Registration form

#1 Personal information

01. How old are you?*

Between 18 and 30 years old

Between 31 and 40 years old

Between 41 and 50 years old

Between 51 and 60 years old

More than 60 years old

02. What is your gender?*

Male

Female

Non-binary

Other

03. Which canton do you live in?*

04. Why do you want to quit smoking?*

Health motivations

Save money

See the positive effects on my body (skin, teeth, etc.)

External pressure (family, relatives, etc.)

Increase my sporting ability

Contribute to the protection of the environment

Other

05. Have you participated in the Month Without Tobacco in 2022?*

Yes

06. How did you hear about the Month Without Tobacco program?*

Via Instagram

Via Youtube

Via Facebook

Via Tik Tok

Via my company

Someone I know told me about it

Other

#2 Support menu

07. How would you like to receive your Month Without Tobacco practical guide (40-days agenda)?*

By email

By post

I do not wish to receive the Month Without Tobacco practical guide

08. Would you like to join the Month Without Tobacco online community in the Facebook group?*

Yes

09. Would you like to be contacted free of charge by advisors from the Quit Smoking Helpline?*

Yes

10. What is your email adress ?*

# Personal information

11. What is your adress ?*

As you asked to receive the 40 days agenda in your mailbox, we need this information to send it over to you.

Street Locality Postal code

Consent

I accept that my address is shared with a third party only for sending the agenda and deleted after.

# Personal information

11. What is your phone number?*

As you asked to be contacted by the Quit Smoking Helpine, we need this information to get in contact with you.

# Last step

Consent*

I confirm that I wish to register for the Month Without Tobacco (and receive information by email)*

Consent*

I agree to the privacy policy*

Consent

I accept to be contacted for scientific studies to support knowledge on quit smoking and future public health campaigns.

CAPTCHA

Congrats for this 1st step toward a smokefree life !

« It is difficult to fail. But it is even harder not to have tried to succeed. » Théodore Roosevelt