Test your dependence on cigarettes

  • After answering, you will receive a personalized feedback report, with a rating of your dependence level and a comparison with standard scores.
  • This survey is also aimed at comparing between each other 3 different scales measuring dependence on cigarettes. The results will be published in an international scientific journal.
  • Your participation will contribute to a better understanding of tobacco dependence and to the development of better treatments for smokers.
  • Thank you + + for taking time 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?
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 smoked any tobacco (even one puff of cigarette, cigar, pipe, etc)...
.               ... in the past 24 hours?
.               ... in the past 7 days?
During the past 31 days, on how many days did you smoke?  I smoked on days
How old were you when you first started smoking daily? I was years old
Currently, what sort of tobacco product do you use most? Currently, I use mainly:
Is it likely that, in one month from now,
you will be an EX-smoker?
If you decided to quit smoking,
would you be likely to succeed in quitting?
In the past 7 days, have you made a serious attempt to quit smoking?
In the past 12 months, have you made a serious attempt to quit smoking?
How long did your most recent serious attempt to quit smoking last? My last serious quit attempt lasted:
During the first week of your last quit attempt, did you feel the urge to smoke?
How much would you be willing to pay for a treatment that would give you a 100% chance of quitting smoking for good, without suffering from tobacco withdrawal or craving? I would pay
Usually, on how many days per week do you smoke? I usually smoke on days per week
For how long have you been smoking at this frequency? For
Do you currently use a nicotine replacement product (nicotine patch, gum, inhaler or tablet)?
Do you currently use the smoking cessation drug called "bupropion" or "Zyban"?
Question for ex-smokers:
When did you quit smoking?
I stopped smoking on:
Day:
Month:
Year:

Please answer ALL questions:
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

Addiction
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
For you, quitting smoking for good would be:
Do you find it difficult to refrain from smoking in places where it is forbidden, e.g. in a church, at the library, in cinema, etc.?
Which cigarette would you hate most to give up?
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Do you smoke when you are so ill that you are in bed most of the day?
Imagine that you were paid to quit smoking. What is the minimal amount that you would ask for, in order to quit smoking for ever?

I would quit smoking if I were paid at least:
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 smoking, I feel an irresistible urge to smoke

The idea of not having any cigarettes causes me stress

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

I am a prisoner of cigarettes

I smoke too much

Sometimes I drop everything to go out and buy cigarettes

I smoke all the time

I smoke despite the risks to my health

Totally disagree

Somewhat disagree

Neither agree nor disagree

Somewhat agree

Fully agree

A cigarette calms me down when I am stressed

Smoking calms me down when I am upset

A cigarette helps me deal with difficult situations

After a cigarette, I am able to concentrate better

I like the motions of smoking

It feels so good to smoke!

I love smoking

I like to hold a cigarette between my fingers

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 smoking for a while, I need to smoke to relieve feelings of restlessness and irritability

2 Whenever I go without a smoke for a few hours, I experience craving

3 After not smoking for a while, I need to smoke in order to keep myself from experiencing any discomfort

4 When I'm really craving a cigarette, 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 smoking, I can "take it or leave it" at any time

6 I tend to avoid restaurants that don't allow smoking, even if I would otherwise enjoy the food

Not at all True

Somewhat True

Moderately
True

Very True

Extremely True

7 Sometimes I decline offers to visit with my non-smoking friends because I know they'll feel uncomfortable if I smoke

8 Even if traveling a long distance, I'd rather not travel by airplane because I wouldn't be allowed to smoke

9 Since the time when I became a regular smoker, the amount I smoke has either stayed the same or has decreased somewhat

10 Compared to when I first started smoking, I need to smoke a lot more now in order to really get what I want out of it

11 Compared to when I first started smoking, I can smoke much, much more now before I start to feel nauseated or ill

12 It's hard to estimate how many cigarettes I smoke per day because the number often changes

13 My smoking pattern is very irregular throughout the day. It is not unusual for me to smoke many cigarettes 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 cigarettes I smoke per day is often influenced by other factors - how I'm feeling, what I'm doing, etc.

15 I smoke at different rates in different situations

16 My smoking is not much affected by other things. I smoke about the same whether I'm relaxing or working, happy or sad, alone or with others, etc.

17 My cigarette smoking is fairly regular throughout the day

18 I smoke consistently and regularly throughout the day

19 I smoke about the same amount on weekends as on weekdays 

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

Finally, here are some questions about yourself:
Are you?
How old are you? I am years old
In which country do you live?
What is your mother tongue?
Other mother tongue, please specify:
In total, how many school years have you completed? school years
How would you describe the income of your household?

a- Much 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 than 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, in order to assess the stability of answers to this questionnaire.
- in one month from now, to ask you whether you are still a smoker. This will enable us to study associations between level of dependence and smoking cessation.
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 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.

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 take part in the follow-up.
- If you do NOT want your answers to be stored, please tick this box.
- Also tick this box if you answered the questionnaire just to see how it works, and if the answers are not to be taken seriously.
- You will receive your feedback report even if you tick this box.
I do not want my answers to be stored:


Important: please check that you have answered ALL questions.

Thank you + + + for your participation !

Back to Stop-Tabac.ch

Created by JF Etter, last modified 13 May 2004