Smoking Decisional Balance

Long Form

The following statements represent different options about smoking. Please rate how important each statement is to your decision to smoke according to the following five point scale:

1 = Not important at all

2 = Slightly important

3 = Moderately important

4 = Very important

5 = Extremely important

Please read each statement and circle the number on the right to indicate how you rate its level of importance as it relates to your making a decision about whether to smoke at the present time.

How important is this to me? Importance in making a decision about smoking:

Not at all Slightly Moderately Very Extremely

1. Smoking cigarettes is pleasurable. 1 2 3 4 5

2. My smoking affects the health of 1 2 3 4 5

others.

3. I like the image of a cigarette smoker. 1 2 3 4 5

4. Others close to me would suffer if I 1 2 3 4 5

became ill from smoking.

5. I am relaxed and therefore more 1 2 3 4 5

pleasant when smoking.

6. Because I continue to smoke, some 1 2 3 4 5

people I know think I lack the

character to quit.

7. If I try to stop smoking I’ll be irritable 1 2 3 4 5

and a pain to be around.

8. Smoking cigarettes is hazardous to 1 2 3 4 5

my health.

9. My family and friends like me better 1 2 3 4 5

when I am happily smoking than

when I am miserable trying to quit.

10. I’m embarrassed to have to smoke. 1 2 3 4 5

11. I like myself better when I smoke. 1 2 3 4 5

How important is this to me? Importance in making a decision about smoking:

Not at all Slightly Moderately Very Extremely

12. My cigarette smoking bothers other 1 2 3 4 5

people.

13. Smoking helps me concentrate and 1 2 3 4 5

do better work.

14. People think I’m foolish for ignoring 1 2 3 4 5

the warnings about cigarette smoking.

15. Smoking cigarettes relieves tension. 1 2 3 4 5

16. People close to me disapprove of my 1 2 3 4 5

smoking.

17. By continuing to smoke I feel I am 1 2 3 4 5

making my own decisions.

18. I’m foolish to ignore the warnings 1 2 3 4 5

about cigarettes.

19. After not smoking for a while a 1 2 3 4 5

cigarette makes me feel great.

20. I would be more energetic right now 1 2 3 4 5

if I didn’t smoke.