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

Lung Saskatchewan has partnered with Nicorette to provide a Nicotine Replacement Therapy sampling kit (2-days of combination NRT therapy plus a $10 coupon) for the first 750 participants of the Saskatchewan Quits initiative. By checking this box, you certify that you are 19 years or older, and are agreeing to provide your mailing address and receive the sampling kit.

You understand that Lung Saskatchewan will use the mailing address you provide in order to ship you the product. Additionally, by registering for the Saskatchewan Quits initiative, you are being entered to win prizes. If your name is drawn, your prize will be sent to the address provided.

Yes, I would like to receive a Nicotine Replacement Therapy sampling kit

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

Stay Quit

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 major life event

Other:

Other:

Have you tried to quit before?*

Yes

No

How (select all that apply)?

Nicotine replacement patch (ex: Nicoderm)

Nicotine replacement gum (ex: Nicorette)

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

Vapes/e-cigarettes

Other (ex: self help books, acupuncture, hypnotism):

Other (ex: self help books, 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 quit method I tried was ineffective for me (ex: patch, medication) 

No strong desire

Other...

Other...

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

Nicotine replacement patch (ex: Nicoderm)

Nicotine replacement gum (ex: Nicorette)

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

Vapes/e-cigarettes

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

Other (ex: self help books, acupuncture, hypnotism):

Other (ex: self help books, acupuncture, hypnotism):

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

Triggers

Nicotine Replacement Therapy/drug options (ex: Nicorette products)  

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 confident are you in starting 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 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:

Thank you for taking the time to provide us with more information about you and your quit journey as you register for the Saskatchewan Quit Smoking Challenge. All remaining questions are optional, but your responses are valuable in helping us tailor the challenge, and our other resources and supports, to the Saskatchewan residents who benefit from them!

Do you identify as an Indigenous person, who is First Nations, Metis, or Inuit?

First Nations

Métis

Inuit

Prefer not to say

I do not identify as Indigenous

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 sexual orientation?

Straight or heterosexual

Gay or lesbian

Bisexual

Pansexual

Prefer not to say

Prefer to self describe

Prefer to self describe

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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