A Study by Health Action by People – Survey Questionnaire for Tobacco Selling Shops Only

Assessing the Purchase Patterns of Cigarettes and other Tobacco

Products in Kerala
Observation Format for TOBACCO SELLING SHOPS ONLY

(To be completed by the FIELD INVESTIGATORS ONLY using observation method/simulated

purchase, as feasible. No questions are to be asked to the shop owner/keeper; the field investigator
has to complete the questionnaire)

Date of Visit:

Ward:
City:

1 Type of Tobacco Tea shop

vendor Pan shop
Mobile street vendor
Small grocery store/Convenience Store
Super market
Tobacco Specialist
Cafe/Restaurant
Bar/Hotel
2 Please select all visible Cigarettes
tobacco products being Beedis
sold by this vendor Smokeless Tobacco
Loose cigarette for smoking
Hookah Tobacco
Cigars
Cheeroots
E-cigarettes/E liquid

3 Please select all types Posters/signs

of ADVERTISING of Stickers
tobacco products and Banners
brands that you see. If Fliers/Leaflets/Pamphlets
you do not see any Window ads
advertising, select Brand marking on physical structures (e.g. umbrella, counter, paint)
"NONE" Toys or sweets resembling tobacco products
Mock-up packs (fake packs, often enlarged)
Vendor wearing clothing with tobacco brand
Video Screen
Illuminated Ads
None

1 | P a g e Assessing the Purchase Patterns of Cigarettes and other Tobacco Products in Kerala
A Study by Health Action by People – Survey Questionnaire for Tobacco Selling Shops Only

4 Please select all types Discounts/coupons (e.g. buy 1 get 1 free)

of PROMOTION of Free gifts with purchase of tobacco products
tobacco products and Free samples of tobacco products (e.g. free single cigarettes)
brands that you see Competitions associated with tobacco products or brands
None

5 Please select all types Power wall (many packs displayed on wall behind cash register)
of DISPLAYS of tobacco Organized shelf (anywhere in venue)
products that you see. Illuminated/light-up display
Hanging display (e.g. packets hanging from ceiling)
Packs laid out on tray, table, or other surface
None

6 Is the shop situated Yes No Don’t

near a school or If yes, please note distance know
college? ______km
7 Are pictorial warnings Yes No
stating “No Smoking
Area – Smoking Here is
an Offence” of at least
60 cm x 30 cm
displayed in the shop?
8 Are pictorial warnings Yes No
boards of at least 60
cm x 30 cm stating
“Sale of tobacco
products to a person
below the age of
eighteen years is a
punishable offence”
visibly displayed at the
shop?
9 Does the vendor sell Yes No
candy and/or chips?

10 Does the vendor sell Yes No

any other products If yes, list major items
(other than tobacco,
candy, chips)?

11 Estimate, to the best of Child (12 and Teenager (13- Young adult Adult (Over 25)
your ability, the under) 17) (18-25)
approximate age of the
person selling tobacco
products

12 Do you see single Yes No

sticks/loose cigarettes
or beedis for sale

2 | P a g e Assessing the Purchase Patterns of Cigarettes and other Tobacco Products in Kerala
A Study by Health Action by People – Survey Questionnaire for Tobacco Selling Shops Only

(cigarettes or beedis
being sold individually:
indicated by open
packs sitting out,
cigarettes or beedis in
cup or displayed, etc.)?

13 Do you see Yes No

cigarette/beedi
packets with a picture
of a man affected with
throat cancer?
14 Do you see smokeless
tobacco products
packets with a picture
of a man affected with
mouth cancer?
15 Do you see tobacco Yes No
products being
displayed in a manner
that enables easy
access to children
(placed near candies,
chocolates etc to
attract children’s
attention)?
16 At the time of your Yes No
visit, did you see
anyone smoking in the
shop premises
17 At the time of your Yes No
visit, did you see any
ashtrays, matches,
lighters or other things
designed to facilitate
smoking

18. Were you able to see a similar signboard in

the shop you visited?

Yes

No

19. While at the shop, please take the geo point Latitude Longtitude

3 | P a g e Assessing the Purchase Patterns of Cigarettes and other Tobacco Products in Kerala