Tobacco Freedom

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* 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)

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* 2. Are you interested in a Freedom from Smoking class online?

Yes

No

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* 3. What is your first name?

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* 4. What is your last name?

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* 5. Phone number

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* 6. Please list mailing address

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* 7. Please list email