|In the past 12 months, did you smoke tobacco
more than once to feel better, or to change your
|Do you currently smoke tobacco?
|Please rate your addiction to
cigarettes on a scale of 0 to 100:
- I am NOT addicted to cigarettes
at all = 0
- I am extremely addicted to cigarettes =
|On average, how many cigarettes do you smoke per
|Usually, how soon after waking
up do you smoke your first cigarette?
|For you, quitting smoking for good would be:
|Do you find it difficult to
refrain from smoking in places where it is forbidden,
e.g. in a church, at the library, in cinema, etc.?
|Which cigarette would you hate most to give up?
|Do you smoke more frequently
during the first hours after waking than during
the rest of the day?
|Do you smoke when you are so ill that you are
in bed most of the day?
|How much would you pay for a
treatment that would give you a 100% chance of quitting
smoking for good, without suffering from tobacco
in U.S. dollars:
|Considering your tobacco smoking in the past
|Have you found that you needed
to smoke more tobacco to get the same effect that
you did when you first started smoking?
|When you reduced or stopped smoking, did you have
withdrawal symptoms (depressed mood, irritability,
frustration or anger, difficulty sleeping, difficulty
concentrating, increased appetite or weight gain,
decreased heart rate, feeling agitated, anxious
|Did you smoke any tobacco to
keep yourself from getting any of these withdrawal
symptoms or so that you would feel better?
|Have you often found that when you smoked tobacco,
you ended up smoking more than you thought you would?
|Have you tried to reduce or
stop smoking but failed?
|On the days that you smoked, did you spend substantial
time (more than 2 hours) smoking, obtaining tobacco,
or thinking about tobacco?
|Did you spend less time working,
enjoying hobbies, or being with family or friends
because of your smoking?
|Have you continued to smoke, even though it caused
you health or mental problems?
|After a few hours without smoking, I feel an
irresistible urge to smoke
|The idea of not having any cigarettes causes
|Before going out, I always make sure that I have
cigarettes with me
|I am a prisoner of cigarettes
|I smoke too much
|Sometimes I drop everything to go out and buy
|I smoke all the time
|I smoke despite the risks to my health