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| | This statement describes me… |
|
| Withdrawal subscale | Not at all | A little | Pretty well | Very well |
| When I go too long without a cigarette I get nervous or anxious | 0 | 1 | 2 | 3 |
| When I go too long without a cigarette I lose my temper more easily | 0 | 1 | 2 | 3 |
| When I go too long without a cigarette I get strong urges that are hard to get rid of | 0 | 1 | 2 | 3 |
| When I go too long without a cigarette I get impatient | 0 | 1 | 2 | 3 |
| Psychological Dependence subscale | | | | |
| I would go crazy if I could not smoke | 0 | 1 | 2 | 3 |
| I rely on smoking to deal with stress | 0 | 1 | 2 | 3 |
| I rely on smoking to take my mind off being bored | 0 | 1 | 2 | 3 |
| I rely on smoking to focus my attention | 0 | 1 | 2 | 3 |
| Cue-Induced Craving subscale | | | | |
| After eating I want a cigarette | 0 | 1 | 2 | 3 |
| When I smell cigarette smoke I want a cigarette | 0 | 1 | 2 | 3 |
| When I see other people smoking I want a cigarette | 0 | 1 | 2 | 3 |
| When I feel stressed I want a cigarette | 0 | 1 | 2 | 3 |
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