Smoking review

If you have been advised by the practice to submit a smoking review on a regular basis, please complete this form.

Do you currently smoke? *Required
Smoking/tobacco use

Please provide the following information in relation to smoking (please tick all that apply):

Cigarette smoker
Cigar smoker
Pipe smoke
Roll own cigarettes
Use electronic cigarette
Chew tobacco
Passive smoking
Are you exposed to smoke at work? *Required
Are you exposed to smoke at home? *Required