Smoking Survey


Smoking Survey (PDF format)


Well Woman




Smoking Survey






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Anonymous Smoking Survey

Quitting smoking can be very hard, but more than 3 million Americans quit each year. You can do it, too. Smoking is a leading cause of death and more than 1,000 people are killed every day by cigarettes. In fact, a woman who smokes cigarettes shortens her life by several years. Smoking increases a woman’s risk of cancer, heart disease, and reproductive problems.

With each puff of a cigarette, a smoker’s body is ex- posed to more than 7,000 chemicals. Hundreds are toxic and may cause cancer. For instance, cigarettes contain: 

n Nicotine— a highly addictive drug
n Carbon monoxide— the poisonous gas in car exhaust fumes
n Tar— a gummy substance used to pave roads

Smoking is the most preventable cause of illness and death. It doubles the risk of heart disease and cervical cancer in women and increases the risk of many other cancers as well. Smoking is also linked to higher rates of miscarriage, ectopic pregnancy, premature birth, fetal abnormalities and low birth weight. 

Women who smoke casually or have an occasional cigarette may suffer from increased health risks, too. Casual smoking has been linked to higher risks of heart disease deaths and increased risks of lung cancer. 

For more information about how to quit smoking, call the NYS Quitline at 1-866-NY-QUITS





1. Tobacco Use (check/circle one)

q Current

q Former (skip to question 5)

q Never (please return form to receptionist)


2. Do you consider yourself a casual smoker?

q Yes          q No

a. If yes, would you like help quitting?

q Yes         q No


3. How many cigarettes do you smoke:

          Per day

          Per week

          Per month


4. Do you smoke (check all that apply)

 q  a. At home 
 q  b. During work 
 q  c. In social situations
 q  d. In the car 
 q  e. On the telephone
 q  f. When drinking alcoholic beverages
 q  g. When stressed 
 q  h.                                                               




5.  How many years have you smoked?                 


6. In the past, has your ob-gyn doctor ever talked to you about smoking?

q Yes    q No






American Congress of Obstetricians and Gynecologists
District II
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Albany, NY 12210  





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American Congress of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998