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* 1. How many total people live in your home? 

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* 2. How many kids live in your home (ages 0-17)?

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* 3. Do you, or does anyone in your home smoke?

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* 4. Does anyone in your household have a chronic illness?

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* 5. Are you aware of the health risks associated with secondhand smoke exposure in the home?

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* 6. Would you be interested in making your home a smoke-free home?

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