| Do you currently smoke tobacco?
Yes, I smoke tobacco every day = a
Yes, I smoke occasionally (not every day) = b
No, I have stopped smoking = c
No, I never was a smoker = d
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| During the past 30 days, on how many days did you smoke? |
days/30 |
| On average, how many cigarettes do you currently smoke per day? |
Cig./day, now
(If you have stopped smoking, answer zero) |
| How many cigarettes did you smoke per day, 4 weeks ago? |
Cig./day, 4 weeks ago |
| Usually, how soon after you wake up do you smoke your first cigarette
of the day? |
minutes |
| Please rate your desire or craving to smoke |
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| Please rate your level of motivation to quit smoking, on a scale of 0-100
I have absolutely no intention of quitting smoking = 0
I have firmly decided to quit smoking immediately = 100
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motivation |
| Please rate your level of confidence in your ability to quit smoking,
on a scale of 0-100
I have absolutely no chance of succeeding in quitting smoking = 0
I am absolutely sure that I will succeed if I try to quit smoking = 100
|
confidence |
| Do you intend to quit smoking?
No = a
Yes, but not in the next 2 weeks = b
Yes, I intend to quit in the next 2 weeks = c
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|
| If you intend to quit smoking in the next 2 weeks, do you...
...strongly prefer to quit abruptly = a
...strongly prefer to first reduce your cigarette consumption, then quit
smoking in 2 weeks from now = b
...have no strong preference for either a or b = c
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| During the past month, have you often been bothered by feeling down,
depressed or hopeless? |
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| During the past month, have you often been bothered by little interest
or pleasure in doing things? |
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| Are you ? |
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| When were you born? |
I was born in
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| In which country do you live? |
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| If you have ever tried to quit
smoking: |
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During your last quit attempt, did you quit smoking abruptly or did you
first
cut down on your cigarette consumption before quitting smoking? |
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| If you started to smoke again, after an attempt
to quit smoking: |
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| When did you relapse to smoking? |
After trying to quit, I relapsed to smoking on:
Day:
Month:
Year:
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| Questions for EX-smokers: |
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| When did you stop smoking? |
I stopped smoking on:
Day:
Month:
Year:
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Data storage:
We would like to store your answers on a computer file, in order to conduct
statistical analyses (in an anonymous format). If you do NOT want your answers
to be stored, please tick this box. |
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