes No

When people follow the hero and heroines in all other aspects of fashion, do you think that that people also follow the film stars in smoking tobacco?

Yes No

Do you think showing cigarette smoking in films can influence some youngsters to smoke?

Yes No

If the movies do not show tobacco use/smoking situation will that affect your decision to watch movies?

Yes No

If the movies do not show tobacco use/smoking situation will that in any way affect the quality of movies?

Yes No

If stars like Shahrukh Khan, Jackie Shrof, Akshya Kumar, Ajay Devgan, etc. quit tobacco publicly do you think that it will make some people quit tobacco?

Yes No

Would you like to participate in anti-tobacco activities?

Yes No May be

Please V mark the appropriate

Do you think smoking is injurious to health? On a scale of 0 to 10 in increasing order of danger how do you rate tobacco?

1 2 3 4 5 6 7 8 9 10

On a scale of 0 to 10 in increasing order of awareness, how do you rate your awareness level of anti-tobacco laws?

1 2 3 4 5 6 7 8 9 10

Out of the 10 closest people/friends in your circle, how many consume any kind of tobacco products? Even occasionally.

None 1 2 3 4 5 6 7 8 9 10

Please þ tick the appropriate

Do your parents or any of the family members living in the same house consume any tobacco product?

Yes No

Do you smoke? (Any tobacco product like cigarettes/bidi/cigar/pipe/etc.)

Yes No

If you don’t smoke (If you have answered ‘No’ to the previous question), have you ever smoked in your life? Even an occasional puff.

Yes No

Do you consume any other tobacco product?

Yes No

Are you an Ex-Smoker or an Ex-Tobacco user? Did you quit using tobacco products?

Yes No

If you smoke or consume any tobacco product or have ever consumed any tobacco product, please proceed, otherwise click the submit button at the end.

If yes, mark the type of product? (Mark all relevant products, hold the Shift key & click)

Cigarette Bidi Cigar Pipe Hukka Gutka Jurda Khaini Others

How many Cigarette/ Bidi sticks or Gutka/Jurda/Khaini pouches etc. you consume every day?

- Less than 5 5 to 10 10 to 20 Above 20

Approximate age when you consumed it for the first time?

Years

Did you ever light a cigarette, etc. in the style of any film star?

- Yes No

Have you ever held a cigarette in your hand in the style of a film star?

- Yes No

Did you ever consider smoking to be a style statement or fashionable or a requirement for moving around in the company of successful people during social gatherings?

- Yes No

Do you think that watching film stars smoke in movies with a style was one of the factors to make you believe that smoking is a style statement?

- Yes No

Have you ever thought of quitting tobacco?

- Yes No

Did you ever try quitting tobacco?

- Yes No

Do you need professional help in quitting tobacco?

- Yes No