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Your Sex:
 
Male
 
Female
 
 
 
What is your age?
   
 
 
 
I consider myself_________?
 
A social smoker
 
A habitual smoker
 
A non-smoker
 
 
 
( Answer this question only if you answered to being a smoker above) I smoke ________ cigarettes per week.
 
1-5
 
6-10
 
10-15
 
15-20
 
21+
 
 
How familiar are you with Electronic Cigarettes:
Never Heard Of Them Unfamiliar Neutral Familiar Very Familiar
Safe Cig
 
 
How Interested are you in this product
Very interested Somewhat interested Neutral Very little interest No interest at all
Safe Cig
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