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Your name

Your email

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Your phone no.

Age

What made you decide to quit smoking?
Health reasons (without further specification)I am aware of the damages smoking causes to my healthI am expecting / I've just given birth to a babyIt is too expensive / I want to save moneyMy partner/my family asked me toDoctor's ordersIt does not give me pleasure any moreProhibitions (at work, in public places, etc.)No specific reason / I have just decided to quitOther

How many cigarettes a day do you smoke?

How much does a pack of cigarettes cost?

When do you smoke the first cigarette in the morning?

Do you find it difficult to keep off smoking in places where it is forbidden?

Which cigarette do you find the most difficult to give up?

Do you smoke more frequently during the first hours after waking than during the rest of the day?

Do you smoke even when you are ill in bed?

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