Have you ever smoked 100 cigarettes or more in your lifetime? |
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Do you currently smoke tobacco? |
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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? |
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Are you currently trying to quit smoking? |
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Have you made a serious attempt to quit smoking?...
. ... in the past 7 days? |
|
. ... in the past 12 months?
|
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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 |
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Have you ever used nicotine replacement products (i.e. nicotine
gums, patches, tablets or inhalers)? |
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Do you currently use nicotine replacement products (i.e. nicotine
gums, patches, tablets or inhalers)? |
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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? |
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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? |
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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? |
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In the past 12 months, have you made a serious attempt
to stop using nicotine gums? |
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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? |
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During the first week of your last attempt to stop using nicotine gums, did
you feel the urge to smoke? |
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Do you currently use the smoking cessation drug called "bupropion" or
"Zyban"? |
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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:
|