Assessment of smoking history, current smoking status, and related behaviors
| {Each question block is a separate module that can be combined with other modules, and the items can be renumbered.} |
|---|
| Initial Assessment |
| 1. Have you smoked at least 100 cigarettes in your entire life? (5 packs = 100 cigarettes) |
| (a) Yes |
| (b) No (If no, this is the end of section) {Code as: Never Smoker} |
| (c) Don't know/Not sure |
| 2. Do you NOW smoke cigarettes? |
| (a) Everyday (Skip to item 5) |
| (b) Some days (Skip to item 5) {a and b—Code as: Current Smoker} |
| (c) Not at all {Code as: Former Smoker} |
| 3. For how many years did you smoke regularly? ____ {Duration—Former Smoker} |
| 4. If you do not currently smoke cigarettes but did in the past, how long has it been since you last smoked regularly (i.e., everyday or some days)? |
| (a) Within the past month (0-1 month ago) |
| (b) Within the past 3 months (1-3 months ago) |
| (c) Within the past 6 months (3-6 months ago) |
| (d) Within the past year (6-12 months ago) |
| {a-d—Code as: Recent Former Smoker} |
| (e) Within the past 5 years (1-5 years ago) |
| (f) Within the past 15 years (5-15 years ago) |
| (g) More than 15 or more ago |
| {e-g—Code as: Long-term Former Smoker} |
| (h) Don't know/Not sure |
| (i) Never smoked regularly |
| 5. On average, about how many cigarettes a day do (or did) you smoke? (1 pack = 20 cigarettes) _____ cigarettes {Dose} |
| 6. At what age did you begin smoking regularly? _____ {Age at Initiation}* |
| *{To calculate duration for current smokers, subtract age at initiation from current age.} |
| Follow-up Assessment |
| 1. Do you NOW smoke cigarettes? |
| (a) Everyday |
| (b) Some days {a and b—Code as: Current Smoker} |
| (c) Not at all {If you do not smoke cigarettes at all, this is the end of section.} {Code as: Quit} |
| 2. On average, about how many cigarettes a day do you smoke? (1 pack = 20 cigarettes) _____ cigarettes {Dose} |
| Nicotine Dependence |
| 1. How soon after you wake up do you smoke your first cigarette? |
| (a) After 30 minutes |
| (b) Within 30 minutes {Code as: Highly Dependent} |
| Readiness to Stop Smoking |
| 1. How many times in the last 12 months have you tried to quit smoking cigarettes and stayed off for at least 24 hours? _____ |
| 2. Are you seriously thinking about quitting in the next month? |
| (a) Yes (If yes, this is the end of section) {Code as: Preparation Stage if >1 quit in item 1 or Contemplation Stage if 0 quits in item 1} |
| (b) No |
| 3. Are you seriously thinking about quitting smoking in the next 6 months? |
| (a) Yes {Code as: Contemplation Stage} |
| (b) No {Code as: Precontemplation Stage} |
| Other Forms of Tobacco |
| 1. Have you ever used other forms of tobacco? |
| (a) Yes |
| (b) No (If no, this is the end of section) |
| 2. What other forms of tobacco do (did) you use? |
| (a) Pipe |
| (b) Cigar |
| (c) Chewing tobacco |
| (d) Snuff |
| (e) Other, specify _____ |
| 3. Do you use other forms of tobacco everyday, some days, or not at all? |
| (a) Everyday (This is the end of section) |
| (b) Some days (This is the end of section) |
| (c) Not at all |
| 4. If you do not currently use other forms of tobacco but did in the past, how long has it been since you last used other forms of tobacco regularly (i.e., daily)? |
| (a) Within the past month (0-1 month ago) |
| (b) Within the past 3 months (1-3 months ago) |
| (c) Within the past 6 months (3-6 months ago) |
| (d) Within the past year (6-12 months ago) |
| (e) Within the past 5 years (1-5 years ago) |
| (f) Within the past 15 years (5-15 years ago) |
| (g) More than 15 years ago |
| (h) Don't know/Not sure |
| (i) Never smoked regularly |
| Exposure to Secondhand Smoke |
| 1. Do people in your household smoke in the home? |
| (a) Yes (If yes, how many? _____) |
| (b) No |
| 2. Is smoking allowed in your workplace? |
| (a) Yes |
| (b) No |