Tell Us About Yourself
The following questions help us to understand you and find the right tools to help you quit using tobacco.
What is your preferred method of contact?
Select
Phone
Text
Chat
How did you hear about My Life My Quit?
Select
Cable TV or local television station
Streaming TV Service (Hulu, etc.)
AM/FM Radio Station
Streaming audio (such as Spotify)
Facebook
Instagram
SnapChat
Tiktok
YouTube
Twitter
Google Search
Poster
Family/Friends
School
Health Care Professional
Other
Unknown
Have you used an e-cigarette such as Puff Bars, Smok, JUUL, Suorin, or other electronic “vaping” product in the past 30 days? This does not include vaping of other substances such as cannabis.
Select
Yes
No
Don't know
Refused
Do you use e-cigarettes every day, some days or not at all?
Select
Every day
Some days
Not at all
Do you use e-cigarette pods, cartridges or a tank system?
Select
Pod
Cartridges
tank
How soon after you wake, do you use e-cigarette or other electronic vaping products?
Select
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Don't know
Refused
What types of tobacco have you used in the past 30 days? This does not include e-cigarettes or vaping products.
Cigarettes
Smokeless tobacco, chew tobacco, snuff, or dip
Cigars, cigarillos, or small cigars
Pipe
Other tobacco products:
What other products do you use?
Kreteks or clove cigarettes:
Select
Yes
No
Tobacco pouches or 'snus':
Select
Yes
No
Tobacco 'orbs:'
Select
Yes
No
Tobacco strips:
Select
Yes
No
Water pipes or hookahs:
Select
Yes
No
Do you currently use other types of tobacco every day, some days, or not at all?
Select
Every day
Some days
Not at all
How soon after you wake, do you use other tobacco?
Select
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Don't know
Refused
Do you usually smoke/chew/vape/JUUL a particular flavor?
Select
Yes
No
How old were you when you started using tobacco products, including vaping?