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健康促進學校輔導與網路維護計畫-菸害防制議題評量工具菸害防制問卷(前測)-施測班
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一.「吸菸行為」：1.請問你是否嘗試過吸菸，即使只吸一、兩口？
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2.過去30天（一個月）內，你一共吸菸多少天呢？
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3.你是否曾經在學校裡抽菸
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二、「自我效能」1.當同學或朋友邀你吸菸時，你有多少把握會說「不」
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2.你有多少把握能在分析同儕與媒體對吸菸的影響後而決定不吸菸？
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「危險知覺」 1. 你認為吸菸會損害你的健康嗎？
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2. 你認為吸二手菸會危害你的健康嗎？
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五、「態度」 1. 你是否同意自己吸菸？
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2.你是否同意若電視或電影上的演員吸菸，會讓青少年想吸菸？
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3.你認為吸菸會讓人看起來更有吸引力嗎？
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六、「二手菸暴露」 1. 過去七天內，你在學校時，有人在你面前吸菸的天數有幾天？
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2. 過去七天內，你在學校時，最常在你面前吸菸的人是誰？（可複選）
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3.在過去七天內，你在家時，有人在你的面前吸菸的天數有幾天？
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七、「戒菸意圖/經驗」 1. 在過去一年裡，你是否曾經嘗試過戒菸？
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2. 是否曾經有人幫助或勸告你戒菸？（可複選）
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八、「菸害預防教育經驗」 1. 在過去一年中，你是否曾經上過有關吸菸危害健康的課程？
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2.在過去一年中，你是否曾參與過學校的反菸活動？
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九、「菸害認知」 1. 在台灣，過半數成年人吸菸？
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2. 菸品有六千種多化學物，六十多種致癌物，會導致各種癌症（如肺癌、口腔癌等、喉癌）？
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3. 菸品中的尼古丁是導致人們菸品成癮的主要原因？
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4. 二手菸沒有安全劑量值，暴露二手菸易罹患肺癌、心臟病、氣喘惡化等？
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5. 菸品使用為許多國家第一死因，菸品導致死亡約佔總死亡數五分之一？
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6. 我國菸害防制法規定室內工作與公共場所全面禁止吸菸？
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7. 我國菸害防制法規定高中職以下校園內全面禁止吸菸，違規吸菸最高罰一萬元？
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8. 我國菸害防制法規定18歲以下青少年吸菸，需要接受戒菸教育？
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9. 您是否知道我國有提供戒菸專線(0800636363)與門診戒菸服務來幫助吸菸者戒菸？
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請問你的性別是?
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請問你是 _____年級_____班_____號
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