This pre-program assessment takes a "look under the hood" of what makes you smoke or chew tobacco and what makes it hard for you to stop. We'll build your customized Stop Smoking, Stop Chewing or Stop Vaping Hypnosis Program based on your answers. To maximize your success, please answer the questions to the best of your ability.
Click the "Start" button below to begin:
There are two sections to this questionnaire. This first section helps us understand your habit(s) around tobacco/nicotine use and your motivation to stop using tobacco and nicotine. We'll use this information to help you increase your motivation and maximize your success.
Question 2 of 33
1. Why do you want to stop smoking, chewing tobacco and/or vaping? What are your own reasons and what do you see as the benefits for you?
Question 3 of 33
2. Do you really want to stop?
Yes! Definitely!
Yes, but I have reservations or doubts.
Yes, but I'm not sure I'm ready.
No, but I'd like to get ready.
No, not really. I know I should be but I'm just not ready. Can you help me?
No, I definitely want to keep smoking or chewing. I might want to stop smoking or chewing someday in the future.
Question 4 of 33
3. How much tobacco/nicotine do you use each day? First please answer about smoking cigarettes.
I smoke half a pack or less of cigarettes a day.
I smoke between a half a pack and a whole pack of cigarettes a day.
I smoke one pack of cigarettes a day.
I smoke two packs of cigarettes a day.
I smoke more than two packs of cigarettes a day.
I don't smoke cigarettes anymore.
I have never smoked cigarettes.
Question 5 of 33
4. How much tobacco/nicotine do you use each day? Now please answer about smoking cigars.
I smoke one or fewer cigars a week.
I smoke one or fewer cigars a day.
I smoke one to two cigars a day.
I smoke more than two cigars a day.
I don't smoke cigars anymore.
I have never smoked cigars.
Question 6 of 33
5. How much tobacco/nicotine do you use each day? Now please answer about chewing tobacco.
I chew half a tin or less of tobacco a day.
I chew a tin of tobacco a day.
I chew one to two tins of tobacco a day.
I chew two tins of tobacco a day.
I chew more than two tins of tobacco a day.
I don't chew tobacco anymore.
I have never chewed tobacco.
Question 7 of 33
6. How much nicotine do you use each day? Now please reply about your vaping habit.
Question 8 of 33
7. If you smoke cigarettes, do you smoke them all the way down?
Yes.
No.
About half the time.
I don't know.
I don't smoke cigarettes.
Question 9 of 33
8. If you chew tobacco, how long does a chew last?
10-15 minutes
30 minutes
About an hour
1-2 hours
3 hours
4 hours or more
Question 10 of 33
9. If you smoke, what brand of cigarettes do you smoke? This helps gauge how much nicotine you're getting.
Question 11 of 33
10. If you chew, what brand of tobacco do you chew? This helps gauge how much nicotine you're getting.
Question 12 of 33
11. What age did you start smoking, chewing and/or vaping? What made you start?
Question 13 of 33
12. Have you stopped and started smoking, chewing and/or vaping again before?
Question 14 of 33
13. If you stopped smoking, chewing and/or vaping before, how did you stop?
Question 15 of 33
14. How easy or hard was it to stop then?
Really easy
Fairly easy
Somewhat easy
Neither easy nor difficult
Somewhat difficult
Moderately difficult
Really hard
Question 16 of 33
15. If you stopped before, what made you start again?
Question 17 of 33
16. List all the times you usually smoke, chew or vape, for example, before you have breakfast, on the drive to work, while you're on the phone, etc.
Question 18 of 33
17. What are the triggers that make you want to smoke, chew and/or vape? A trigger can be any situation, feeling, event, or even a person, that makes you feel like you want or need to smoke, chew or vape. List as many as you can think of.
Question 19 of 33
18. If you smoke, what do you like and dislike about smoking? If you chew, what do you like and dislike about chewing? If you vape, what do you like and dislike about vaping?
Question 20 of 33
19. Do you have any fears or worries about stopping smoking, chewing and/or vaping?
Question 21 of 33
19. Are there times you can go many hours without smoking and/or chewing and it does not bother you? If so, what are you doing at those times?
Question 22 of 33
20. Do you have any of these other habits that may make it harder to stop smoking, chewing or vaping? If you do, we'll want to talk further about how to increase your chances of success.
Alcohol use beyond 1-2 drinks per week.
Smoking marijuana
Using THC (the hallucinatory ingredient in marijuana)
Other drug use
Medication for chronic pain or other medical or mental health conditions.
In this second and final section of the questionnaire, we'll look at the reasons you smoke, chew and/or vape. Your answers will help us customize your Hypnosis Program to maximize your success. We'll use your own words to help your subconscious mind really get on board with what you consciously desire.
Question 24 of 33
1. Do you smoke, chew or vape because of anger or boredom?
Question 25 of 33
2. Is handling the cigarettes, lighter, matches, tin, chew, or vape pen, etc. or watching the smoke or vapor, or the feel of the chew, part of the enjoyment? If so, please describe.
Question 26 of 33
3. Do you think smoking, chewing and/or vaping is pleasant and relaxing? If so, please describe.
Question 27 of 33
4. When you run out of cigarettes, cigars, chew, or vaping liquid, do you find it almost unbearable until you get some again?
Yes, almost always.
Yes, most of the time.
Sometimes.
Not usually unless I'm stressed.
No, almost never.
Running out doesn't bother me at all.
Question 28 of 33
5. Do you smoke, chew and/or vape automatically without even being aware of it?
Yes! It happens pretty often.
Rarely.
Never.
Question 29 of 33
6. Do you smoke, chew and/or vape to stimulate or perk yourself up?
Yes, whenever I feel tired. And I feel tired a lot.
Yes, sometimes but not every day.
Yes, one or two times a week.
Yes, once or twice a month.
Question 30 of 33
7. Do you get a real gnawing hunger for a smoke, chew and/or vape when you have not had one recently?
Yes, always.
Yes, quite often.
Once in a while I notice feeling that way.
I don't miss smoking and/or chewing when I haven't recently.
Question 31 of 33
8. Do you often find a cigarette, cigar, chew or vape pen in your mouth and not remember putting it there?
Yes, it happens every day.
Yes, fairly often.
Not very often but it does happen.
Question 32 of 33
9. Do you smoke, chew and/or vape at work as a means of getting away for a few moments? If so, please describe.
Question 33 of 33
10. Do you smoke, chew and/or vape at home as a means of getting away for a few moments? If so, please describe.