Personal Information  
 

Habits

To optimize your quit program, we need to know what kind of smoker you are. Once we know how often you’ve smoked, and for how long, we’ll have that much more of a chance to help you succeed with your quit.

 

Anything marked with an asterisk * is required information

Average daily cigarettes*


Time of first cigarette*


How many years have you been a smoker?*


What time of day do you smoke the most?*

Morning Middle of the day Later in the day Throughout the day

How many times have you previously attempted to quit?


Anything marked with an asterisk * is required information
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Your Quit Contract

Please fill in the rest of your profile and define a quit plan.

The right site?

This is the Nicorette® site. For the NicoDerm® CQ® site visit NicoDerm® CQ® Committed Quitters®.

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Feelings

Please move both sliders to indicate how your quit attempt is going.

Confidence of quitting

How hard are you finding the quit attempt right now?