| 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:
|
| 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 :
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 |
|
|
|
|
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| 22 |
... to deal with nicotine withdrawal symptoms |
|
|
|
|
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| 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 |
|
|
|
|
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| 26 |
...because I cannot stop using them |
|
|
|
|
|
| 27 |
...to deal with stress |
|
|
|
|
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| 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 |
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| 19- I have felt hopeless or discouraged |
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| 20- I have thought about smoking a lot |
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| 21- I have felt hungry |
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| 22- I feel that I am getting enough sleep |
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| 23- It is hard to pay attention to things |
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| 24- I have felt happy and content |
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| 25- My sleep has been troubled |
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| 26- I have trouble getting cigarettes off my mind |
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| 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 |
|
Created by
, last modified
Sept. 22, 2004