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
Tribal Tobacco Program
Billboard
County Health Department
Dentist/Hygienist
Direct Mail/Post Card
Facebook
Family/Friends
Flyer/Poster at Community Event
Flyer/Poster/Brochure from Work
Gas Station/Gas Pump Signage
Google Search
Health Care Provider
Health Fair/Community Event
Instagram
Insurance/HMO
Movie Theatre Advertising
National Quit Line Phone Number
News Story/Article
Newspaper Ad
No response
Nurse
Other Healthcare Provider
Other Referral
Pharmacist
Pharmacy Posters
Quit Line Website
Radio Ad
School Flyer/Poster
SnapChat
Source Unknown/Don’t Remember
Sports Event
State Program (WIC, Healthy MT Families, etc.)
Streaming TV Service (Hulu, etc.)
Television Ad
Website Ad
YouTube
Have you used an e-cigarette such as Puff Bars, Smok, JUUL, Suorin, or other electronic “vaping” product in the past 30 days?
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?
Cigarettes
Chewing 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?