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How long have you been smoking for?
1 Year
1-5 Years
5-10 Years
10-20 Years
20+ Years
Have you ever quit smoking before?
No
Yes, 1 Month
Yes, 6 Months
Yes, 1 Year
Yes, 1+ Years
Have you used nicotine gum or patches?
Yes
No
used Hidden &
Do you smoke inside your house or car?
Yes, house and car
Yes, house
Yes, car
No
Do you normally have any activities between waking up & smoking?
No
Bathroom, coffee, etc
Yes, more than 3 activities
Have you ever been emotionally effected by a movie, story, etc?
almost always
Often
Sometimes
Rarely
Never
Do other people in your home smoke?
No
Yes, one
Yes, more than one
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Email
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