Tobacco Use Survey Answer the following 6 questions to gain insight into your addiction to nicotine and your

readiness to quit. 1. For how many years have you used tobacco? _______ years - Cigarettes ____ packs/day
(Researchers determine the number of pack years that you have smoked by multiplying the number of years you have smoked by the packs you smoke per day by how many years have you used tobacco. The effects of tobacco use are cumulative. Once you get close to 20 pack years really nasty things potentially can begin happening to you.)

2. How soon after you get up in the morning do you first use tobacco? within 30 minutes After 30 minutes
(If you answered within the first 30 minutes you are definitely addicted. If you wait beyond 30 minutes, your success rate of quitting is greatly improved.)

3. Have you tried to quit within the 12 months? yes no For how long were you tobacco free? ________________________________________
(So youve tried before and werent successful. What that means to me is that you want to quit, you just need the help to stay quit.)

4. What was the longest period of time that you have ever been able to quit? _______________
(Further insight into your wanting to quit, but never for good.)

5. Do you use alcohol? yes no Do you find that drinking and smoking go hand-in-hand? yes no
(Its important to evaluate those factors that lead to you starting up again and plan to avoid those circumstances when you do quit.)

6. Are you seriously interested in quitting once and for all?

(These answers are a huge help in determining you readiness to quit. If you are in the Preparation Stage, lets get going and set a quit date. If youre in the Pre-Contemplative Stage, youve got a bunch of stuff to do before you can set a quit date.)

Yes! Within the next month Preparation stage

7. If you decided to stop using tobacco completely during the next two weeks, how confident are you that you would succeed? Very confident Confident Not very confident Maybe sometime within the next 6 months Contemplative Stage Not really, I havent thought much about it Pre-contemplative stage If you are interested in quitting smoking please see the Resources (link to resources page) Section or call your physician or our office for a Tobacco Cessation Consultation. For further information on the Stages of Change, refer to the book by Prochaska in the Resources (link to resources page) Section.

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