Kick the Butt Support Group
Exit this survey
1
. Evidence suggests that using nicotene replacement products and joining a support group increases success.
If you want to quit smoking, would attend a FREE support group for one hour for six weeks?
Evidence suggests that using nicotene replacement products and joining a support group increases success. If you want to quit smoking, would attend a FREE support group for one hour for six weeks?
Yes
No
2
. Would you use NRT replacement products?
Would you use NRT replacement products?
Yes
No
3
. Do you have a source for free NRT supplies?
Do you have a source for free NRT supplies?
Yes
No
4
. Many people want to quit but report that they are
Many people want to quit but report that they are
Afraid of weight gain
Too stressful for me
It didn't work before
My spouse smokes/no support
I am ready to quit
5
. What day of the week would best fit your schedule?
What day of the week would best fit your schedule?
Mon
Tues
Wed
Thurs
Fri
6
. Which location would be the easiest for you?
Which location would be the easiest for you?
At the WIC building(Public Health Services-Liberty)
At my local community center/town hall
At my local church
At place of employment
*
7
. What town do you live in?
What town do you live in?
8
. What time of the day is the best for you?
What time of the day is the best for you?
Mornings
Afternoons before 3pm
Evenings before 8 pm
9
. If you would like us to contact you if a support group becomes available at a time convenient for you - please leave your phone or address
If you would like us to contact you if a support group becomes available at a time convenient for you - please leave your phone or address
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