Smoker's Self-Test
The Quit Now! Program - Dr Lionel Hartley et. al.

You can complete the highlighted fields on this form online and then print the form for easy reference. Any text you enter into these fields will be cleared when you close the form; you cannot save it.
What would motivate you to quit smoking? Take a moment to fill out the smoker's self-test. Be honest when you answer the questions. You may discover that you have more good reasons to quit than to continue using tobacco.

Click on the box next to the statements that you agree with.

It makes me uncomfortable to know that I am hooked on nicotine.

I dislike the way my hair, hands, teeth, clothes, and home look and smell. I probably spend more time and money cleaning them than a non-smoker does.

I am concerned about how my smoking habit affects the health of my family and friends.

My opportunities for employment may be limited because I smoke.

I am concerned about the negative effects smoking may have on my sex life.

I worry that smoking may shorten my life.

I am embarrassed by the way other people look at me when I light a cigarette in a public place.

I could afford to buy more of the things I want if I didn't spend so much money on cigarettes.

I am (or would like to become) pregnant, but I'm worried about how my smoking habit might affect my baby.

I think others have a lower opinion of me because I smoke.

I wish I had more control over my smoking habit.

I worry about becoming a burden to my family if I get sick due to smoking.

Add any other concerns you have about smoking here:

Click HERE to print this page:

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Congratulations! If you clicked on any of the above statements, you've just started creating a list of reasons to quit smoking! Take a closer look at some of the issues that you indicated are of concern to you. Are any of them stronger or more meaningful to you than the reasons why you like to smoke?
Making a list of reasons to quit smoking is a good first step toward getting yourself motivated to quit smoking. Keep your list with you before you quit and for several weeks or months after you quit. Review it whenever you are struggling with the quitting process. Add to your list whenever another reason to quit occurs to you.
For added motivation, you can come back to this form anytime and re-do the test if you wish.

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