Form No number No number Smoking diary

Form Approved
OMB No. 0920-0736
Exp. Date 3/31/2010

Human Smoking Behavior Study
Smoking Diary Form

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR
Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0736)

ID #:

Human Smoking Behavior
Study

Daily Cigarette Use Diary

Centers for Public Health Research and Evaluation
Human Exposure Assessment Laboratory

2007

Dates: ____________ to ______________

Battelle is conducting this study on behalf of the Centers for Disease Control and Prevention.
All information provided will be kept confidential and will be identified by code number only.

The column headings refer to these questions:
1.
2.
3.
4.
5.
6.

Cigarette number for that day.
What time did you start smoking this cigarette? Please circle the am or pm.
What are you doing right now as you smoke; working, resting, driving, on the phone, or other?
Where are you as you smoke; home, work, car, or other place?
Are you smoking at a hurried or a normal pace?
Are you smoking your own cigarette brand, or did you get another brand from somebody else for
this smoke?

When you reached for the cigarette:
7. On a scale of 1-5, how much did you crave the cigarette? 1=Did not crave at all to 5=Craved it
very much
8. On a scale of 1-5, how active were you? 1=Inactive to 5=Very active
9. What was your mood: sad, neutral, or happy?

1

DATE:

-

DAY 1

- 2007

When you reached for the cigarette:

While smoking:

1.

2.

Cig

Time

1

am
_____ pm

2

am
_____ pm

3

am
_____ pm

4

am
_____ pm

5

am
_____ pm

6

am
_____ pm

7

am
_____ pm

8

am
_____ pm

9

am
_____ pm

10

am
_____ pm

11

am
_____ pm

12

am
_____ pm

13

am
_____ pm

14

am
_____ pm

15

am
_____ pm

16

am
_____ pm

17

am
_____ pm

18

am
_____ pm

3.

4.

5.

Doing while smoking

Location

Pace

 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone

 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone

6.
Own
Brand?

7.
Craving
1–5

8.
Activity
1–5

9.
Mood

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Sad
 Neutral
 Happy

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy

2

DAY 1 (continued)
When you reached for the cigarette:

While smoking:

1.

2.

Cig

Time

19

am
_____ pm

20

am
_____ pm

21

am
_____ pm

22

am
_____ pm

23

am
_____ pm

24

am
_____ pm

25

am
_____ pm

26

am
_____ pm

27

am
_____ pm

28

am
_____ pm

29

am
_____ pm

30

am
_____ pm

31

am
_____ pm

32

am
_____ pm

33

am
_____ pm

34

am
_____ pm

35

am
_____ pm

36

am
_____ pm

37

am
_____ pm

3.

4.

5.

Doing while smoking

Location

Pace

 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone

6.
Own
Brand?

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

7.
Craving
1–5

8.
Activity
1–5

9.
Mood
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy

3

DAY 2
DATE:

-

- 2007
When you reached for the cigarette:

While smoking:

1.

2.

Cig

Time

1

am
_____ pm

2

am
_____ pm

3

am
_____ pm

4

am
_____ pm

5

am
_____ pm

6

am
_____ pm

7

am
_____ pm

8

am
_____ pm

9

am
_____ pm

10

am
_____ pm

11

am
_____ pm

12

am
_____ pm

13

am
_____ pm

14

am
_____ pm

15

am
_____ pm

16

am
_____ pm

17

am
_____ pm

18

am
_____ pm

3.

4.

5.

Doing while smoking

Location

Pace

 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone

 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone

6.
Own
Brand?

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

7.
Craving
1–5

8.
Activity
1–5

9.
Mood
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy

 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy

4

DAY 2 (continued)
When you reached for the cigarette:

While smoking:

1.

2.

Cig

Time

19

am
_____ pm

20

am
_____ pm

21

am
_____ pm

23

am
_____ pm

23

am
_____ pm

24

am
_____ pm

25

am
_____ pm

26

am
_____ pm

27

am
_____ pm

28

am
_____ pm

29

am
_____ pm

30

am
_____ pm

31

am
_____ pm

32

am
_____ pm

33

am
_____ pm

34

am
_____ pm

35

am
_____ pm

36

am
_____ pm

37

am
_____ pm

3.

4.

5.

Doing while smoking

Location

Pace

 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone
 Working  Resting
 Driving  Other
 On the phone

6.
Own
Brand?

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

 Home
 Car

 Work
 Other

 Hurried
 Normal

 Yes
 No

7.
Craving
1–5

8.
Activity
1–5

9.
Mood
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy
 Sad
 Neutral
 Happy

5

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