Daily Cigarette Count Wrap Sheet
Instructions: Wrap this "Daily Cigarette Count" around your pack of cigarettes and hold it fast with two rubber bands. Complete the information below if you unwrap your pack or are offered a cigarette by someone else. Use a word or two to describe your "activity," "feeling," and "need rating" at the time.
Day of the Week _____________ Date __________ Pack # of the Day ______
|
Cigarette (circle) |
Time of the Day
|
Activity
|
Feeling
|
Need Rating* (circle) |
Strategy for avoiding cigarette
|
|
1
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
2
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
3
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
4
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
5
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
6
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
7
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
8
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
9
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
10
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
11
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
12
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
13
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
14
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
15
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
16
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
17
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
18
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
19
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
20
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
21
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
22
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
23
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
24
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
|
25
|
___________
|
________________
|
____________
|
1... 2... 3
|
___________________________
|
Sample "Feelings" - bored, angry, tire, relaxed, anxious, upset, happy, nervous, energetic, tense, sad, sorrowful, excited.
Sample "Activity" - driving, coffee break, after meal, cocktails, telephone, TV, arguing, talking to boss, waiting, reading, studying, waking up, worrying, etc.
*Need Rating: How important that particular cigarette is to you at the time.
1. - Most important (would have missed it very much)
2. - Average
3. - Least important (would not have missed it)
American Cancer Society
Massachusetts Division, Inc.