Comparison stages of change

Health On the Net Foundation
QUESTIONNAIRE
for smokers and EX-smokers only

Health On the Net Foundation	QUESTIONNAIRE for smokers and EX-smokers only

Health On the Net Foundation and the Institute for Social and Preventive Medicine of Geneva, Switzerland, have joined forces to help you kick the habit.

This survey is aimed at identifying the best questions to assess Stages of change in smokers and ex-smokers.
Various questions are compared. Please answer to ALL questions, even if some questions are similar or repetitive.
Your collaboration contributes to scientific research and to the development of smoking cessation programs.
Thanks + + for your help.

Please answer to ALL questions

1- Have you smoked AT LEAST 100 cigarettes in your lifetime ?

2- Which of the following statements describes the best your current situation ?

3- Are you currently a smoker ?

4- For smokers only:
IN THE LAST YEAR, how many times have you quit smoking for at least 24 hours ?

5-
For smokers only:
Are you seriously thinking of quitting smoking ?

Questions for all participants:

6- Are you currently a cigarette smoker ?

7- Are you seriously considering quitting smoking within the next 6 months ?

8- Are you planning to quit in the next 30 days ?

9- Have you smoked ANY cigarettes during the past 6 months ?

10- Have you smoked ANY cigarettes during the past 30 days ?

11- Have you smoked ANY cigarettes during the past 7 days ?

Questions for all participants:

12-	Do you currently smoke tobacco ?
13-	In the past 12 months, did you try to quit smoking and succeed in not smoking for at least 24 hours?
14-	In the past 30 days, did you try to quit smoking and succeed in not smoking for at least 24 hours?
15-	In the past 7 days, did you try to quit smoking and succeed in not smoking for at least 24 hours?
16-	For smokers only: Please rate your level of intention to quit smoking I have absolutely NO intention of quitting smoking = 0 I have made a firm decision to quit in the next days = 10
17-	For smokers only: What do you smoke mainly ?
18-	Please comment on questions 1-17:

19-
For EX-smokers only:
When did you quit smoking ?

Date when you have quit:

day

month

year

Questions for all participants:

20-
Do you currently use smokeless tobacco ?

Questions for all participants:

	The following are some statements concerning smoking. Please indicate whether or not you agree with each of them	Totally disagree	Do not really agree	More or less agree	Agree	Fully agree
21-	I love smoking
22-	Smoking is extremely dangerous to my health
23-	A cigarette calms me down when I am stressed
24-	Smoking is ruining my health
25-	I like to hold a cigarette between my fingers
26-	My cigarette smoke leaves an unpleasant smell
27-	Smoking calms me down when I am upset
28-	Smoking gives me very bad breath
29-	It feels so good to smoke!
		Totally disagree	Do not really agree	More or less agree	Agree	Fully agree
30-	I spend too much money on cigarettes
31-	A cigarette helps me deal with difficult situations
32-	My cigarette smoke bothers other people a great deal
33-	After a cigarette, I am able to concentrate better
34-	My second-hand smoke is dangerous to those around me
35-	Smoking is bad for my skin
36-	I like the motions of smoking
37-	It bothers me to be dependent on cigarettes
38-	I would have more energy if I did not smoke
		Totally disagree	Do not really agree	More or less agree	Agree	Fully agree

Questions for all participants:

39- Are you ?

40- What is year of birth ? I was born in the year:

41- Cigarette smokers:
How many cigarettes do you smoke per day, on average ?
Cig./day:

42- To assess the stability of responses, we would like you to answer the same questionnaire again in 1 week from now. We would also like to assess your smoking status in 1 month from now. If you agree, please indicate your first name and e-mail. Thanks + + First name:
E-mail:

Important: please check that you answered ALL questions

Thank you + + for your help ! ! !

http://www.hon.ch/QuitSmoking/scales.html

Last modified: Thu Jul 25 2002

6-	Are you currently a cigarette smoker ?
7-	Are you seriously considering quitting smoking within the next 6 months ?
8-	Are you planning to quit in the next 30 days ?
9-	Have you smoked ANY cigarettes during the past 6 months ?
10-	Have you smoked ANY cigarettes during the past 30 days ?
11-	Have you smoked ANY cigarettes during the past 7 days ?

39-	Are you ?
40-	What is year of birth ?	I was born in the year:
41-	Cigarette smokers: How many cigarettes do you smoke per day, on average ?	Cig./day:
42-	To assess the stability of responses, we would like you to answer the same questionnaire again in 1 week from now. We would also like to assess your smoking status in 1 month from now. If you agree, please indicate your first name and e-mail. Thanks + +	First name: E-mail: