1) About how much money do you spend on cigarettes each week?

2) About how many cigarettes do you smoke in an average day?

• 5 or less per day
• 6 to 10 per day
• 11 to 20 per day
• 21 to 30 per day (a pack to a pack-and-a-half per day)
• 31 to 40 per day (a pack-and-a-half to two packs per day)
• More than 40 per day (more than two packs per day)

3) About how long have you been smoking?

4) About how soon after waking up do you have your first cigarette?

• 15 minutes or less
• 15 to 30 minutes
• 30 to 60 minutes
• 1 to 2 hours
• More than 2 hours

5) In the past three months, which of these have caused you problems as a result of your smoking?

• 5a) Problems between you and your spouse or significant other

  • No Problem
  • Some Problem
  • Large Problem

• 5b) Problems between you and your friends or family

  • No Problem
  • Some Problem
  • Large Problem

• 5c) Coughing or breathing problems

  • No Problem
  • Some Problem
  • Large Problem

• 5d) Difficulty exercising

  • No Problem
  • Some Problem
  • Large Problem

• 5e) Difficulty sleeping

  • No Problem
  • Some Problem
  • Large Problem

• 5f) Smoked more than you had planned

  • No Problem
  • Some Problem
  • Large Problem

• 5g) Spent more on cigarettes than you had planned

  • No Problem
  • Some Problem
  • Large Problem

• 5h) Felt bad about your smoking

  • No Problem
  • Some Problem
  • Large Problem

• 5i) Used other substances (alcohol or drugs) during or after smoking

  • No Problem
  • Some Problem
  • Large Problem

• 5j) Someone else suggested you cut down or quit

  • No Problem
  • Some Problem
  • Large Problem

• 5k) Had trouble in not smoking in places where it was not allowed

  • No Problem
  • Some Problem
  • Large Problem

• 5l) Noticed a change in the way you look as a result of smoking (yellow fingers and teeth, leathery skin, etc.)

  • No Problem
  • Some Problem
  • Large Problem

• 5m) Felt guilty about the way your smoking affected others

  • No Problem
  • Some Problem
  • Large Problem

• 5n) Had other health or physical problems

  • No Problem
  • Some Problem
  • Large Problem

• 5o) Gave up other important activities to smoke

  • No Problem
  • Some Problem
  • Large Problem

• 5p) Felt angry or irritable when you couldn't smoke

  • No Problem
  • Some Problem
  • Large Problem

• 5q) People complaining about the stink of cigarette smoke in your clothes or hair

  • No Problem
  • Some Problem
  • Large Problem

• 5r) Worried about the health impact of your smoking on children and other adults

  • No Problem
  • Some Problem
  • Large Problem

6) How interested are you in changing your smoking?

• I am not interested in changing my smoking now or at any time in the near future.
• I may be interested in changing my smoking, but not right now.
• I have some interest in learning about changing my smoking. Tell me more!
• I am very interested in learning and changing my smoking.
• I am extremely interested in changing my smoking.

7) How ready are you to do something about your smoking?

• I do not feel at all ready to do anything about my smoking now.
• I may or may not be ready to change my smoking. I'm not sure.
• I feel somewhat ready to change my smoking.
• I am ready to something about my smoking.
• I am extremely ready to change my smoking now.

8) How much do you feel able to make a change in your smoking?

• I don't feel at all able to make any kind of change in my smoking.
• I may or may not be able to make a smoking change. I'm not sure.
• I think I can do it.
• I am definitely able to make a change in my smoking if I choose to.
• I feel I definitely can quit.

9) If you had a choice about changing your smoking, what would you prefer?

• Cutting down some.
• Cutting way down.
• Cutting down first and then quitting completely.
• Cutting down or quitting. Either is good.
• Quitting all the way.

10) How long would you like to take in changing your smoking?

• Very slowly over several months or never.
• Slowly over 6 to 12 weeks.
• In just a few weeks.
• In one week.
• Right away.