Congratulations on taking this step on your quit journey and joining the Saskatchewan Quit Smoking Challenge!

Need more information before joining? Visit SaskQuits.ca

I acknowledge that my identity and responses will be kept confidential, and I consent to having my anonymized responses used for funding purposes, impact reports, and other reporting as Lung Saskatchewan sees fit.

Consent disclaimer

By registering for the Saskatchewan Quits Challenge, you may be entered to win prizes. If your name is drawn, your prize will be sent to the address you provide.

First Name*

Last Name*

Email*

Phone Number*

Address*

City/Town*

Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code*

Have you participated in the Saskatchewan Quits Challenge before?*

Yes, once before

Yes, multiple times

No, this is my first time

How did you hear about Saskatchewan Quits?*

Facebook

Friend/Family Member

Poster/Post Card at Pharmacy

Poster/Post Card at your Dentists Office

Poster/Post Card at your Doctors Office

Health Care Professional

I have participated in Saskatchewan Quits before

Other:

Other:

How long have you smoked?*

months / years

How many cigarettes do you smoke a day?*

0 cigarettes

1-5 cigarettes

6-10 cigarettes

11-15 cigarettes

16-19 cigarettes

1 pack

2 packs

3 packs or more

What is your goal for this challenge?*

Quit

Reduce usage

Maintain quit status

Learn more

Other

Why do you want to quit or cut back smoking? Select all that apply.*

Financial costs

Current health concerns

To avoid future health concerns

Pregnancy / child birth

Partner / family pressure

Physician recommendation

Smoking bans / policy

Other:

Other:

Have you tried to quit before?*

Yes

No

How (select all that apply)?

Nicotine replacement patch

Nicotine replacement gum

Nicotine replacement lozenge

Nicotine replacement spray

Nicotine replacement inhaler

Nicotine replacement pouch (ex: Zonnic)

Buproprion (Zyban, Wellbutrin)

Varenicline (Chantix, Champix)

Cytisine (Cravv)

Cold turkey

Slowly decreased my use

Other (ex: E-cigarettes/vapes, acupuncture, hypnotism):

Other (ex: E-cigarettes/vapes, acupuncture, hypnotism):

Which supports have you utilized in your quit journey?

Saskatchewan Quits Facebook group

Smokers' Help Line

Talk Tobacco Help Line

Family Doctor

Counsellor or other mental health provider

Pharmacist

Lung Saskatchewan Help Line

None

Other...

Other...

What do you think has stopped you from quitting smoking in the past?

Strong cravings

Triggers (social situations, alcohol, friends who smoke, stress)

Didn’t have a quit plan

Didn’t feel ready

Didn’t feel supported

The NRT I tried to use was ineffective for me

Other...

Other...

Do you have a quit buddy?*A quit buddy is someone you can depend on when you're craving a smoke, feeling down or just need to vent. A quit buddy can be anyone - a family member, friend, co-worker. The person doesn't have to be someone who used to smoke, since all that really matters is that they will be there for you to provide regular and non-judgmental support.

Yes

No

Prefer not to say

What is your plan to quit or reduce smoking during the challenge (select all that apply)?*

Nicotine replacement patch

Nicotine replacement gum

Nicotine replacement lozenge

Nicotine replacement spray

Nicotine replacement inhaler

Nicotine replacement pouch (ex: Zonnic)

Buproprion (Zyban, Wellbutrin)

Varenicline (Chantix, Champix)

Cytisine (Cravv)

Cold turkey

Slowly decreased my use

I don't know if I'll quit yet, I'm here to learn

Other (ex: E-cigarettes/vapes, acupuncture, hypnotism):

Other (ex: E-cigarettes/vapes, acupuncture, hypnotism):

What do you want to know more about when it comes to quitting smoking?*

Triggers

NRT/drug options

Weight gain/healthy alternatives

Side effect management

Social support and environment

Replacement activities

Benefits of quitting

Other...

Other...

How ready are you to start your journey towards quitting?*

How excited are you to start your journey towards quitting?*

How prepared do you feel you are to start your journey towards quitting?*

How supported do you feel with your goal to quit?*

What prizes would motivate you to participate? (Check all that apply)*

Cash/monetary

Restaurant/shopping gift cards

Gas/grocery gift cards

Travel/trips

No prizes needed

Other...

Other...

What other lung health topics would you like to learn about in the future in the Sask Quits group? Let us know below:

Age Demographic*

19-24

25-39

40-49

50-59

60-74

75+

Gender*

Male

Female

Non-binary

Prefer not to say

I identify as:

I identify as:

Are you an Indigenous person that is First Nations, Métis, or Inuit? *

Yes

No

Prefer not to say

How do you identify?

First Nations

Métis

Inuit

Prefer not to say

Other

Other

Are you a member of a visible minority? (Health Canada defines a visible minority as “persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour”)*

Yes

No

Prefer not to say

What is your annual household income before taxes and deductions?*

Less than $50,000

$50,000 to $100,000

More than $100,000

Prefer not to say

What is the highest level of education you have completed?*

No schooling completed

Some high school, no diploma

High school graduate (or equivalent, e.g. GED)

Trade/technical/vocational training

University degree

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