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  • Smoking Cessation Questionnaire

  • Quitting is a process that will work with preparation and step-by-step adherence to a plan. You must feel very strongly that you are ready to quit before you move on. If you are ready, let’s get going!

  • Congratulations! You have just taken your first step down the road to success.
    Remember, one of the keys is to always focus on the positive aspects of quitting.


    Smoking has worked its way into so many areas of your life, and consequently, you
    need to alter your surroundings to limit your temptations. Part of that process is to limit where you smoke. Follow these steps carefully to prepare you to quit on your quit date. These are easy but remember to follow these steps EXACTLY in order to maximize your success. DON’T SKIP ANY STEPS!


    1) First, take a three by five card and write down your most important personal
    reasons for quitting. Keep this with you and look at it often as a reinforcement
    during your final week and as long as you need it after you quit. Especially read this card right before bedtime. Don’t underestimate the power of your own words.


    2) Choose a place to smoke in or around your home that is the least comfortable place you can think of to smoke. This will be the ONLY place in your home you smoke during this final week of smoking. Think about this clearly now. From this moment on, you no longer smoke for pleasure. You are smoking to quit. Now move all your smoking paraphernalia such as ashtrays and lighters to that one spot. This helps by making it more inconvenient to smoke. Limit smoking in the car and limit your smoking at work to the absolute minimum.


    THINK BEFORE YOU SMOKE. DO I REALLY WANT IT OR AM I JUST REACHING FOR IT OUT OF HABIT? DON’T SMOKE OUT OF HABIT! ONLY SMOKE IF IT IS A REAL PHYSICAL NEED.


    3) Next get rid of ALL the brands of cigarettes that you now smoke. Throw them
    away where you cannot retrieve them. You will no longer be smoking any of your regular brands of cigarettes again. Search out and discover and discard any and all of the hidden cigarettes you might have lurking around like in the couch and in the refrigerator.


    4) Next make a commitment to only buy cigarettes during this final week ONE pack at a time. You absolutely will not buy another pack until the one before is completely gone. Now here is the key. Each time you buy a new pack, you must change to a brand you know you don’t like. THIS IS VERY IMPORTANT! Remember, only buy a new pack when the one before is completely gone.

    5) For this final week, cut the cigarettes in half and only smoke the filtered half. Also, smoke the cigarettes in the opposite hand that you normally would. I know, about now you are probably thinking, “What is all this about?” This is about behavior modification. We must break some of the subconscious behaviors associated with smoking. Believe me when I tell you that you must follow these steps exactly in order to maximize your success. DON’T SKIP ANY STEPS!


    6) Limit your alcohol consumption the week prior through at least a week immediately after quitting. Alcohol can lessen your resolve to follow and complete this plan so limit the alcohol to little, or better yet, none.

    7) Reduce caffeine consumption to a minimum during and immediately after this process. Tea is a good replacement. This too can help you through this process.

    8) You MUST get plenty of rest, especially during your first smoke free week. As
    the body begins the healing process, it will help you through the physical changes with greater ease.

    9) Start to increase your intake of water and natural fruit juices now and at least
    through the first smoke free week and pick up a good quality B-complex vitamin supplement and with your doctors approval begin taking it the week before and continue after you quit. This can help the body deal with stress.

    10) Go out and tell all your friends and family you are going to quit on your quit
    date. This public commiment will help you achieve this goal.

    YOU CAN DO IT!!!!

     

  • Promise of Action

    I, ________________________________________ do hereby promise myself 

     

     

    that, as of ___________________ , __________________ I shall promise and

    commit myself to be free and quit smoking completely and remain a permanent ex-smoker.

     

     

    ________________________________________ 

                              Date

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  • Thank you for trusting me to help you quit smoking. This is a reminder that you are not in this alone and that we are working together to help you stop. We have made a contract together that you will follow the plan I have put together for you and NEVER give in to a craving.


    If you the tools provided during our session(s) you can remove the old behaviors and cravings and become smoke free for life. This is a commitment you are making to yourself and your life today and into the future. You are doing this first for yourself but also for those around you that care about you.


    Don’t forget that if you focus on just one craving or thought about cigarettes at a time and invest a few moments or even a few minutes to the tools and reframing of the thoughts you WILL BE FREE!


    Please do not hesitate to call me during the process if you need help and please listen to the recording you will be provided even if you think you don’t need to. It will help. 

    Take back your health, your self-respect, and your life!

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