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About Your Tobacco Habit

Information Survey

The purpose of this survey is to collect information from you about your relationship with tobacco. It also asks a few questions about your equipment. This information will be used to revise and update future editions of our book, "How to Quit Smoking Without Willpower or Struggle", and to better design our web site for faster and easier browsing in the future. You need not fill in all (or any) of the information asked, but the more you offer, the better we may understand and help those who want and need to quit smoking. This survey is divided into the following sections:

Section A: Your history with tobacco
Section B: For cigarette smokers only
Section C: About your system
Section D: About the Survey 
Form Submission

Please fill out the information in each section as requested. Then, at the end of the form, please supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly.

All information offered here is kept confidential, and will not be sold, given, nor transferred to any other company or agency without your expressed written permission.

SECTION A -- Your History With Tobacco

Please fill in the answers to these questions as accurately as you can.

At what age did you start using tobacco?
What form of tobacco did you start with?
What is your current age category? Under 18 18-25 26-50 51 +
What form of tobacco do you use now? (If you've quit, what was the last form?)
How much do you (or did you) use per day?
Were you breast-fed at infancy? Yes No Don't know
Have you any tobacco related health problems? Yes No Don't know
If so, what problem(s)?
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Form Submission

SECTION B -- For cigarette smokers only

The questions in this section deal only with cigarettes.
If you do not now or never have smoked cigarettes, please click here for next section.

What brand did you start with?
What brand do you smoke now? (If you've quit, what was your last brand?)
If you've successfully quit, how did you do it?
Who was the biggest influence to start you smoking?
Have you tried to quit? If so, how many times?
If so, what is the longest you've gone without smoking?
What got you to start back?
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Form Submission

SECTION C -- About your System
We ask these questions so that we may update our site to better accommodate all systems.

What type of system do you use? Mac IBM
What brand?
What version? 386486586/Pentium686/Pentium II 786/Pentium III Newer
What mghtz? 66-100120-166 200-500 More
What OS? Win 3.1 Win 95 Win 98 NT Win 2K or Millennium XP OS2Mac
How much RAM? (Choose closest) 8 megs. or less 16 megs 32 megs 64 megs  128 megs more
Modem speed? 14,4 28,8 33,6 ISDN T1 Cable Modem
Hard disk capacity? 99 megs. or less 100-500501-1 gigmore
Browser & version you normally use?
Size of monitor? 14" 15" 17" 20" other
Normal viewing resolution setting? 640 X 480 800 X 600 1024 X 768 other
Do you normally browse with your graphics display set to On or Off? On Off Depends

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Form Submission

SECTION D -- About this Survey

How would you rate this survey? Excellent Good Fair Poor
Did you find this survey easy to take?
Why or why not?
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Form Submission

If you would like to receive the results of this survey, please fill in the information below. This information will not be passed on to any third party for any reason, and is not subject to reading by any of the email address gathering software.

Name
Email
Do you have a web site? (URL )

Please enter any additional comments regarding our survey or tobacco:

FORM SUBMISSION

Thank you for taking the time to answer the questions in our survey.

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For any questions or further information, contact Mark Whalen - support@presmark.com
Copyright © 1996 PresMark Publishing Co. - All rights reserved.
Revised: December 10, 2007.