Quit Cold Turkey Challenge Registration Form

YesNo
Camera *
Print *
Radio *
Which of the following tobacco/nicotine product do you smoke/use? *
Have you tried to quit smoking before? *
Which products/ methods have you used in your prior attempts to quit?
Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree
I have a desire for a cigarette right now *
Nothing would be better than smoking a cigarette right now *
If it were possible, I would probably smoke right now *
I could control things better right now if I could smoke *
All I want right now is a cigarette *
I have an urge for a cigarette *
A cigarette would taste good right now *
I would do almost anything for a cigarette right now *
Smoking would make me less depressed *
I am going to smoke as soon as possible *
Strongly DisagreeDisagreeSomewhat AgreeAgreeStrongly Agree
I am frightened of being injured *
The thought of injury terrifies me *
I worry about becoming physically ill *
The thought of physical illness scares me *
I worry about being injured *
I worry that I might get a serious physical illness in the future *
I worry about my physical health *
I get scared if I think I am coming down with an illness *
I can't stand the thought of being injured *
How soon after you wake up do you smoke your first cigarette? *
Do you find it difficult to refrain from smoking in places where it is forbidden such as church, library or movie theatres? *
Which cigarette would you hate to give up most? *
DO you smoke more frequently during the first hours after waking than the rest of the day? *
Do you smoke if you are so ill that you are in bed most of the day? *

Page Last Updated: 30/10/2018