Smoking Status 2nd Edition

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* 1. What is your name?

First (+ Middle if applicable)

Surname

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* 2. What is your Date of Birth?

Date

Month

Year

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* 3. How would you best describe your smoking status?

Current Smoker

Ex-Smoker

Attempting to Quit

Never Smoked

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* 4. If you are an ex-smoker, current smoker, or attempting to quit, what do/did you typically smoke?

Cigar

Cigarettes

Pipe

Roll your own

Other (please specify)

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* 5. If you are an ex-smoker, current smoker, or attempting to quit, how many did/do you smoke daily and weekly?

Daily Amount

Weekly Amount