Processes of Change Questionnaire Client ID#_________________

Smoking Version: Long Form Date: ______/______/______

Assessment Point: _____________

INSTRUCTIONS:

THE FOLLOWING EXPERIENCES CAN AFFECT THE SMOKING HABITS OF SOME PEOPLE. THINK OF ANY SIMILAR EXPERIENCES YOU MAY BE CURRENTLY HAVING OR HAVE HAD IN THE LAST MONTH. THEN RATE THE FREQUENCY OF THIS EVENT ON THE FOLLOWING 5-POINT SCALE.

There are five possible responses to each of the items in the questionnaire:

1=Never

2=Seldom

3=Occasionally

4=Often

5=Repeatedly

Please read each statement and circle the number on the right to indicate how often each event occurs. Remember these statements refer to situations or thoughts you may have had dURING THE PAST month.

	Never	Seldom	Occasionally	Frequently	Repeatedly
1) Special people in my life accept me the same whether I smoke or not.	1	2	3	4	5
2) I see “No Smoking” signs in public buildings.	1	2	3	4	5
3) I can be open with at least one special person about my experiences with smoking.	1	2	3	4	5
4) I tell myself I can choose to smoke or not.	1	2	3	4	5
5) Instead of smoking I engage in some physical activity.	1	2	3	4	5
6) I recall articles with the problems of quitting smoking.	1	2	3	4	5
7) I notice that public places have sections set aside for smokers.	1	2	3	4	5
8) I recall information people have personally given me on the benefits of quitting smoking.	1	2	3	4	5
9) I am considering the belief that people quitting smoking will help to improve the world.	1	2	3	4	5

	Never	Seldom	Occasionally	Frequently	Repeatedly
10) I think about information from articles and advertisements on how to stop smoking.	1	2	3	4	5
11) Remembering studies about illnesses caused by smoking upsets me.	1	2	3	4	5
12) Other people in my daily life try to make me feel good when I don't smoke.	1	2	3	4	5
13) I tell myself I am able to quit smoking if I want to.	1	2	3	4	5
14) I have someone who listens when I need to talk about my smoking.	1	2	3	4	5
15) I remove things from my home that remind me of smoking.	1	2	3	4	5
16) I tell myself that if I try hard enough I can keep from smoking.	1	2	3	4	5
17) I recall information people have personally given me on how to stop smoking.	1	2	3	4	5
18) I make commitments not to smoke.	1	2	3	4	5
19) I reward myself when I don’t smoke.	1	2	3	4	5
20) I notice that nonsmokers are asserting their rights.	1	2	3	4	5
21) I stop to think that smoking is polluting the environment.	1	2	3	4	5
22) I can expect to be rewarded by others if I don’t smoke.	1	2	3	4	5
23) I keep things around my place of work that remind me not to smoke.	1	2	3	4	5
24) I find society changing in ways that make it easier for the nonsmoker.	1	2	3	4	5

	Never	Seldom	Occasionally	Frequently	Repeatedly
25) I get upset when I think about my smoking.	1	2	3	4	5
26) I find that doing other things with my hands is a good substitute for smoking.	1	2	3	4	5
27) When I am tempted to smoke, I think about something else.	1	2	3	4	5
28) I do something else instead of smoking when I need to relax or deal with tension.	1	2	3	4	5
29) I remove things from my place of work that remind me of smoking.	1	2	3	4	5
30) Warnings about the health hazards of smoking move me emotionally.	1	2	3	4	5
31) Dramatic portrayals of the evils of smoking affect me emotionally.	1	2	3	4	5
32) I react emotionally to warnings about smoking cigarettes.	1	2	3	4	5
33) I am rewarded by others if I don’t smoke.	1	2	3	4	5
34) I consider the view that smoking can be harmful to the environment.	1	2	3	4	5
35) I reassess the fact that being content with myself includes changing the smoking habit.	1	2	3	4	5
36) I consciously struggle with the issue that smoking contradicts my view of myself as a caring and responsible person.	1	2	3	4	5
37) I put things around my home that remind me not to smoke.	1	2	3	4	5
38) My dependency on cigarettes makes me feel disappointed in myself.	1	2	3	4	5
39) I am considering the idea that the world around me would be a better place without my smoking.	1	2	3	4	5
40) I have someone whom I can count on when I’m having problems with smoking.	1	2	3	4	5