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Institute of Social and Preventive Medicine - University of Geneva - Switzerland and St. George's Hospital Medical School - London - U.K.


Questionnaire for women who smoke
(or who quit smoking within the past 2 weeks)

  • Thank you + + + for taking a few minutes to answer this questionnaire.
  • Your answers will help us devise better programmes for helping women with stopping smoking.
  • You are eligible for this survey if you are a woman and you are currently smoking cigarettes, or
    if you have quit smoking within the last two weeks.
  • If you are pregnant you are particularly welcome to join in the survey.

Please answer to all questions:
Do you currently smoke tobacco?
On approximately how many days have you smoked in the last 30 days? On days/30
How long is it since you last smoked a cigarette?

I last smoked a cigarette ...
days ago
or hours ago
or minutes ago

Does your husband or partner smoke?
One question for EX-smokers.

How long has it been since you last smoked daily?

days since I last smoked daily.
Questions for current smokers:
=> EX-smokers and never-smokers, click here.
How many cigarettes a day do you smoke at the moment? cig./day, at the moment
How soon after waking do you normally smoke your first cigarette of the day? minutes
Are you planning to stop smoking?
How many serious attempts to quit smoking have you made in the last year? serious quit attempts in the last year
How long did your last attempt to quit smoking last? My last quit attempt lasted:
If you tried to quit smoking, how confident are you that you would succeed for at least 12 months?
Do you find it difficult to refrain from smoking in places where it is forbidden?
Which cigarette would you hate to give up the most?
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Do you smoke if you are so ill that you are in bed most of the day?
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

How much of the time have you felt the urge to smoke in the past 24 hours?
How strong have the urges been?

Questions for everybody:
Please indicate on each of the scales below how you have been over the past 24 hours:

  None  

   Slight  

   Mild  

 Moderate

 Severe  

Angry, irritable, frustrated

Anxious, nervous

Depressed mood, sad

Desire or craving to smoke

Difficulty concentrating

Increased appetite, hungry

Insomnia, sleep problems, awakening at night

Restless

Impatient

Constipation

Dizziness

Coughing

None

Slight

Mild

Moderate

Severe

Increasing dreaming or nightmares

Nausea

Sore throat

Mouth ulcers

Drowsy

Pain in limbs

Headache

Sweating

Tremor

Diarrhoea

Fatigue

Backache

None

Slight

Mild

Moderate

Severe 

Here are some questions about yourself:
How old are you? I am years old
How much to you weigh? kilos and grams
Are you...?
In which country do you live?
What is your occupation?
How would you describe the income of your household, compared to the average income of all other households in your country?
What is your ethnic group?

Other, please describe:

Are you currently pregnant?
Follow-up:
We would like to contact you in one week from now, to ask you a few more questions. If you agree, please indicate your first name and e-mail address:
First (given) name:
E-mail:
Data storage:
We would like to store your answers on a computer file, in order to conduct statistical analyses (in an anonymous format), and to contact participants who wish to be contacted.
- If you do NOT want your answers to be stored, please tick this box.


If you are NOT pregnant, please click the button below for the next step.
If you are pregnant, don't click, the survey continues:


Questions for those who are currently pregnant:
How many weeks pregnant are you? I am weeks pregnant
About how many cigarettes a day did you smoke before you were pregnant? cig./day, before pregnancy
How pleasant do cigarettes taste now compared with before your pregnancy?
During your pregnancy, have you experienced any food cravings, i.e. have you had an intense desire for a particular food or drink, or another substance?
If yes, what foods, drinks and substances have you fancied?
During your pregnancy have you experienced any food aversions, i.e. have you experienced a strong dislike for any particular foods or drink, or another substance?
If yes, what foods, drinks and substances did you / do you now dislike?
Please indicate how much you have experienced any of the following during the previous week:

Not at all

A little

Moderately so

Very much so

Extremely so

I have felt deprived of my usual pleasures (e.g. alcohol).

I have fantasized about smoking again once my baby is born

I have felt nauseous, sick

I have vomited

Click here for the next step:

[Last modified by Jean-Fr. Etter , 06 March 2006]