Step Ahead Tobacco Dependency Programs


History of use

1. Which tobacco product(s) have you used in the past and in what amount(s)?


2. Which tobacco product(s) do you use currently and in what amount(s)?


3. How old were you at the time of your first tobacco use?


4. When did you begin using tobacco regularly?


5. How long have you been using tobacco product(s)?


6. What quantity of tobacco did you use at your heaviest use period?


7. Have you switched brands? If so, what brand(s) did you use initially and what brand(s) are you using now?


8. How did you feel the first time you consumed a tobacco product?


9. What are the effects of your tobacco use currently?


10. Have you ever tried to cut down or quit your tobacco use? _______

If yes, answer the following questions:

a. For how long did you cut down or quit?


b. If you cut down, by how much did you reduce you use?


c. Did you quit? If so, for how long?


d. Why did you resume tobacco use?


11. Has tobacco use ever resulted in limiting your activities (e.g. reduced sports participation, avoidance of social events where smoking is not allowed, didn't take or left a job because smoking was not permitted)?


12. If you awaken during the night, do you have a cigarette?


13. Have you ever been reprimanded or received consequences for non-compliance with tobacco policies (school, workplace, restaurant, movie theater, healthcare facility, etc.)?


14. To what extreme have you gone to use tobacco (i.e. what's the most bizarre thing you've done to obtain or use tobacco?)


15. Which withdrawal symptoms have you experienced when tobacco was not available or you quit?

___ a. Agitation

___ d. Cravings

___ g. Disorientation

___ j. Weight gain

___ m. Restlessness

___ b. Anger

___ e. Crying

___ h. Frustration

___ k. Nervousness

___ c. Anxiety

___ f. Depressed feelings

___ i. Sleep disturbance

___ l. Irritability/Hostility

16. Have you ever or do you now have symptoms of the following conditions? Check the ones you've had.

____ Substance Abuse/Dependence

____ Asthma

____ Cataracts

____ Diabetes

____ Emphysema

____ Any form of oral cancer(s)

____ Halitosis (bad breath)

____ HIV-associated illness

____ Infertility

____ Kidney cancer

____ Leukoplakia (leathery gum patches)

____ Muscular degeneration

____ PMS

____ Peptic ulcer disease

____ Wrinkles

____ Atherosclerosis (hardening of the arteries)

____ Bronchitis

____ Cavities

____ Circulatory Problems

____ Early menopause

____ Gingivitis (gum disease)

____ Heart problems

____ Impotence

____ Influenza

____ Bladder cancer

____ Lung cancer

____ Pancreatic cancer

____ Osteoporosis

____ Stroke(s)

____ Cardiomyopathy

Level of Nicotine Toxicity (The following point count can help to determine your nicotine level and provide a guide for which patch dosage is appropriate for you should you choose to use a transdermal patch. These questions are taken in part from the Fagerström Test.)

1. How many cigarettes do you smoke daily?

a. ____ 10 or less(0 points)

b. ____ 11-20(1 point)

c. ____ 21-30(2 points)

d. ____ 31+(3 points)

2. Do you smoke more frequently during the first hours after waking than during the rest of the day? ___ Yes (1 point)____ No (0 points)

How soon after you wake up do you smoke your first cigarette?

a. ____ Within 5 minutes(3 points)

b. ____ 6-30 minutes(2 points)

c. ____ 31-60 minutes(1 point)

d. ____ 60+ minutes(0 points)

3. Is it hard to not use tobacco in certain places (e.g. movies, church, smoke-free setting?)

a. ____ Yes (1 point)b. ____ No (0 points)

4. If you are ill to the extent you are in bed most of the day, do you smoke?

a. ____ Yes (1 point)b. ____ No (0 points)

5. Which cigarette would you dislike most to give up?

a. ____ The first one in the morning (1 point)

b. ____ Any others (0 points)


Stage of Change Assessment (based on the work of Drs. Prochaska and DiClemente.)

Check the statement which best describes you current attitude toward your tobacco use:

1._____ I currently smoke/use tobacco and am certain that I do not want to quit.

2._____ I am willing to think about quitting, but am not sure I am ready to quit now.

3._____ I am interested in quitting smoking/tobacco use in the next 6 months, and I would be interested in any assistance I could get.

4._____ I have recently stopped smoking/using tobacco, and I need to work at not slipping back to using.

5._____ I have not smoked/used tobacco products for over 6 months.

6._____ I have recently begun smoking/using tobacco after a period of abstinence.

The material in this questionnaire has been modeled after a nicotine assessment form developed by the Addressing Tobacco Project, Inc. © 1998. Though not a definitive tool, it gives valuable information to support clinical judgement.

If you are interested in help for a tobacco-use problem, print out and answer this questionnaire and fax or mail it to:

Step Ahead, Inc.,
54 Main Street, Suite 201
Succasunna, NJ 07876 &endash;

FAX: (973) 927-2250.

To email this questionnaire, copy the questionnaire in your web browser and paste it into your email program. Then fill out the answers and email to:

Your Name ________________________________

Tele. No. __________________________________

Fax: ______________________________________

Email: _____________________________________

Address ___________________________________

City _____________________________

State _____Zip ____________________


Step Ahead Inc.
54 Main Street,
Suite 201
New Jersey 07876

  • 1-877-927-7837
  • 1-973-927-9555
  • 1-973-927-2250 (fax)

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