Pre-program Survey

Congratulations on thinking about quitting smoking!

This short questionnaire will help to assess your readiness to quit smoking. 

Please take a moment to complete these questions and then you will be directed to information which is appropriate for your stage of readiness. Or, you may choose your stage from the list below.

Questions

Are you currently a smoker?

Yes, I currently smoke.
No, I quit within the last 6 months.
No, I quit more than 6 months ago.

1. In the last year, how many times have you quit smoking for at least 24 hours?

2. Are you seriously thinking of quitting smoking?

Yes, within the next 30 days
Yes, within the next 6 months
No, not thinking of quitting

References

Pallonen, U.E., Velicer, W.F., Prochaska, J.O., Rossi, J.S., Bellis, J.M., Tsoh, J.Y., Migneault, J.P., Smith, N.F., Prokhorov, A.V. (1998). Computer-based smoking cessation interventions in Adolescents: description, feasibility, and six-month follow-up findings.  Substance Use & Misuse, 33(4), 935-965.

Stern, R.A., Prochaska, J.O., Velicer, W.F., & Elder, J.P. (1987). Stages of adolescent cigarette smoking acquisition: measurement and sample profiles. Addictive Behaviors, 12, 319-329.

Choose a stage . . .

Pre-contemplation Stage

Contemplation

Preparation

Action

Maintenance