Full Name
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Last Name
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How Long Were You A Smoker?
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Less Then A Year
1-2 Years
3-5 Years
6-10 Years
Over 10 Years
How Many cigarettes Did You Smoke A Day?
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1-5 Cigarettes a day
6-15 Cigarettes a day
16-25 Cigarettes a day
25+ Cigarettes a day
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