Exit this survey

Quit Now Indiana - I Quit Survey

50% of survey complete.

Thanks for taking this brief survey. Your responses will help identify the proper resources needed to help smokers quit.

Survey feedback cannot be responded to directly. Questions and comments may be e-mailed to info@QuitNowIndiana.com.

Question Title

* 1. Have you been thinking about quitting?

Yes

No

Question Title

* 2. Have you tried to quit before?

Yes

No

Question Title

* 3. Have you talked to a healthcare provider about quitting?

Yes

No

Question Title

* 4. Why do you want to quit?

Health

Family

Cost

Personal

Question Title

* 5. How long have you used tobacco?

Under 5 years

Between 5-10 years

Over 10 years

Question Title

* 6. Do you want help quitting?

Yes

No

Question Title

* 7. Do you understand that nicotine is addictive and it takes time to break free?

Yes

No

Question Title

* 8. Would you like helpful information about quitting?

Yes

No

If yes, please enter your email address: