The Effect of Tobacco Use on Exercise
Perception and Cardiac Rehabilitation Enrollment among Patients with Heart Disease – Questionnaire
Instructions:
Please answer each question to the best of your ability. If you need an explanation about any of the questions in the following survey, please ask __________________, the research associate who will remain available to you while you complete the study questionnaires. You may skip any question if you wish. However, complete and honest answers are appreciated. If you do not wish to quit smoking, do not want to start an exercise program, or choose not to attend cardiac rehabilitation, we still very much welcome and encourage your participation in this study.
What is Cardiac Rehabilitation?
Cardiac rehabilitation (rehab) is a program that takes place outside the hospital. The main goal of cardiac rehab is to help people feel better and live longer, healthier lives. It is supervised by nurses, clinical exercise physiologists, and physicians. Cardiac rehab includes an exercise program as well as education for a healthy lifestyle. Patients who have had a heart-related event or procedure can attend cardiac rehab. The usually start attending within a few weeks following hospital discharge for support in the management and treatment of their heart disease. The program usually lasts for 3-4 months. The program is designed to improve your health and wellness, as well as reduce risk factors that may contribute to heart disease and future health problems. The program is designed to support a long term change in a patient’s lifestyle in order to help reduce their risk of future heart problems.
Smoking Status:
4. Which of the following categories best describes your current feelings toward smoking?
I do not intend to quit smoking in the next 6 months
I am considering quitting smoking in the next 6 months
I intend to quit smoking within the next month
I have already taken action toward quitting smoking
5. On a scale of 1 to 5 how interested are you in quitting smoking? (Please circle a number) 1 ———— 2 ———— 3 ———— 4 ———— 5
Not Interested at all Very Interested
6 On a scale of 1 to 5 how confident are you that you can quit smoking? (Please circle a number) 1 ———— 2 ———— 3 ———— 4 ———— 5
Not Confident at all Highly Confident
1. What is the highest level of education you have completed?
Some high school
GED
High school graduate
Some college
Trade/technical/vocational training
College Graduate
Some post graduate work
Post Graduate Degree
2. How many cigarettes do you typically smoke per day?
3. How many years have you been an active smoker?
7. On a scale of 1 to 5 please indicate how much you agree or disagree with the following statement, “quitting smoking is important to my health.” (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Strongly Disagree Strongly Agree
8. On a scale of 1 to 5 please indicate how much you agree or disagree with the following
statement, “my smoking habit is related to my current health problem (the main medical reason I was hospitalized). (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Strongly Disagree Strongly Agree
9. Which of the following, if any, do you think would help you quit smoking? (Check all that apply)
Self-help materials/instructions
Education on the health effects of smoking and smoking cessation
Individual smoking cessation counseling
Group smoking cessation counseling
Physician smoking cessation counseling
The 1-800-QUIT-NOW national smoking quit line
Cardiac rehabilitation
An exercise program
Medications to help quit smoking
None of the above
Other: ______________________________
10. What is the longest period of time (in the past 10 years) you have gone without a cigarette?
One day or less
Two days to one week
One week to one month
One to five months
Six months to one year
More than one year
Exercise Perception:
11. Do you participate in exercise regularly?
Yes (see question 12)
No (skip to question 13) If Yes:
12. During the 7 days prior to hospital admission, how many days did you
participate in planned physical activity (such as: walking, jogging, bicycling, weight lifting, aerobics, tennis, etc.) for bouts lasting 10 minutes or longer?
1 to 2 days
3 to 4 days
5 to 6 days
Every day
13. On a scale of 1 to 5 please rate how much you think regular exercise would help you stop smoking. (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Not at all A lot
14. Please indicate your level of agreement with the following statement, “exercise helps reduce nicotine cravings.” (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Strongly Disagree Strongly Agree
15. Please indicate your level of agreement with the following statement, “my smoking habit decreases my interest in being physical activity.” (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Strongly Disagree Strongly Agree
16. Do you think exercise would be beneficial or harmful for patients that smoke and/or relapse?
Beneficial Harmful Neither
17. Please indicate your level of agreement with the following statement, “I should not start an exercise program until after I quit smoking.” (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Strongly Disagree Strongly Agree
Cardiac Rehabilitation:
18. Please indicate which of the following statements best describes your intentions:
I am not planning to attend cardiac rehab
19. Please describe in a few words why you do not plan to attend cardiac rehab.
__________________________________________________________________
__________________________________________________________________
I am considering attending cardiac rehab, but am still uncertain (See questions 20 and 21)
I am planning to attend cardiac rehab (See questions 20 and 21)
20. On a scale of 1 to 5 how likely are you to attend cardiac rehab?
1 ———— 2 ———— 3 ———— 4 ———— 5 Not Likely Highly Likely
21. On a scale of 1 to 5, if you continue smoking and/or relapse following discharge, would you be more or less likely to attend cardiac rehab?
1 ———— 2 ———— 3 ———— 4 ———— 5 Not Likely Highly Likely
22. Making multiple health behavior changes at the same time can often be difficult. Which of the following would you consider important behavior change(s) you should make? (Check all that apply)
Quit smoking
Follow a healthy diet
Lose weight
Start an exercise program
Attend cardiac rehab
Consistently take prescribed medications
Attend all doctor’s appointments
Reduce stress
Other:
______________________________
23. Based upon your response to the previous question (question 22), please rank the answers you selected according to how important you think they are. Place a “1” next to the behavior change you find most important, a “2” next to the second most important, and a “3” next to the third most important behavior change. (If you selected more than 3 responses, please only rank your top 3 choices. If you selected less than 3 responses only rank those you selected).
_____ Quit smoking _____ Follow a healthy diet _____ Lose weight
_____ Start an exercise program _____ Attend cardiac rehab
_____ Consistently take prescribed medications _____ Attend all doctor’s appointments
_____ Reduce stress
_____ Other: ____________________
24. On a scale of 1 to 5 how confident are you that attending cardiac rehab will improve your overall health? (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Not Confident Highly Confident
25. On a scale of 1 to 5 how helpful do you think a cardiac rehab program would be toward helping you quit smoking? (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Not Helpful Very Helpful
26. On a scale of 1 to 5, would you be more or less likely to attend cardiac rehab if the program would help you quit smoking? (Please circle a number)
1 ———— 2 ———— 3 ———— 4 ———— 5
Much less likely Much more likely
27. If you continue smoking and/or relapsed following hospital discharge, do you think you might be concerned about feeling judged by rehab staff about your continued smoking?
Yes (see question 28)
No (skip to question 29)
28. Would the concern about judgment related to smoking make you more or less likely to attend cardiac rehab?
More likely to attend
Less likely to attend
No difference in the likelihood to attend
29. Which of the following programs, if any, would make you more likely to attend cardiac rehab if they were offered as part of cardiac rehab?
Individual smoking cessation counseling
Group smoking cessation counseling
An educational program on the health effects of smoking
An exercise program in combination with smoking cessation counseling
Medications to help you quit smoking
Individualize physician assessment and advice
Self-help materials/instructions
A stress management program
None of the above
Other: ______________________________
Thank you for taking the time to complete this questionnaire.