Tobacco Freedom
1.
In the past 30 days, which of the following tobacco products have you used? (Please select all that apply.)
Cigarettes
Cigars
Dipping or chewing tobacco
Electronic cigarettes
Hookah
Pipe
Other
Other (please specify)
2.
Are you interested in a Freedom from Smoking class online?
Yes
No
3.
What is your first name?
4.
What is your last name?
5.
Phone number
6.
Please list mailing address
7.
Please list email
Current Progress,
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