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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
you or emotionally
Have you used nicotine gum or patches?
Yes
No
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
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Email
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