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1.	How soon after you wake up do you smoke your first cigarette?
	After 30 minutes Within 30 minutes
2.	Do you find it difficult to refrain from smoking in places where it is forbidden, such as the library, theater, doctor's office?
	No Yes
3.	Which of all the cigarettes you smoke in a day is the most satisfying?
	Any other than the first one in the morning The first one in the morning
4.	How many cigarettes a day do you smoke?
	1-15 16-25 More than 25
5.	Do you smoke more during the morning than during the rest of the day?
	No Yes
6.	Do you smoke when you are so ill that you are in bed most of the day?
	No Yes
7.	Does the brand you smoke have a low, medium, or high nicotine content?
	Low (0-.4 mg nicotine) Medium (.5-.9 mg nicotine) High (1.0 mg nicotine and above)
8.	How often do you inhale the smoke from your cigarette?
	Never Sometimes Always
How motivated are you?
9.	When you make up your mind to do something, do you follow through on it?
	Most of the time Some of the time Usually not
10.	Do you find that getting help from family, friends or professionals has helped you achieve desired goals?
	No Yes