Quit Now 1 2 3 4 What age did you start smoking cigarettes regularly? 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 Next Do you currently smoke cigarettes Daily Occasionally Not at all If you've recently quit or are using this tool to manage craving and/or stay smoke free, please enter your estimate based on how much you smoked before quitting. Please estimate the amount you smoke per week How many days a week do you smoke? On average, how many cigarettes do you smoke on the days that you smoke? What is the average price you pay for a pack of cigarettes? 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 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. Select your quit date *If you already quit, please enter the date of your last cigarette. 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 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
