Register - Text Messages
1
Tobacco Use / History
2
Contact Info
3
Demographics (optional)
4
Extra Programs
Please let us know a little more about what type of tobacco cessation support would be most helpful for you.
What type of tobacco cessation support are you interested in?
Please select
Help to quit SMOKING
Help to quit VAPING
Which of the following best describes you?
Please select
I currently smoke
I used to smoke but I have since quit and am now smoke free.
Do you currently use vapes/e-cigarettes, in addition to smoking?
Please select
Yes
No
Do you currently smoke regular cigarettes, in addition to vaping?
Please select
Yes
No
Are you using vaping as a tool to quit smoking regular cigarettes?
Please select
Yes
No
Do you currently smoke cigarettes:
Please select
Daily
Occasionally (if less than 7 days per week or less than 1 cigarette per day)
Do you plan on quitting smoking in the next 30 days?
Please select
Yes, I plan to quit in the next 30 days
No, it may take a little longer
When did you quit?
MM slash DD slash YYYY
How soon after you wake up do you smoke your first cigarette?
Please select
Within 5 minutes
6-30 minutes
31-60 minutes
More than 60 minutes
How many cigarettes do you smoke per day on the days that you smoke?
During the past 12 months, how many times did you stop smoking/using tobacco for at least 24 hours because you were trying to quit?
Please select
Once
Twice
Three times or more
None
We'll need your contact information to set you up with this program. All of the information you share will be protected and confidential.
Name
*
Phone Number for Texts (including area code)
*
There are a few demographic questions that all quitlines typically ask. Most are optional, but your answers can help us to improve our programs and services. (Thanks for sharing!)
How did you hear about or connect with the NL Smokers' Helpline website?
Please select
On the tobacco package health warnings
Link from other website
Facebook
From a healthcare provider
From family/friends
From a Helpline counsellor
Pamphlet
Radio
Television
Newspaper
At my workplace
At my school
At a community organization
Don't Know
Do you remember which station?
Do you remember which channel?
What is your postal code?
*
Gender
male
female
not listed
prefer not to answer
Year of birth (YYYY)
One of the key services of the Helpline is over-the-phone support where you can discuss strategies and your quit plan with one of our 'quit coaches'. The texts are really going to help, however if you would like extra one-on-one support over-the-phone then we will call you.
In addition to receiving text messages from the Helpline, would you also like to receive a phone call from us to discuss our services?
Yes
No thanks
Please let us know if there is a different phone number that we should call. Please enter it below.
When we try calling, is it okay for us to leave a message if someone else answers the phone or if we reach a voice mail?
Yes
No thanks
What is the best time for us to try calling?
Morning
Afternoon
Evening
Anytime
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