Smoking Survey

First Name:

Last Name:

Street Address:

City:

State

Zip:

Email Address:

Phone:

Age:

Gender:	Household income:	Marital status:

Number of Kids	Occupation	Education
Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender

What do you smoke? Cigar Pipe Cigarette
How often do you smoke? Daily Weekly Special Occasion
If you smoke cigarettes, how many packs a day do you smoke? 1/4 ½ 1 1+
What is your preferred brand of cigarettes?
If you are a cigar smoker, where do you shop? online catalog Cigar Shop-Smoke Shop N/A
Do you have a preferred brand of cigars?
Do you own/rent a humidor? own Rent N/A
If you enjoy a libation with your cigar, what is your drink?
How do you characterize yourself as a smoker? casual social heavy
Is your right to smoke important to you? yes no depends
What is the most important factor in choosing what to smoke?
Are you interested in quitting? yes no

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