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1. The Nickname you'd like to use for this program is:
This is the anonymous name you'll use for the Support Group and Quitting Buddies Instant Messenger. Please choose a nickname that's different from your real name.
2. The country I live in is:
3. Your E-Mail Address:
After you sign up we’ll send your password and motivational support emails to this email address. If you’re concerned about your privacy we suggest signing up with an anonymous Yahoo! or Hotmail email address. We will never share or sell your email address with anyone else. You may opt out of motivational support emails at any time.
4. The password you would like to use for this program is:
Strong password required. Must be at least 8 characters, contain at least one lower case letter, one upper case letter and one digit.
Please confirm your password by retyping it here:
5. In past quit attempts, which of the following methods did you try (please select all that you've tried)?
6. What best describes your occupation (please select the best answer)?
7. What is the highest grade or level of education that you have ever attained?
8. Where is smoking allowed (please check all that apply)?
9. Given everything going on in your life right now, how important is it for you to be smoke free?
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10. How confident are you that you stay smoke-free in the next six months?
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11. Please acknowledge that your non-identifiable information will be used for purposes of improving this program. Your use of this program is subject to your data being used for research purposes. We do not collect or analyze individual statistics. Please review our Privacy Policy.
Please Note: By clicking "Submit" you acknowledge that this program is for educational purposes only and is not to be used as a substitute for a consultation or visit with your family physician or other healthcare provider.
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