Tobacco & Alcohol Use Questionnaire
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How old are you? *
What gender were you assigned at birth? *
When was the last day of your menstrual cycle? *
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What is your highest level of education? *
What is your marital status?

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Please indicate the ethnic or national origin group(s) to which you belong: *
Required
What is your total annual household/family income from all sources? *
What is the size of your household, including yourself? *
Are you a veteran or have you ever been in military active duty in the past? *
Are you currently in active duty in the military? *
Do you smoke? *
How old were you when you smoked a whole cigarette for the first time? 
If you have never smoked please type "N/A" into the text box.
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Have you smoked at least 100 cigarettes in your entire life? *
Have you ever smoked at least 1 cigarette daily for 6 months or longer? *
Have you smoked cigarettes on one or more of the past 30 days? *
If the answer is yes, how many days have you smoked in the last 30 days? (please write your best estimate)
If the answer is No or if you have never smoked, please type N/A into the text box.
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What is your smoking status?
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If you smoke daily, how many cigarettes do you smoke per day on average? 
(number of cigarettes per day, 20 cigarettes in a pack) 
If you do not smoke, please type "N/A" into the text box.
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If you smoke only some days, about how many cigarettes did you smoked per day? 
(number of cigarettes per day, please state your best estimate)
If you do not smoke, please type "N/A" into the text box.
 *
During the past 30 days, on how many days did you use one or more of these tobacco products? Cigars, Cigarillos, Little Cigars, Snus, Chewing Tobacco, Snuff, Dip, Hookah (water pipe), E-cigarettes
If you do not use any of these products please type "N/A" into the text box.
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If you have used e-cigarettes during the past month, how many cartridges/disposable e-cigarettes did you use per week?
If you do not use e-cigarettes please type "N/A" into the text box.
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What type of cigarettes do you usually smoke?
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Have you ever changed this type of cigarette?
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If so, for how long have you smoked your present brand?
If you do not smoke please type "N/A" into the text box.
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In the past year how many times have you intentionally stopped smoking cigarettes for at least 24 hours?
If you do not smoke please type "N/A" into the text box.
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Think of the longest time you quit smoking. For how long did you stop?
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During your longest quit attempt, did you gain weight? *
If yes, how much weight did you gain?
If you do not smoke please type "N/A" into the text box.
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Are you in general concerned about your weight? *
Would you start smoking again if you gained: *
Required
How many pounds (or kilograms) gained do you think would prompt you to smoke again?
If you do not smoke please type "N/A" into the text box.
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