You have selected as the quit date. Before you finalize your quit date, let's take a second to answer some questions and see if you're ready?

Please fill out all questions!

• 1. Have you tried to quit before? Yes No
• 1a. If yes, how many times? Select One1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 15+
• 2. Did you use a medication (e.g. prescriptions, patch, gum)?
  Yes No
• 2a. Which medications did you try? Nicotine gum Nicotine patch Nicotine inhaler Nicotine nasal spray Nicotine lozenge Varenicline (non-nicotine medication) Bupropion (non-nicotine medication)
• 3. Do you have a major life event in the near future, e.g., a job change, marriage, vacation, etc.?
  Yes No
• 4. Have you started tracking your cigarettes? Yes No
• 5. Do you have a medication (e.g. prescriptions, patch, gum) in mind?
  Yes No