Register for the Saskatchewan Quits Challenge

I acknowledge that my identity and responses will be kept confidential, and I consent to having only my responses from the registration pre-survey and the post-survey used for funding purposes, impact reports, and other reporting as Lung Saskatchewan sees fit.

1. You will receive a Nicotine Replacement Therapy sample kit as well as be entered to win prizes!
2. Be sure to join our online Facebook Support Group

First Name*

Last Name*

Email*

Phone Number*

Age Demographic*
18-24 25-39 40-59 60+

Lung Saskatchewan will provide a Nicotine Replacement Therapy sampling kit for the first 500 participants of the Saskatchewan Quits initiative. By checking this box, you certify that you are over the age of 18, and are agreeing to provide your mailing address and receive the sampling kit. You understand that Lung Saskatchewan will provide your contact information to SampleSource in order to ship you the product. Additionally, by registering for the Saskatchewan Quits initiative, you are being entered to win prizes drawn throughout the month of May. If your name is drawn, your prize will be sent to the address provided.

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

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

Gender*

Male

Female

Non-binary

Prefer not to say

Let me type:

Let me type:

Did you participate in the Saskatchewan Quits program last year?*

yes

no

How did you hear about Saskatchewan Quits?*

Facebook

Radio

Friend

Other:

Other:

How long have you smoked?*

How old were you when you started smoking?*

How many cigarettes do you smoke a day?*

1-5

6-25

1-2 packs

3 packs or more

What is your goal for this challenge?*

Quit

Reduce usage

Learn more

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

Financial costs

Current health concerns

To avoid future health concerns

COVID pandemic

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

Buproprion (Zyban, Wellbutrin)

Varenicline (Chantix, Champix)

Cold turkey

Slowly decreased usage over time

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

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

Which resources have you utilized?

“Saskatchewan Quits” Facebook group

Smokers' Help Line

Health Care Provider

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 he/she will be there for you to provide regular and non-judgmental support.

yes

no

What is your plan to quit during the month of May (select all that apply)?*

Nicotine replacement patch

Nicotine replacement gum

Nicotine replacement lozenge

Nicotine replacement spray

Nicotine replacement inhaler

Buproprion (Zyban, Wellbutrin)

Varenicline (Chantix, Champix)

Cold turkey

Slowly decreased usage over time

No plan to quit, just learn

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

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

Which resources do you have access to?*

“Saskatchewan Quits” Facebook group

Smokers' Help Line

Health Care Provider

Other...

Other...

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

Triggers

NRT/drug options

Side effect management

Social support and environment

Replacement activities

Other...

Other...

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

Not at all

Very

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

Not at all

Very

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

Not at all

Very

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

Not at all

Very

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