Name *Email Address *How many cigarettes do you smoke in a day?PhoneHow long have you been smoking?What's the most important reason(s) for you to become a non-smoker?Controlled by cigarettesMoney/Expense of smokingChildrenSmell of smokingCurrent health problemsHealthy but concerned about your future healthCoughs and coldsBreathingDeath and dyingPressure from other peopleInconvenience of smokingAnti-social pressuresWhen do you smoke?On wakingAt breakfastAfter mealsDrivingWith coffeeOn the phoneAt workSociallyIn bedOther times?Other reason(s)What other methods have you tried (if any) to stop smoking?From 1-10, How committed are you to stopping smoking now? *Committment.Are you currently seeing a doctor other health professional about your smoking? *YesNoHow do you want me to contact you? *By phoneBy text messageBy emailWhat other information is relevant to your smoking I should know about?Best time(s) to connect with you? *Submit your information!
