Step 1 of 2

Congratulations on making the very important decision to quit!

Please tell us a bit about yourself so we can personalize the tools that can best help you in the process of becoming smoke-free. This should only take you about 5 minutes.

1. Do you currently smoke cigarettes?
Daily
Occasionally (if less than 7 days per week or less than 1 cigarette per day)
Not at all
2. When was your last cigarette? 
Less than 24 hours
More than 24 hours
3. How many cigarettes do you or did you smoke on the days that you smoke?   Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+  

4. At what age did you start smoking regularly?   Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75+  

5. What is your date of birth?   Year After 1995 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910   Month January February March April May June July August September October November December     Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     

6. How soon after you wake up do you or did you have your first cigarette? 
Within 5 minutes
6-30 minutes
31-60 minutes
After 60 minutes
7. How many times have you tried to quit smoking where an attempt has lasted longer than 1 day?   Select 0 1 2 3 4 5 6 7 8 9 10+  

8. How many members of your household smoke cigarettes?  Select 0 1 2 3 4 5 6 7 8 9 10+

9. You are:  Male
Female
Transgender
10. About how much does/did a pack of cigarettes cost you?   $  [Example: 6.50] 

11. How many cigarettes are in the packs you buy/bought?   Select 10 15 20 25 30