Have you ever wondered how your smoking compares to others? This exercise will provide you with the sometimes surprising answer.
To provide you with meaningful and personal information please think carefully, then answer each of the following questions:
1. How soon after you wake up do you smoke your first cigarette?
2. Do you find it difficult to not smoke in places where it is not allowed (in the office or at the movies)?
3. Which cigarette(s) of the day would you hate to give up most?
4. How many cigarettes do you smoke per day on average? Please make a choice 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 or more
5. Do you smoke more often during the first 3 hours after waking than during the rest of the day?
6. Do you smoke even when you're sick, or when you have a sore throat, cold, or cough?
7. Are you male or female?
8. What country do you live in?
9. What is your approximate age? Please make a choice under 18 19-24 25-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71+
10. How confident are you that you could attempt to quit smoking in the next one to two months?
1 2 3 4 5 6 7 8 9 10 Not Confident Confident
11. At this point, would you say that your BENEFITS of quitting are...
12. Have you taken small steps towards quitting? (delayed you first cigarette of the morning, cut out one or two cigarettes a day, stopped smoking in the car...)
13. What is your first name (if you are concerned about your privacy use your nickname or an alias):
Financial Contribution from the Tobacco Control Programme/Prevention, Cessation and Education, Health Canada. The views expressed herein do not necessarily represent the officials policies of Health Canada.Pregnets Support Group Software (WebTriage) and Nicotine Dependency Test copyright 2009-2012 by Evolution Health Systems Inc. All worldwide patent rights reserved. All rights reserved.
