Test your dependence on cigarettes

• After answering, you will get 2 scores:
  - your score on the Fagerström Test for Nicotine Dependence,
  - your score on the Cigarette Dependence Scale (CDS-12)

• Your will also obtain a comparison of your score with the average score of all other participants.

• Important: please answer to ALL questions.

In the past 12 months, did you smoke tobacco more than once to feel better, or to change your mood?	Yes No
Do you currently smoke tobacco?	Yes, every day Yes, but NOT every day No, never
Please rate your addiction to cigarettes on a scale of 0 to 100: - I am NOT addicted to cigarettes at all = 0 - I am extremely addicted to cigarettes = 100	0 1 2 3 4 5 8 10 12 15 20 25 30 35 40 45 48 49 50 51 52 55 60 65 70 75 80 85 88 90 92 95 98 100 Addiction
On average, how many cigarettes do you smoke per day?	0 0.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 25 28 29 30 35 40 45 50 55 60 65 70 75 80 90 100 Cig./day
Usually, how soon after waking up do you smoke your first cigarette?	0 0.5 1 2 3 4 5 6 8 10 15 20 25 30 35 40 45 50 60 75 90 120 180 240 300 360 420 480 600 720 840 960 Minutes
For you, quitting smoking for good would be:	Impossible Very difficult Fairly difficult Fairly easy Very easy
Do you find it difficult to refrain from smoking in places where it is forbidden, e.g. in a church, at the library, in cinema, etc.?	Yes No
Which cigarette would you hate most to give up?	The first one in the morning All others
Do you smoke more frequently during the first hours after waking than during the rest of the day?	Yes No
Do you smoke when you are so ill that you are in bed most of the day?	Yes No
How much would you pay for a treatment that would give you a 100% chance of quitting smoking for good, without suffering from tobacco withdrawal?	in Euros: 0 1 10 20 50 100 200 500 1000 2000 5000 10000 20000 50000 100000 200000 500000 1000000 in U.S. dollars: 0 1 10 20 50 100 200 500 1000 2000 5000 10000 20000 50000 100000 200000 500000 1000000
Considering your tobacco smoking in the past 12 months:
Have you found that you needed to smoke more tobacco to get the same effect that you did when you first started smoking?	Yes No
When you reduced or stopped smoking, did you have withdrawal symptoms (depressed mood, irritability, frustration or anger, difficulty sleeping, difficulty concentrating, increased appetite or weight gain, decreased heart rate, feeling agitated, anxious or restless)?	Yes No
Did you smoke any tobacco to keep yourself from getting any of these withdrawal symptoms or so that you would feel better?	Yes No
Have you often found that when you smoked tobacco, you ended up smoking more than you thought you would?	Yes No
Have you tried to reduce or stop smoking but failed?	Yes No
On the days that you smoked, did you spend substantial time (more than 2 hours) smoking, obtaining tobacco, or thinking about tobacco?	Yes No
Did you spend less time working, enjoying hobbies, or being with family or friends because of your smoking?	Yes No
Have you continued to smoke, even though it caused you health or mental problems?	Yes No

Please indicate whether you agree with each of the following statements:

	Totally disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Fully agree
After a few hours without smoking, I feel an irresistible urge to smoke
The idea of not having any cigarettes causes me stress
Before going out, I always make sure that I have cigarettes with me
I am a prisoner of cigarettes
I smoke too much
Sometimes I drop everything to go out and buy cigarettes
I smoke all the time
I smoke despite the risks to my health
	Totally disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Fully agree

Are you?	A man A woman
How old are you?	I am 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 95 years old
We would like to contact you in some time from now, to ask you whether you are still a smoker. This information will enable us to study the association between level of dependence and smoking cessation. If you agree to be contacted, please indicate your first name and e-mail address:	First name: E-mail:
We would like to archive your answers in a computer file, in order to conduct statistical analyses (in an anonymous format), and to contact those who wish to be contacted. - If you do not want your answers to be archived, please tick this box. - Please also tick this box if you answer the questionnaire just to see how it works, and not seriously.

Please check that you answered to ALL questions.

Source: Etter JF, Le Houezec J, Perneger TV. A self-administered questionnaire to measure dependence on cigarettes: the cigarette dependence scale. Neuropsychopharmacology. 2003 Feb;28(2):359-70.

Created by , last modified Aug. 30, 2002