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 a 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)