Smoking Cessation Survey Question Title * 1. What is your gender identity? Male Female Transgender - Male Transgender - Female Non-binary Prefer not to say Question Title * 2. What is your sexual orientation? Gay Lesbian Bisexual Pansexual Queer Questioning Other Prefer not to say Question Title * 3. Do you use nicotine products? Yes No Question Title * 4. If yes, what type of nicotine products do you use? Cigarettes E-cigarettes Cigars Pipe tobacco Chewing tobacco Snuff Other (please specify) Question Title * 5. How long have you been using nicotine products? Less than 1 year 1-5 years 5-10 years More than 10 years Question Title * 6. How motivated are you to quit? 1 - Not motivated at all 2 3 4 5 6 7 8 9 10 - Extremely motivated Question Title * 7. Have you previously tried to quit? Yes No Question Title * 8. If yes, what methods have you tried to quit? Cold turkey Nicotine replacement therapy Prescription medication Counseling or therapy Support groups Alternative therapies Other Question Title * 9. What challenges do you face in quitting? Question Title * 10. Are you interested in receiving services to quit? Yes No Question Title * 11. If yes, what type of services would you be interested in? Individual counseling Group counseling Nicotine replacement therapy Prescription medication Online support Quit smoking app Other Question Title * 12. Would you like to be contacted regarding information and services to quit? Yes No Next
