| How much do you value the following (Specific to Questions 1-2). | |
| 1. My cigarette habit is very important to me. | 0 1 2 3 4 |
| 2. I handle and manipulate my cigarette as part of the ritual of smoking. | 0 1 2 3 4 |
| Please indicate your choice by circling the number that best reflects your choice. (Specific to Questions 3-11). 0 = Never; 1 = Seldom; 2 = Sometimes; 3 = Often; 4 = Always | |
| 3. Do you place something in your mouth to distract you from smoking? | 0 1 2 3 4 |
| 4. Do you reward yourself with a cigarette after accomplishing a task? | 0 1 2 3 4 |
| 5. If you find yourself without cigarettes, will you have difficulties in concentrating before attempting a task? | 0 1 2 3 4 |
| 6. If you are not allowed to smoke in certain places, do you then play with your cigarette pack or a cigarette? | 0 1 2 3 4 |
| 7. Do certain environmental cues trigger your smoking, e.g. favourite chair, sofa, room, car, or drinking alcohol? | 0 1 2 3 4 |
| 8. Do you find yourself lighting up a cigarette routinely (without craving)? | 0 1 2 3 4 |
| 9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick, chewing gum, etc.) in your mouth and sucking to get relief from stress, tension or frustration, etc.? | 0 1 2 3 4 |
| 10. Does part of your enjoyment of smoking come from the steps (ritual) you take when lighting up? | 0 1 2 3 4 |
| 11. When you are alone in a restaurant, bus terminal, party, etc., do you feel safe, secure, or more confident if you are holding a cigarette? | 0 1 2 3 4 |
| TOTAL | |
| A high numerical response indicated a high behavioural dependence, and the lower numerical response indicated a lower behavioural dependence. | |
| Scoring for Behavioural Dependence | |
| <12 Mild | |
| 12–22 Moderate | |
| 23–33 Strong | |
| >33 Very strong |
Please indicate your choice by circling the number that best reflects your choice: 0 = not at all; 1 = somewhat; 2 = moderately so; 3 = very much so; 4 = extremely so.