Tell Us About Yourself
The following questions help us to understand you and find the right tools to help you quit using tobacco.
What is your preferred method of contact?
Select
Phone
Text
Chat
How did you hear about My Life My Quit?
Select
Social Media Advertisement
MyLifeMyQuit.com
Billboard(s)
Booth at an event
Brochure/Flyer
Busses & Bus Stops
Community Organization
County Health Department
Court Referral Youth
Dentist
Direct mail
Employer
Family/Friends
Health Care Professional
Insurance company
Internet
Newspaper
Other
Post Card
Quit Card
Radio
School
Television
Text To Quit
Theater ad, before movie
Unknown
In the past three months, did you hear about 1-800-QUIT-NOW from any advertisements with smokers telling personal stories and tips about living with health problems?
Select
Yes
No
Unsure
Have you used an e-cigarette such as Puff Bars, Smok, JUUL, Suorin, or other electronic “vaping” product in the past 30 days?
Select
Yes
No
Don't know
Refused
Do you use e-cigarettes every day, some days or not at all?
Select
Every day
Some days
Not at all
Do you use e-cigarette pods, cartridges or a tank system?
Select
Pod
Cartridges
tank
How soon after you wake, do you use e-cigarette or other electronic vaping products?
Select
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Don't know
Refused
What types of tobacco have you used in the past 30 days?
Cigarettes
Chewing tobacco, snuff, or dip
Cigars, cigarillos, or small cigars
Pipe
Other tobacco products:
What other products do you use?
Kreteks or clove cigarettes:
Select
Yes
No
Tobacco pouches or 'snus':
Select
Yes
No
Tobacco 'orbs:'
Select
Yes
No
Tobacco strips:
Select
Yes
No
Water pipes or hookahs:
Select
Yes
No
Do you currently use other types of tobacco every day, some days, or not at all?
Select
Every day
Some days
Not at all
How soon after you wake, do you use other tobacco?
Select
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Don't know
Refused
Do you usually smoke/chew/vape/JUUL a particular flavor?
Select
Yes
No
How old were you when you started using tobacco products, including vaping?