Gender

Age

Amount smoked daily

Have you ever tried to stop smoking?

How long has your best attempt to stop lasted?

Do you believe smoking helps to relax you?

Do you believe that smoking helps you concentrate?

Do you believe that smoking relieves stress or cope with anxiety?

Smoking keeps me thin / Quitting makes me put on weight

Do you believe that it takes willpower to quit smoking

Do you believe that nicotine withdrawal is difficult?

When you quit smoking, you are nicotine-free after: