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Self-Assessments

Tobacco Use History

The following assessment is designed to help one think about his/her tobacco usage. This assessment may also shared with a health care provider or a Counseling and Health Promotion staff member to help evaluate usage and available options.

1. Check the box that best describes you:

  • I am using tobacco and have not thought about quitting. (Pre-contemplation)
  • I am using tobacco and have just started thinking about quitting. (Contemplative)
  • I am using tobacco and am preparing to quit. (Preparation)
  • I quit using tobacco less than 3 weeks ago. (Action)
  • I quit using tobacco 3 or more weeks ago. (Maintenance)

2. How old were you when you first began to smoke?

3. In the past year, which of the following tobacco products have you used?

  • Cigarettes
  • Cigars
  • Pipe
  • Dip/chew
  • Other (please specify)

4. On average, how many days in the past month have you used tobacco? ______ days

5. When you used any of the following, how much did you usually use in one day? ______ Cigarettes (20 cigarettes = 1 pack) ______ Cigars ______ Dip/Chew (dips per day) ______ Pipe (bowls per day)

6. How many years have you used tobacco? ______ years

7.Have you ever tried to quit using tobacco?

  • Yes
  • No

a. If yes, how many times? _____

b. What methods have you tried: (check all that apply)

  • On my own
  • Oral inhaler
  • Nicorette gum
  • Zyban/Wellbutrin
  • Nicotine patch
  • Web site for tobacco cessation
  • Nasal spray
  • Other (please specify)

c. What is the longest period of time you stayed away from tobacco since you started using?

What is your greatest obstacle to quitting?

8. Which of the following people in your life currently use tobacco?

  • Close friends
  • Significant other
  • Roommate
  • Parent(s)
  • Sibling(s)
  • Co-worker(s)

9. Have you experienced any of the following in the past year?

  • Bronchitis
  • Shortness of breath with exertion
  • Other long-term illness
  • Asthma
  • Persistent cough
  • Other respiratory condition
  • Allergies
  • Persistent hoarseness
  • Sinus infection
  • Heartburn
  • Sores in your mouth/lips
  • Ear infection

For more information on tobacco cessation, contact your health care provider or Counseling and Health Promotion at 320-363-2587.

Tobacco Self-Assessment

What stage best describes you at the current time:

  • Precontemplation: I am using tobacco and have not thought about stopping. Individuals in this stage have no interest in changing their behavior (i.e., smoking) in the next six months.
  • Contemplation: I am using tobacco and have just started thinking about stopping. People in this stage intend to make a change within the next six months. Generally people in this stage are ambivalent about making the change. They may be thinking about the barriers to change (e.g., time, expense, hassle, fear) as well as the benefits of changing. Giving up an enjoyed behavior can cause a feeling of loss despite the perceived gain.
  • Preparation: I am using tobacco and am preparing to stop. Individuals in this stage plan to take action within the next 30 days and have begun to take some steps in that direction.
  • Action: I stopped using tobacco less than 3 weeks ago. In this stage the individual has changed the behavior in the recent past.
  • Maintenance: I quit using tobacco 3 or more weeks ago. The changed behavior is more established.
  • Relapse/Recycle: Most people who stop the use of tobacco find themselves “recycling” through the stage of change several times before the change becomes truly established.