Enregistrer – Tobacco Free Nova Scotia

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Congratulations on making the decision to put your wellness first and become tobacco free!

Please tell us a bit about yourself.

This should only take about 5 minutes.

- E-mail*
- Username* Usernames cannot be changed.
- Password* Type your password.
  Le mot de passe doit avoir une résistance minimale de MoyenIndicateur de sûreté
- Repeat Password* Type your password again.
- Date of Birth*
- Gender*
  - Male
  - Female
  - Transgender
- Contact Information
- First Name*
- Phone Number* Numéro de téléphone requis(###) ###-####, Standard, Standard
- Address*
- City*
- Province, Country*
- Postal Code*
- 1. Do you currently smoke cigarettes? *
  - Daily
  - Occasionally (less than 7 days per week or less than 1 cigarette per day)
  - Not at all
- 2. When was your last cigarette? *
  - Less than 24 hours ago
  - More than 24 hours ago
- 3. How many cigarettes do you or did you smoke on the days that you smoke?*
- 4. At what age did you start smoking regularly?*
- 5. How many times have you tried to quit smoking where an attempt has lasted longer than 1 day?*
- 6. How many members of your household smoke cigarettes?*
- 7. About how much does or did a pack of cigarettes cost you? Ex. $6.50*
- 8. How many cigarettes are in the packs you buy or bought?*
- 1. How soon after waking do you smoke your first cigarette?*
  - Within 5 minutes (3 points)
  - 5-30 minutes (2 points)
  - 31-60 minutes (1 point)
- 2. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g. church, library, etc.?*
  - Yes (1 point)
  - No (0 points)
- 3. Which cigarette would you hate to give up?*
  - The first in the morning (1 point)
  - Any other (0 points)
- 4. How many cigarettes a day do you smoke?*
  - 10 or less (0 points)
  - 11-20 (1 point)
  - 21-30 (2 points)
  - 31 or more (3 points)
- 5. Do you smoke frequently in the morning?*
  - Yes (1 point)
  - No (0 points)
- 6. Do you smoke even if you are sick in bed most of the day?*
  - Yes (1 point)
  - No (0 points)

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