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1. Your details? (Required.)

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2. Your mobile number without the initial zero (Required.)

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3. Email (Required.)

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4. Age (Required.)

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5. Gender : (Required.)

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6. Do you live with a partner? (Required.)

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7. If yes,does your partner smoke? (Required.)

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8. Are you exposed to secondhand smoke ( the smoke of other people's tobacco products')in your workplace or home? (Required.)

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9. While you were grown up ,how many of your parents /guardians  smoked at all? (Required.)

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10. What type of tobacco do you consume? (Required.)

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11. How many years have you been smoking ? (Required.)

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12. During the past 12 months , have you tried to stop smoking? (Required.)

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13. During any visit of a doctor or other professional in the past 12 months ,were you advice to quit smoking tobacco? (Required.)

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14. How soon after you wake up do you smoke your first cigarette? (Required.)

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15. How many cigarettes, pipes of tobacco, shisha, sugar flavored shisha do you smoke each day? (Required.)

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16. Do you find it difficult to refrain from smoking in places where it is forbidden? (Required.)

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17. How did you hear about the program? (Required.)

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