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What is your name?

What is your age?






What is your gender?



What is your name?

On average, how many cigarette packs do you smoke daily?





At what age did you start smoking?

0
250
500

Did you ever consider smoking?




Please select all family members who DO smoke:

What would you do if you find out your children are smoking cigarettes?




What is your general opinion on smoking?

Select any health problem that can be caused by smoking cigarettes: