Welcome – Tobacco Free Nova Scotia

E-mail*
Username* Usernames cannot be changed.
Password* Type your password.
The password must have a minimum strength of MediumStrength indicator
Repeat Password* Type your password again.
Date of Birth*
Gender*
- Male
- Female
- Transgender
Contact Information
First Name*
Phone Number* Required phone number format: (###) ###-####, 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)