• Thanks + + + for taking 10 minutes to answer this questionnaire.

Survey for smokers and EX-smokers

1a Have you ever smoked?
2a Have you ever smoked at least 100 cigarettes or the equivalent amount of tobacco in your lifetime?
3a Do you now smoke daily, occasionally, or not at all?
4a Do you currently smoke tobacco? A) Yes, I smoke every day
B) Yes, I smoke occasionally (NOT every day)
C) No, I am an EX-smoker
D) No, I never was a smoker
5a During the past 30 days, on how many days did you smoke? In the past 30 days,
I smoked on days.
6 Do you now smoke cigarettes?
7 Do you now smoke cigars?
8 Do you now smoke cigarillos?
9 Do you now smoke pipes?
10 Do you now use chewing tobacco?
11 Do you now use tobacco snuff?
12 Have you used smokeless tobacco (=snuff or chewing tobacco) in the past 7 days?
13a Have you smoked at least a part of a cigarette (or part of
a cigar or pipe, etc) in the past 7 days?

How confident are you about your answer to
this question?

14a If not, have you smoked at least part of a cigarette (or part of a cigar or pipe, etc) in the last 30 days?

How confident are you about your answer to
this question?

15a If not, have you smoked at least part of a cigarette (or part of a cigar or pipe, etc) in the last 6 months?

How confident are you about your answer to
this question?

16a If not, have you smoked at least part of a cigarette (or part of a cigar or pipe, etc) in the last 12 months?

How confident are you about your answer to
this question?

Questions for smokers and users of smokeless tobacco:
EX-smokers, please click here
17 Currently, which type of tobacco do you use mainly? Currently, I use mainly:
18a How many cigarettes per day do you smoke, on average? cigarettes per day
19a Usually, how soon after waking up do you smoke your first cigarette? minutes
20a In the past 12 months, did you make an attempt to quit smoking?

How confident are you about your answer to
this question?

20c In the past 12 months, did you make an attempt to quit smoking and succeed in not smoking for at least 24 hours?

How confident are you about your answer to
this question?

21 How long did your last attempt to quit smoking last? My last quit attempt lasted:
22a In the last year, how many times have you quit smoking for at least 24 hours?

times

How confident are you about your answer to
this question?

23a In the last year, how many times have you made an attempt to quit smoking?

times

How confident are you about your answer to
this question?

23c In the last year, how many times have you made an attempt to quit smoking and succeeded in not smoking for at least 24 hours?

times

How confident are you about your answer to
this question?

24a Are you seriously thinking of quitting smoking?
Questions for EX-smokers:
25a When did you quit smoking?

I quit smoking on:
Day:
Month:
Year:

How confident are you about your answer to
this question?

Comments on the questions above:


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[Last modified 12 June 2003, by ]