Study Questionnaire

To qualify for the study, please answer the following:

How many cigarettes do you smoke a day ? *

Have you quit for at least once for 1 week or more? *

Yes No

Are you on medication for anxiety and/or depression? *

Yes No Maybe

Are you on medication to quit smoking? *

Yes, right now No, not now Have taken in past

Have you been diagnosed with a mental or personality disorder (i.e., anxiety or depression)? *

Yes, recently No, never In the past Not Sure

Do you wish to quit smoking? *

Yes, now No, never

Your Name *

Your Location *

Zip code *

Your Phone Number *

-

Email *

Submit