1. Have you smoked tobacco one or more times within the past month?

? Yes ? No

2. If you checked Yes, which is the closest to describing the amount that you smoke:

? 1 pack or less per month
? 1 pack per week
? 1 pack per day

3. Check the box that best represents how you feel about smoking.

? I don't want to quit smoking
? I'm thinking about quitting at times
? I have decided to quit smoking
? I am ready to quit smoking now
? I have quit smoking for over one month
? I never smoked

4. Can people get addicted to cigarette smoking just like they can get addicted to
cocaine or heroin?

? definitely yes ? probably yes ? probably not ? definitely not

5. Do you think it is safe to smoke for only a year or two, as long as you quit after
that?

? definitely yes ? probably yes ? probably not ? definitely not

6. Do you believe 1 out of 3 people who start smoking by age 18 will die because
of their smoking?

? definitely yes ? probably yes ? probably not ? definitely not

7. Do you believe that 1 out of 2 teenagers who continue to smoke long term will die, on av-erage, 15 years early because of their smoking?

? definitely yes ? probably yes ? probably not ? definitely not