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

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

2. 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

3. 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

4. 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

5. 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

6. In this Program I learned something new about tobacco use

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

7. This Program was effective in convincing me not to smoke

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

8. This Program may be helpful for my friends or family members who smoke

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

Comments or suggestions_________________________________________________
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