* 1. Address

* 2. How would you describe yourself?

* 3. What is your insurance coverage? (check all that apply)

* 4. Would you say in general your health is:

* 8. How did you hear about the Live Tobacco Free Program?

* 9. Which form of nicotine do you currently use? (Check all that apply)

* 10. About how much do you currently use per day?

* 11. Which of the following best describes your current income?

* 12. What is your date of birth?

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