Tobacco-free Retailers Survey

The purpose of the Tobacco-free Retailer Survey is to gather information for a centralised database of all tobacco-free retailers as this provides an overview of the number and type of tobacco-free retailers throughout the country and their reasons for making this decision. The national data base will also provide robust evidence for future research.

The survey can also help you gather information to support possible media opportunities.

We would appreciate it if you could complete the Tobacco-free Retailer Survey with the retailer. This can either be downloaded or completed below.

When you have completed the survey, please scan and email to smokefree@akcansoc.org.nz or enter detail directly into survey form below.

...OR complete the form below

Proprietor's name *
Proprietor's name
Physical address
Physical address
Mailing address
Mailing address
If different than above
Name of person completing survey *
Name of person completing survey
Date form completed *
Date form completed
Do you agree to have your shop listed on the tobacco-free retailer website? (business name and address) *
Date, if possible
Were any of the following reasons why you decided to stop selling?
Survey *
Survey
To what extent do you agree with the following statement "I would recommend other retailers to consider stopping selling tobacco."?
Do you agree to be contacted at a later date to discuss your experience of not selling tobacco? *
Would you be interested in joining an interest group for retailers who have stopped selling tobacco? *
(If one was formed)
Do you agree to have your shop listed on the smokefree shops website? *
(Business name and address)
Would you be willing for a photo of your shop to be taken for publicity purposes? *
Would you be open to media coverage? *
(If any)