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* 1. What is your name?

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* 2. What is your Date of Birth?

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

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

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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?

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