Note: The online version of STOP is a simplified version of the main STOP system, and does not perform certain computationally time-consuming types of tailoring.
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Name:
Age: Male: Female:
(If you don't fill in your name and age the program cannot produce a letter for you!)
How many cigarettes do you smoke in a day?
Less than 5 5 - 10 11 - 15 16 - 20 21 - 30 31 or more Do you smoke your first cigarette within 30 minutes of waking? Yes No Are you intending to stop smoking in the next 6 months? Yes No
If Yes, Are you intending to stop within the next month? Yes No
If NO, Would you like to stop if it was easy? Yes No Not Sure If you were to try to stop smoking, how confident would you be about succeeding? very confident fairly confident not confident If you were to try to stop smoking, how supportive or helpful do you think the following people would be? | Very | Quite | Not at all | N/A | your husband/wife/partner | | | | | other members of your family | | | | | your friends | | | | | your workmates | | | | | What are the good things for you about smoking? | Very important | Quite important | Not important | it helps me to relax | | | | it helps to break up my working time | | | | it is something to do when I am bored | | | | it helps me to cope with stress | | | | I enjoy it | | | | it is something I do with my friends or family | | | | it stops me putting on weight | | | | it stops me getting withdrawal symptoms | | | | What are the things you don't like about your smoking? | Very important | Quite important | Not important | it is expensive | | | | it is bad for my health | | | | I don't like feeling dependent on cigarettes | | | | it makes my clothes and breath smell | | | | it is a bad example for children | | | | it is unpleasant for people near me | | | | it makes me less fit | | | | people around me disapprove of my smoking | | | | it is bad for the health of people near me | | | | What might make it difficult for you to stop smoking? | Very important | Quite important | Not important | I enjoy smoking too much | | | | I don't think I have enough willpower | | | | I think I would put on weight | | | | I would be too stressed | | | | I think I am too addicted to cigarettes | | | | my partner smokes | | | | I would miss smoking with friends | | | | I can't resist the craving for a cigarette | | | | I don't really want to stop | | | | I would be bored | | | | I would miss smoking breaks at work | | | | Tick any of these that you have. breathlessness cough wheeze chest pain frequent chest infections circulation problems asthma heart attack bronchitis emphysema angina stroke Tick any of these health problems that you are worried about getting in the future
Heart disease stroke lung cancer bronchitis circulation problems Do you think that ... | Yes | No | Don't know | If you keep smoking you are more likely to become ill in the future? | | | | If you stop smoking, you will be healthier in the future? | | | | The number of cigarettes you smoke will damage your health? | | | | Does your smoking worry you? Yes No Have you tried to stop smoking before? Yes No
If No, please go to end of questionnaire and submit this form. Thank you.
If Yes, please continue. When did you last try to stop smoking?
Within the last 6 months 6 - 12 months ago
1 - 5 years ago Over 5 years ago What is the longest time you ever stopped for?
Less than one week 1 week - 1 month 1 - 3 months
3 - 12 months More than 1 year Why did you start smoking again? | Very important | Quite important | Not important | I enjoy smoking too much | | | | I put on weight | | | | I felt too stressed | | | | my partner smoked | | | | a lot of my friends smoked | | | | I couldn't resist the craving for a cigarette | | | | I didn't really want to stop in the first place | | | | the withdrawal symptoms were too unpleasant | | | | Have you ever tried nicotine patches or nicotine chewing gum? Yes No If Yes, how useful did you find them? Very useful Quite useful Not useful
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