Quit Now 1 2 3 4 Answer a few quick questions to get started! What triggers you? Life's everyday stresses After a feed Drinking When I'm bored When I'm feeling anxious or sad Breaktime at work When I smell smoke When I'm fidgety When I'm angry Talking on the phone When I'm out for a long drive Drinking coffee Any remotely social situation Waking up in the morning Seeing someone else light a cigarette When I'm with other people who smoke Other Other triggers: Next Do you currently smoke cigarettes, vape, or use both? Please check all that apply. I smoke cigarettes I recently quit smoking cigarettes I vape (e-cigarettes, vape pens, etc.) I recently quit vaping I use both cigarettes and vapes Other Other: Please estimate the amount you smoke or vape per week If you’ve recently quit or are using this tool to manage cravings and/or stay nicotinefree, please enter your estimate based on how much you smoked or vaped before quitting, this will help to calculate your $ savings. How many days a week do you smoke or vape, or how many days per week did you use before quitting? What is the average price you pay (or paid) per week for cigarettes or vaping? Consider what is the total cost you pay (or paid) per week for all cigarettes, vapes, e-liquid, and other items you use (or used) for smoking and/or vaping? Next Why do you want to quit? Current health problem For my family For my children For my grandchildren Financial To increase my energy Smoking is not socially accepted Advice from a health professional Concern over a future health problem Other Other: Who would be most proud of you for quitting? Upload a picture to remind yourself about who would be most proud of you for quitting. This is totally optional, but it may be a fantastic motivator for you! Upload Select one or more files and drag and drop them here. Set a Quit Date to aim for to be completely nicotine-free — we’ll help you prepare every step of the way. You can always adjust it later. If you already quit, please enter the date of your last cigarette or vape. How do you want to receive notifications and updates? Email Text Please note: Text messaging only available for phone numbers registered in Newfoundland Labrador. Still down with the phone line? That’s cool. Let us know if you would you like to have someone from the Smokers’ Helpline connect with you over-the-phone to provide more help with quitting! Yes No Thanks Okay with Voice Mail? We'll try calling you within the next few days to give you a little more information. Is it okay for us to leave a message if we reach a voicemail or if someone else answers the phone? Yes No Thanks Next Or Thank you for linking your Facebook account. Please complete the rest of the form to finish your account registration. Fill out your Personal Details First Name Last Name Password This will enable you to login to your personalized KickAsh dashboard. Confirm Password Sex: Male Female Prefer not to answer Year of birth Postal Code* *Collecting data for statistical purposes only Email Mobile (include area code) How did you hear about KickAsh? Finish
