Smoker's Tracking Form

Instructions: Print, then cut out this form, fold it, and put it in your cigarette package or another convenient place. Record every cigarette you smoke until the chart is complete. Then answer the questions at the end of this page.

For the column on mood put:

G if your mood is good or happy before smoking
B if you're in a bad mood, angry or sad before smoking
? if you're not sure how you feel before smoking

For the column marked "Rate", put in a number between 1 and 5 where,

1 = I could have done without this smoke
5 = I really had to have this cigarette

When the form is complete, use it to answer these questions:

• About how much do you smoke each day?
• What time of day do you usually smoke?
• When do you usually smoke your first cigarette of the day?
• In which places do you smoke the most?
• Could you avoid these places for a couple of weeks after you quit smoking?
• Do you tend to smoke around certain people?
• Would you feel comfortable asking them for help to quit smoking?
• Do you have friends around whom you don't smoke?
• Would it be possible to see these people more often during the time you are trying to quit?
• Do you feel a certain way before, during or after you smoke?
• Are there ways, other than smoking, that you could use to deal with negative feelings or produce positive feelings?
• How many times did you smoke, even when you didn't have a strong desire to have a cigarette?
• Which cigarettes are most important to you?