Please take one minute to answer 3 questions on smoking cessation websites
 
 

Institute of social and preventive medicine - University of Geneva - Switzerland

Survey for users of nicotine chewing gums

  • This survey is intended only for nicotine gum users.
  • The results of this survey will be published in a scientific journal.
  • Your participation will contribute to a better understanding of nicotine gum use.
  • This study is independent from the pharmaceutical and tobacco industries.
  • Thank you + + + for taking a few minutes to answer.

Important: please answer ALL questions, even if there are some repetitions:
Have you ever smoked 100 cigarettes or more in your lifetime?
Do you currently smoke tobacco?
How old were you when you first started to smoke daily? I was years old
During the past 31 days, on how many days did you smoke?  I smoked on days
Have you smoked any tobacco (even one puff of cigarette, cigar, pipe, etc)...
.          ... in the past 24 hours?
.          ... in the past 7 days?
Are you currently trying to quit smoking?
Have you made a serious attempt to quit smoking?...

.          ... in the past 7 days?

.          ... in the past 12 months?
Which of the following statements best describes your current situation?
- I am a smoker, and...
A. ...I have NO intention to quit smoking in the next 6 months
B. ...I seriously consider quitting smoking in the next 6 months
C. ...I have decided to quit smoking within the next 30 days
- I am an EX-smoker, and...
D. ...I stopped smoking LESS than 6 months ago
E. ...I stopped smoking MORE than 6 months ago 
Have you ever used nicotine replacement products (i.e. nicotine gums, patches, tablets or inhalers)?
Do you currently use nicotine replacement products (i.e. nicotine gums, patches, tablets or inhalers)?
Have you used any nicotine replacement products during the past 7 days (even one nicotine gum, one nicotine patch, one nicotine tablet or one puff of nicotine inhaler)?
Currently, what type of nicotine replacement product do you use? Currently, I use:
-Nicotine chewing gums:...Yes /  No
-Nicotine patches:..............Yes /  No
-Nicotine tablets:...............Yes /  No
-Nicotine inhalers:.............Yes /  No
Currently, on how many days per week do you use nicotine chewing gums? I currently use nicotine gums on days per week
How long lasted your current episode of nicotine gum use?
Currently, how many nicotine chewing gums do you use per day, on average? I use nicotine gums / day
What dosage do you use? I use gums containing milligrams (mg) nicotine
What flavor of nicotine chewing gum do you use?
What brand of nicotine chewing gum are you currently using?
Other brand name, please specify:
In packs of how many gums do you buy your nicotine gums? In packs of gums

Other pack size, please specify:

Where do you buy your nicotine gums? I buy my nicotine gums at:

Other, please specify where:

Which of the following statements best describes your current situation?

A. I have never used nicotine chewing gums.

I currently use nicotine chewing gums, and...
B. ...I have NO intention to stop using them in the next 6 months
C. ...I seriously consider stopping using them in the next 6 months
D. ...I have decided to stop using them within the next 30 days

I used nicotine chewing gums in the past, and...
E. ...I stopped using them LESS than 6 months ago
F. ...I stopped using them MORE than 6 months ago

Is it likely that, in one month from now, you will have stopped using nicotine gums?
If you decided to stop using nicotine gums and all other nicotine replacement products (patches, tablets, inhalers), would you be likely to succeed in stopping using these products?
In the past 12 months, have you made a serious attempt to stop using nicotine gums?
How long did your most recent serious attempt to stop using nicotine gums last? My last serious attempt to stop using
nicotine gums lasted:
During the first week of your last attempt to stop using nicotine gums, did you feel the urge to use nicotine gums?
During the first week of your last attempt to stop using nicotine gums, did you feel the urge to smoke?
Do you currently use the smoking cessation drug called "bupropion" or "Zyban"?
One question for EX-smokers:
When did you stop smoking?
I stopped smoking on:
Day:
Month:
Year:
...and 3 questions for smokers:

-  On average, how many cigarettes do you smoke per day?

Cig./day
-  Usually, how soon after waking up do you smoke your first cigarette? Minutes
- If you started to smoke again, after an attempt to quit smoking, when did you relapse to smoking? I relapsed on:

Day:
Month:
Year:

Everybody: please answer ALL questions:
Please rate your addiction to nicotine chewing gums on a scale of 0 to 100:

- I am NOT addicted to nicotine gums at all = 0
- I am extremely addicted to nicotine gums = 100

Addiction to gums (0-100)
Usually, how soon after waking up do you chew your first nicotine gum of the day? minutes
For you, stopping using nicotine gums and all other nicotine replacement products (e.g. patches, tablets, inhalers) for good would be:
Do you find it difficult to refrain from chewing nicotine gums in places where you are not supposed to (e.g. in a business meeting)?
Which nicotine gum would you hate most to give up?
Do you chew nicotine gums more frequently during the first hours after waking than during the rest of the day?
Do you chew nicotine gums when you are so ill that you are in bed most of the day?
Imagine that you were paid to stop using nicotine gums and all other nicotine replacement products (patches, tablets, inhalers). What is the minimal amount that you would ask for, in order to stop using all nicotine replacement products for ever? I would stop using these products for ever if I were paid at least:
Smokers, imagine that you were paid to stop smoking. What is the minimal amount that you would ask for, in order to stop smoking for ever? I would stop smoking for ever if I were paid:
How would you rate your addiction to nicotine gums, compared with your addiction to cigarettes (when you were smoking)? My addiction to nicotine gums is...

...than my addiction to cigarettes
Do you often feel sad or depressed?
During the past month, have you often been bothered by feeling down, depressed or hopeless?
During the past month, have you often been bothered by little interest or pleasure in doing things?

Please indicate whether you agree with each of the following statements :

Totally disagree

Somewhat disagree

Neither agree nor disagree

Somewhat agree

Fully agree

After a few hours without chewing a nicotine gum, I feel an irresistible urge to chew one

The idea of not having any nicotine gums causes me stress

Before going out, I always make sure that I have nicotine gums with me

I am a prisoner of nicotine gums

I chew too many nicotine gums

Sometimes I drop everything to go out and buy nicotine gums

I chew nicotine gums all the time

I chew nicotine gums despite the risks to my health

I am unable to stop using nicotine gums

   

Totally disagree

Somewhat disagree

Neither agree nor disagree

Somewhat agree

Fully agree

Chewing a nicotine gum calms me down when I am stressed

Chewing a nicotine gum calms me down when I am upset

Chewing a nicotine gum helps me deal with difficult situations

After chewing a nicotine gum, I am able to concentrate better

It feels so good to chew a nicotine gum!

I love chewing nicotine gums

I fear that I will start smoking again if I stopped using nicotine gums

I fear that I will gain weight if I stopped using nicotine gums

I fear that I will get mouth ulcers if I stopped using nicotine gums

   

Totally disagree

Somewhat disagree

Neither agree nor disagree

Somewhat agree

Fully agree

Please tick the response option that indicates how well each of the following statements describes you :

Not at all True

Somewhat True

Moderately
True

Very True

Extremely True

1 After not chewing nicotine gums for a while, I need to chew one to relieve feelings of restlessness and irritability

2 Whenever I go without a nicotine gum for a few hours, I experience craving for nicotine gums

3 After not chewing nicotine gums for a while, I need to chew one in order to keep myself from experiencing any discomfort

4 When I'm really craving a nicotine gum, it feels like I'm in the grip of some unknown force that I cannot control

5 I feel a sense of control over my use of nicotine gums, I can "take it or leave it" at any time

6 I tend to avoid places where I cannot chew nicotine gums, even if I would otherwise enjoy the company

 

Not at all True

Somewhat True

Moderately
True

Very True

Extremely True

7 Sometimes I decline offers to visit with my friends because I know they'll feel uncomfortable if I chew nicotine gums

9 Since the time when I became a regular user of nicotine gums, the amount of gums I chew has either stayed the same or has decreased somewhat

10 Compared to when I first started using nicotine gums, I need to use a lot more nicotine gums now in order to really get what I want out of them

11 Compared to when I first started using nicotine gums, I can use many, many more nicotine gums now before I start to feel nauseated or ill

12 It's hard to estimate how many nicotine gums I use per day because the number often changes

13 My pattern of nicotine gum use is very irregular throughout the day. It is not unusual for me to chew many nicotine gums in an hour, then not have another one until hours later

 

Not at all True

Somewhat True

Moderately
True

Very True

Extremely True

14 The number of nicotine gums I smoke per day is often influenced by other factors - how I'm feeling, what I'm doing, etc.

15 I use nicotine gums at different rates in different situations

16 My use of nicotine gums is not much affected by other things. I use them about the same whether I'm relaxing or working, happy or sad, alone or with others, etc.

17 My use of nicotine gums is fairly regular throughout the day

18 I use nicotine gums consistently and regularly throughout the day

19 I chew about the same amount of nicotine gums on weekends as on weekdays 

For what purpose or reason do you use nicotine gums?

Not at all True

Somewhat True

Moderately
True

Very True

Extremely True

20 I use nicotine gums...

...to deal with my craving for cigarettes

21 ...to quit smoking or avoid relapsing to smoking

22 ... to deal with nicotine withdrawal symptoms

23 ...to deal with situations where I cannot smoke (e.g. during business meetings, at work, at home, when visiting non-smoking friends, in a plane or train, etc.)

24 ...in order to decrease my cigarette consumption

25 ...because I am addicted to nicotine gums

26 ...because I  cannot stop using them

27 ...to deal with stress

28 ...because nicotine gums help me control my weight

 

Not at all True

Somewhat True

Moderately
True

Very True

Extremely True

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
2- I am getting restful sleep
3- I have been tense or anxious
4- My level of concentration is excellent
5- I awaken from sleep frequently during the night
6- I have felt impatient
7- I have felt upbeat and optimistic
8- I have found myself worrying about my problems
9- I have had frequent urges to smoke
10- I have felt calm lately
11- I have been bothered by the desire to smoke a cigarette
12- I have felt sad or depressed
13- I have been irritable, easily angered
14- I want to nibble on snacks or sweets
15- I have been bothered by negative moods such as anger, frustration, and irritability
16- I have been eating a lot
17- I am satisfied with my sleep
18- I have felt frustrated
19- I have felt hopeless or discouraged
20- I have thought about smoking a lot
21- I have felt hungry
22- I feel that I am getting enough sleep
23- It is hard to pay attention to things
24- I have felt happy and content
25- My sleep has been troubled
26- I have trouble getting cigarettes off my mind
27- It has been difficult to think clearly
28- I think about food a lot
29- I have put on weight recently
9b- I have had frequent urges to use nicotine gums
11b- I have been bothered by the desire to chew a nicotine gum
20b- I have thought about chewing nicotine gums a lot
26b- I have trouble getting nicotine gums off my mind

Finally, here are some questions about yourself:
Are you?
How old are you? I am years old
In which country do you live?
How would you describe the income of your household?

a- Far below the average income of other households in your country
b- Somewhat below the average income of other households
c- Like the average income of other households in your country
d- Somewhat higher the average income of other households
e- Much higher than the average income of other households in your country
x- I don't know / I don't want to answer

Follow-up:
We would like to contact you by e-mail
- in one week from now, to ask you the same questions again (to assess the stability of answers), and
- in  one month from now, to ask you whether you still use nicotine gums and if you smoke.
If you agree, please indicate your first name and e-mail address.

Information enabling identification of survey participants will be accessed only by Jean-Francois Etter (PhD, University of Geneva lecturer) 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 or used for any other purpose than conducting the one-week and one-month follow-up surveys for this study.

First (given) name:

E-mail:

Data storage:
We would like to store your answers on a computer file, in order to conduct statistical analyses (using an anonymous format), and to contact participants who would like to take part in follow-up surveys.
- If you do not want your answers to be stored, please tick this box.
- Also tick this box if your answers are not to be taken seriously.
I do not want my answers to be stored:


Important: please check that you have answered ALL questions.

Thank you + + + for your participation !

Created by JF Etter, last modified Sept. 22, 2004