Contact us – if you became addicted to smoking before 1990

Your Name (required)

Your Email (required)

Date of Birth

Phone number

City or County

How old were you when you started smoking?

How old were you when you became a daily smoker?

Do you currently smoke?
YesNo

If you currently smoke, have you tried to quit?
YesNoN/A: I no longer smoke

If you've tried to quit, how many quit attempts have you made?

If you still smoke, do you plan to quit in the future?
YesNoN/A: I no longer smoke

What type of cigarettes do you/did you smoke?
Factory-made cigarettesRoll-your-own cigarettesCigarsPipesHookahBidi or clove cigarettes

Please list all the brand/s of cigarettes or tobacco you have smoked:

Have you been diagnosed with a disease caused by smoking? If yes, please describe the diagnosis (e.g. lung/mouth/throast cancer, COPD, emphysema):

Were you diagnosed within the past two years?
YesNo

Please include any further comments below:

Please indicate if you are happy for ASH to contact you further.