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SMOKING HISTORY INSTRUCTIONS Please Answer the Following Questions Based on Your Experiences with Smoking

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SMOKING HISTORY INSTRUCTIONS Please Answer the Following Questions Based on Your Experiences with Smoking SMOKING HISTORY INSTRUCTIONS Please answer the following questions based on your experiences with smoking. Each question allows you to choose from several alternatives. Please select one of the alternatives by circling the number within the column on the right that corresponds with your answer. Be sure to answer each question. Please be sure to select only one number per question. Question Response 1. Are you currently smoking? 1 = Yes 2 = No 1 2 2. Have you smoked a cigarette, even a puff, during the past 7 days? 1 2 1 = Yes 2 = No 3. Have you smoked a cigarette, even a puff, during the past month? 1 2 1 = Yes 2 = No 4. Were you smoking 6 months ago? 1 = Yes 2 = No 1 2 5. Were you smoking 12 months ago? 1 = Yes 2 = No 1 2 6. Do you inhale? 1 2 3 4 1 = Never 2 = Sometimes 3 = Always 4 = I don’t smoke 7. Do you smoke more during the morning than the rest of the day? 1 2 3 1 = Yes 2 = No 3 = I don’t smoke 8. Do you find it difficult to refrain from smoking in places where 1 2 3 it is prohibited, for example in church, cinema, etc.? 1 = Yes 2 = No 3 = I don’t smoke 9. Do you continue to smoke when you are so ill that you are in bed 1 2 3 most of the day? 1 = Yes 2 = No 3 = I don’t smoke 10. When you smoke a cigarette, do you usually burn it: 1 = All the way down 2 = About 3/4 the way down 1 2 3 4 3 = 1/2 the way down 4 = I don’t smoke 11. Which cigarette would you hate to give up? (choose only one) 1 2 3 4 5 6 7 1 = The first one of the day 2 = After meals 3 = While drinking 4 = When around others who smoke 5 = Just before bed 6 = With coffee 7 = I don’t smoke 12. At this time what is your personal goal with regards to smoking? 1 2 3 4 5 1 = To quit and stay off forever 2 = To stay off forever (I have already quit) 3 = To not smoke for a limited time 4 = To be able to control how much I smoke 5 = To quit someday but not now 6 = To continue to smoke 13. How often have you used each of the following in your efforts to quit smoking? (Answer each item) Cold turkey (quitting all at once) 1 2 3 4 5 1 = Never Gradually cutting down 1 2 3 4 5 Nicorette gun 1 2 3 4 5 2 = Seldom Professional stop smoking clinic 1 2 3 4 5 3 = Occasionally Hypnosis 1 2 3 4 5 4 = Frequently Support group 1 2 3 4 5 5 = Repeatedly Self-help manuals of books 1 2 3 4 5 Other ______________________________ 1 2 3 4 5 14. Are you seriously considering quitting within the next 6 months? 1 2 3 1 = Yes 2 = No 3 = I already quit 15. Are you planning to quit in the next 30 days? 1 2 3 1 = Yes 2 = No 3 = I already quit 16. Have you reduced the number of cigarettes you smoke in the last month? 1 2 3 1 = Yes 2 = No 3 = I already quit 17. Do you have a spouse of close friend that is interested and concerned 1 2 about your smoking? 1 = Yes 2 = No 18. Since you stated smoking regularly, have you ever quit for a period of 1 2 at least 24 hours? 1 = Yes 2 = No 19. How confident are you that you will be able to stop smoking at this time? 1 2 3 4 5 (If you do not smoke, how confident are you that you be able to stay off at this time?) 1 = Not at all confident 2 = Somewhat confident 3 = Moderately confident 4 = Very confident 5 = Extremely confident 20. While trying to quit, how serious have each of the following problems been for you? (If you have never tried to quit, fill in 1 for each item) Weight gain 1 2 3 4 5 Increased eating 1 2 3 4 5 PLEASE ANSWER EACH ITEM Digestive problems 1 2 3 4 5 Nausea 1 2 3 4 5 Headaches 1 2 3 4 5 Drowsiness 1 2 3 4 5 1 = Not at all Depression or low mood 1 2 3 4 5 Fatigue 1 2 3 4 5 2 = A little 3 = Moderately Insomnia 1 2 3 4 5 4 = Very Difficulty concentrating 1 2 3 4 5 Heart pounding, or sweating 1 2 3 4 5 5 = Extremely Irritability 1 2 3 4 5 Restlessness 1 2 3 4 5 Anxiety 1 2 3 4 5 Craving for tobacco 1 2 3 4 5 21. To the best of your knowledge, categorize the use of cigarettes by the following people in your life. 1 = Smoker Father 1 2 3 4 2 = Ex-Smoker Mother 1 2 3 4 Spouse 1 2 3 4 3 = Never Smoked Best friend 1 2 3 4 4 = Not Applicable Closest work associate 1 2 3 4 22. 23. 24. Lbs. Feet Inches Age 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 22. How much do 3 3 3 23. How tall are 3 3 3 24. How old were 3 3 you weigh? 4 4 4 you? 4 4 4 you when you 4 4 5 5 5 5 5 5 started smoking? 5 5 6 6 6 25. 6 6 6 6 6 7 7 7 7 7 7 7 7 8 8 8 8 8 8 26. 8 8 9 9 9 9 9 9 9 9 Times 0 0 1 1 26. In the last year 2 2 how many times 3 3 0 have you quit for During the past 7 days, how 1 25. 4 4 at least 34 hours? many cigarettes did you 5 5 2 (If more than 9 3 smoke on a typical day? (If 6 6 times, put 9) you smoke 1 or less, put 01, 7 7 4 if you didn’t smoke at all put 8 8 5 00.) 9 9 6 7 8 28. 9 27. Days Month/ Date/ Year 28. After your most recent 0 0 0 What was the date of your MOST quit attempt how long 27. 1 1 1 RECENT attempt to quit smoking 0 0 0 0 0 0 did you stay off 2 2 2 for at least 24 hours, as accurately 1 1 1 1 1 1 cigarettes (if you have 3 3 3 as you can remember? (If you 2 2 2 2 2 2 not attempted to quit 4 4 4 have not attempted to quit put 3 3 3 3 3 3 put 000, if more than 00/00/00) 4 4 4 4 4 4 999 days put 999 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 30. 29. Type Days 30. What brand and type of 29. Since you first started Lights cigarette do you usually smoking what was the 0 0 0 smoke? (Write in brand Regular longest period of time that 1 1 1 below and fill in one answer Non-Filtered you were able to stay off 2 2 2 in each section to the right) Filtered cigarettes? (If you never quit 3 3 3 put 000. If your longest quit Menthol 4 4 4 lasted more than 3 years put Non-Menthol 5 5 5 Brand _____________________ 999). 6 6 6 Regulars 7 7 7 Kings 8 8 8 100’s 9 9 9 120’s 31. 32. 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 31. How many years have you 4 4 32. During the period you were 4 4 smoked or did you smoke 5 5 smoking the most, about 5 5 before quitting? (total 6 6 how many cigarettes a day 6 6 number of years) 7 7 did you smoke? 7 7 8 8 8 8 9 9 9 9 33. 34. Years 0 0 0 1 1 1 2 33. As best as you can 2 2 remember, how long ago 3 3 3 did you make your first 4 4 4 34. How many times in your life attempt to quit smoking? (If 5 5 5 have you made a serious you never made an 6 6 6 attempt to quit smoking? (If attempt, put 00, if in the more than 9 times, put 9) 7 7 7 past year, put 01) 8 8 8 9 9 9 35. 36. Hours Minutes 0% C 10% 36. How confident are you that O 20% 0 0 0 you will be able to resist the N 30% 1 1 1 urge to smoke altogether in F 35. How soon after you awake 40% do you usually smoke your 2 2 2 the future, regardless of the I 50% first cigarette? (If you don’t 3 3 3 situation? Mark only one D smoke, put 000.) 4 4 4 circle, with 0% meaning E 60% 5 5 5 NOT AT ALL CONFIDENT N 70% 6 6 6 and 100% meaning C 80% EXTREMELY CONFIDENT 7 7 7 E 90% 8 8 8 100% 9 9 9 For each question choose from the following alternatives and circle the choice in the right hand margin with the code number that best suits you.
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