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2. How much do you pay for a packet of cigarettes?

3. How long have you been smoking?

4. What feelings can you remember from the time you first started smoking?

5. Where do you smoke most of your cigarettes?

6. When do you enjoy a cigarette most?
First get up in the morningWith a cup of Coffee or TeaAs a rewardTo give time to yourselfAfter eating mealsAfter love making

Any other reason?

7. Where and when do you have the first cigarette of the day?

8. Do you smoke after meals?
YesNo
9. Do you smoke more in social situations?
YesNo
10. Are you usually in company with other Smokers when you smoke?
YesNo
11. Do you live with anyone else who smokes?
YesNo
Who?

12. Do you smoke at work?
YesNo
13. Do any of your work colleagues smoke?
YesNo
14. Do you wake up at night to have a cigarette?
YesNo

            PREVIOUS ATTEMPTS TO STOP
15. Have you stopped smoking before?
YesNo
If yes, for how long?

16. What method did you use?
Nicotine PatchesChewing GumHypnotherapyWillpowerOther
17. What made you start smoking again?

            GENERAL HEALTH
18. Do you suffer from breathing difficulties?
YesNo
19. Do you suffer from colds, coughs and/or flu?
YesNo
20. Are you health conscious?
YesNo
21. Would you describe your health as:
ExcellentGoodFairPoor
22. Has any member of your family died through smoking related illnesses?
YesNo
23. Do you have any major stresses in your life at present? If yes, briefly describe below:

            SMOKING PATTERNS
24. Think about when you smoke and please mark which most apply to you. You can also add your own. I smoke more when I am:
StressedAngryLonelyBoredUpsetOn the telephoneDrivingRelaxingSocializingThinkingNervousIrritableUnder pressureTalkingWalkingHappyWorried
Other reasons

25. Would you rather spend your hard earned money on other things than cigarettes?
YesNo
26. Would you like your body to be healthier?
YesNo
27. Would you like to extend your life expectancy?
YesNo
28. Would you enjoy having more energy?
YesNo
29. Would you like to taste your food more?
YesNo
30. Would you prefer your breath and clothes to smell fresher?
YesNo
31. Are you ready to use a drug free way to become a non-smoker?
YesNo

If you answered YES to the above seven questions, then you’re already on your way to becoming a lifelong non-smoker.