1. Are you a first time visitor to SmokeFreePhilly.org?
Yes No Don’t Remember

2. How did you first find SmokeFreePhilly.org?
Newspaper ad SEPTA Postcard Doctor’s office or health clinic Community Group Google or other search engine Personal referral Other (please describe)
Other:

3. During the past 30 days, on how many days did you smoke? Zero, I do not smoke 1 to 5 days 6 to 19 days 20 to 29 days All 30 days (every day)

4. During the past 30 days, on how many days did you use tobacco other than cigarettes? Zero, I do not use tobacco 1 to 5 days 6 to 19 days 20 to 29 days All 30 days (every day)

5. On most days, about how many cigarettes do you smoke? cigarettes

6. If you used to smoke, how many cigarettes did you smoke most days? cigarettes

7. If you used to smoke, how long ago did you quit?
(specify Weeks/Months/Years)

8. If you have stopped smoking, what did you use to help you?
(please check all that apply)
Stop smoking classes
Individual counseling
Medications (such as Chantix, Wellbutrin or Zyban)
Nicotine replacement therapy (such as the patch, gum or lozenge)
Going Cold Turkey
Other

9. Who in your home (other than yourself) uses tobacco now?
(please check all that apply)
No one
Spouse/ partner
Parent(s)
Sister/brother
Roommate
Child/children
Other

10. Which of these groups best describes you? Asian African American Latino White Biracial/ Multiracial Other

11. What is your zip code?
(If you are outside the U.S., please enter the name of your country)

12. What is your age? Under 16 17-18 19-24 25-36 37-49 50-62 63 or more years

13. What is your gender? Male Female Trans Other

14. What is the last level of school that you have completed? Less than High School High School or GED Some college College Grad Post College

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