The following statements describe how you feel today.
Please rate yourself for today:

Depressed mood (sad)	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Insomnia (sleep problems, awakening at night)	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Irritable, frustrated, angry	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Anxious (nervous)	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Difficulty concentrating	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Restless (impatient)	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Increased appetite, weight gain (hungry)	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Desire or craving to smoke	0= None 1= Slight 2= Mild 3= Moderate 4= Severe
Comments on the 8 questions above:

Please answer the following questions based on how you have felt or what you have noticed over the last 24 hours. Answer based on how you have felt in general during this time:

1- Food is not particularly appealing to me	Strongly disagree Disagree Feel neutral Agree Strongly agree
2- I am getting restful sleep	Strongly disagree Disagree Feel neutral Agree Strongly agree
3- I have been tense or anxious	Strongly disagree Disagree Feel neutral Agree Strongly agree
4- My level of concentration is excellent	Strongly disagree Disagree Feel neutral Agree Strongly agree
5- I awaken from sleep frequently during the night	Strongly disagree Disagree Feel neutral Agree Strongly agree
6- I have felt impatient	Strongly disagree Disagree Feel neutral Agree Strongly agree
7- I have felt upbeat and optimistic	Strongly disagree Disagree Feel neutral Agree Strongly agree
8- I have found myself worrying about my problems	Strongly disagree Disagree Feel neutral Agree Strongly agree
9- I have had frequent urges to smoke	Strongly disagree Disagree Feel neutral Agree Strongly agree
10- I have felt calm lately	Strongly disagree Disagree Feel neutral Agree Strongly agree
11- I have been bothered by the desire to smoke a cigarette	Strongly disagree Disagree Feel neutral Agree Strongly agree
12- I have felt sad or depressed	Strongly disagree Disagree Feel neutral Agree Strongly agree
13- I have been irritable, easily angered	Strongly disagree Disagree Feel neutral Agree Strongly agree
14- I want to nibble on snacks or sweets	Strongly disagree Disagree Feel neutral Agree Strongly agree
15- I have been bothered by negative moods such as anger, frustration, and irritability	Strongly disagree Disagree Feel neutral Agree Strongly agree
16- I have been eating a lot	Strongly disagree Disagree Feel neutral Agree Strongly agree
17- I am satisfied with my sleep	Strongly disagree Disagree Feel neutral Agree Strongly agree
18- I have felt frustrated	Strongly disagree Disagree Feel neutral Agree Strongly agree
19- I have felt hopeless or discouraged	Strongly disagree Disagree Feel neutral Agree Strongly agree
20- I have thought about smoking a lot	Strongly disagree Disagree Feel neutral Agree Strongly agree
21- I have felt hungry	Strongly disagree Disagree Feel neutral Agree Strongly agree
22- I feel that I am getting enough sleep	Strongly disagree Disagree Feel neutral Agree Strongly agree
23- It is hard to pay attention to things	Strongly disagree Disagree Feel neutral Agree Strongly agree
24- I have felt happy and content	Strongly disagree Disagree Feel neutral Agree Strongly agree
25- My sleep has been troubled	Strongly disagree Disagree Feel neutral Agree Strongly agree
26- I have trouble getting cigarettes off my mind	Strongly disagree Disagree Feel neutral Agree Strongly agree
27- It has been difficult to think clearly	Strongly disagree Disagree Feel neutral Agree Strongly agree
28- I think about food a lot	Strongly disagree Disagree Feel neutral Agree Strongly agree
Comments on the 28 questions above: (please specify question number)

Here are some questions about yourself:

Are you ?	A woman A man
When were you born?	I was born in 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1910
In which country do you live?	USA Canada England Switzerland ... Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bouvet Island Brazil Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Espana Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (South) Korea, Republic of Kuwait Kyrgyzstan Lao Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Ireland Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa (Independent) San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St. Helena St. Pierre and Miquelon Suriname Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu United States Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wales Western Sahara Yemen Zambia Zimbabwe
Which is your mother tongue?	English-USA English-UK English-Canada English-else French Bilingual French-English Other Other mother tongue, please specify:
Did you ever smoke 100 cigarettes in your lifetime?	Yes No
Did you smoke tobacco (even one puff of cigarette, cigar, pipe, etc) in the past 7 days?	Yes No
Did you smoke tobacco (even one puff of cigarette, cigar, pipe, etc) in the past 4 weeks?	Yes No
Do you currently smoke tobacco?	a= Yes, I smoke tobacco every day b= Yes, I smoke tobacco occasionally (not every day) c= No, I am an EX-smoker d= No, I was never a smoker a b c d
Currently, which type of tobacco do you use mainly?	Currently, I use mainly: cigarettes smokeless tobacco cigars small cigars/cigarillos bidis pipes
Do you currently use a nicotine replacement product (nicotine patch, gum, inhaler, tablet, or nicotine nasal spray)?	Yes, I use one of these products every day Yes, I use them occasionally (not every day) No, I don't use these products currently
Do you currently use the smoking cessation drug called "bupropion" or "Zyban"?	Yes, I use Zyban every day Yes, I use Zyban occasionally (not every day) No, I don't use Zyban currently
Is it likely that, in two months from now, you will be an EX-smoker?	Yes, it is absolutely sure Yes, it is extremely likely Yes, it is very likely Yes, it is rather likely It is more or less likely No, it is unlikely
In order to assess the stability of answers to this questionnaire, we would like to contact you in 2 weeks from now, to ask you the same questions again. If you agree, please indicate your first name and e-mail address:	First name: E-mail:
Questions for SMOKERS: => EX-smokers, please click here. => NEVER-smokers, please click here.
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 = 100	0 1 2 3 4 5 8 10 12 15 20 25 30 35 40 45 48 49 50 51 52 55 60 65 70 75 80 85 88 90 92 95 98 100 Addiction
On average, how many cigarettes do you smoke per day?	0 0.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 25 28 29 30 35 40 45 50 55 60 65 70 75 80 90 100 Cig./day
Usually, how soon after waking up do you smoke your first cigarette?	0 0.5 1 2 3 4 5 6 8 10 15 20 25 30 35 40 45 50 60 75 90 120 180 240 300 360 420 480 600 720 840 960 Minutes
For you, quitting smoking for good would be...	Impossible Very difficult Fairly difficult Fairly easy Very easy
Which of the following statements describes the best your current situation?	1 = I have NO intention to quit smoking in the next 6 months. 2 = I seriously consider quitting smoking in the next 6 months. 3 = I have decided to quit smoking in the next 30 days. 1 2 3
In the past 12 months, did you make an attempt to quit smoking?	Yes No
Since you started to smoke regularly, how long lasted your longest period of smoking abstinence (= longest period WITHOUT smoking)?	I spent a maximum of 2 hours 4 hours 8 hours 12 hours 16 hours 1 day 2 days 3 days 4 days 5 days 6 days 7 days 8 days 9 days 10 days 11 days 12 days 13 days 14 days 15 days 16 days 17 days 18 days 19 days 20 days 21 days 28 days 30 days 35 days 40 days 45 days 50 days 55 days 60 days 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 18 months 2 years 2.5 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 12 years 15 years 17 years 20 years 25 years 30 years 40 years 50 yearsin a row without smoking.
If you started to smoke again, after an attempt to quit smoking:
When did you relapse to smoking?	After trying to quit, I relapsed to smoking on: Day: 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 Month: January February March April May June July August September October November December Year: 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1970 1965 1960 1955 1950
On the day when you relapsed to smoking, at what hour did you smoke the first cigarette of your relapse?	On the day mentioned above, I smoked my first cigarette after my quit attempt at 01-05am 6am 7am 8am 9am 10am 11am 12noon 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12midnighthours
How long lasted your last quit attempt?	My last quit attempt lasted: 2 hours 4 hours 8 hours 12 hours 16 hours 1 day 2 days 3 days 4 days 5 days 6 days 7 days 8 days 9 days 10 days 11 days 12 days 13 days 14 days 15 days 16 days 17 days 18 days 19 days 20 days 21 days 28 days 30 days 35 days 40 days 45 days 50 days 55 days 60 days 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 18 months 2 years 2.5 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 12 years 15 years 17 years 20 years 25 years 30 years 40 years 50 years
Questions for EX-smokers: => Smokers, please click here.
EX-smokers: What type of tobacco did you smoke mainly, before you quit smoking?	Before quitting, I smoked: mainly cigarettes mainly cigars mainly small cigars/cigarillos mainly pipes mainly bidis
Did you quit smoking abruptly ("cold turkey") or did you first cut down on your cigarette consumption before quitting smoking?	I quit abruptly I first cut down, then quit
How many cigarettes did you smoke per day, on average, during the month before you quit smoking?	During the month before I quit smoking, I smoked on average 0 0.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 25 28 29 30 35 40 45 50 55 60 65 70 75 80 90 100 cigarettes per day
Are you sure that you are never going to smoke again?	Absolutely sure Rather sure Not very sure Not at all sure
When did you quit smoking?	I quit smoking on: Day: 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 Month: January February March April May June July August September October November December Year: 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1970 1965 1960 1955 1950
On the day when you quit smoking, at what hour did you smoke your last cigarette?	On the day when I quit smoking, I smoked my last cigarette at 01-05am 6am 7am 8am 9am 10am 11am 12noon 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12midnighthours

If you read French, please indicate which is the best translation for the following items:
If you do not read French, please click here:

à traduire:	La meilleure traduction à votre avis:
Absolument pas d'accord Plutôt pas d'accord Plus ou moins d'accord Plutôt d'accord Tout à fait d'accord	1- Totally disagree; Mostly disagree; More or less agree; Mostly agree; Totally agree 2- Strongly disagree; Disagree; Undecided; Agree; Strongly agree 3- Strongly disagree; Disagree; Feel neutral; Agree; Strongly agree. 4- Strongly disagree; Do NOT really agree; More or less agree; Generally agree; Fully agree 5- Totally disagree; Do NOT really agree; More or less agree; Agree; Fully agree 1 2 3 4 5
63- J'ai de la peine à réfléchir	1- I can hardly think 2- I can't keep my thoughts focused 3- I can't think easily 4- I find it difficult to think 5- I find it difficult to think clearly 6- I find it hard to think clearly 7- I have difficulty to think about things 8- I have trouble reflecting 9- I have trouble thinking 10- I have trouble thinking clearly 11- It's hard to think 12- I have trouble focusing 1 2 3 4 5 6 7 8 9 10 11 12

Please check that you answered to ALL questions

THANKS + + +

Note: Your answers will be stored on a computer file, for statistical analyses. Information enabling identification of survey participants will be accessed only by Jean-Francois Etter, PhD, who is in charge of this survey, and by one computer expert under his supervision; this information will not be made available to anyone else. Archived data will also be used for organizing the follow-up of participants. If you do not want us to retain your answers on file, do not click on the button above.

Created by par , Dec. 17, 2002.