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form_title= Quit Smoking for Good form_header= Improve your health when you quit smoking! How long have you been smoking?*= _ How many cigarettes do you smoke a day?*= {1 to 20, 1 pack, More than 1 pack} Have you tried to quit smoking in the past?*= () Yes () No () Not Sure Are you currently on any medications to quit smoking?*= () Yes () No () Not Sure

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form_title= Quit Smoking for Good form_header= Improve your health when you quit smoking! How long have you been smoking?*= _ How many cigarettes do you smoke a day?*= {1 to 20, 1 pack, More than 1 pack} Have you tried to quit smoking in the past?*= () Yes () No () Not Sure Are you currently on any medications to quit smoking?*= () Yes () No () Not Sure

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