Registration form

01. How old are you?*

Less than 18 years old

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

4.1. If other, please specify :

05. Have you participated in the Month Without Tobacco in 2023?*

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

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

Please note that we will send the practical guide by post until the 15th October 2024, and only if you live in Switzerland or Liechtenstein. In all other cases, you'll be able to receive it by email.

By email (digital format)

By post (paper format)

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 a counsellor from the Stop-smoking counselling?*

Yes

10. What is your email adress ?*

11. What is your adress ?*

As you asked to receive a physical copy of the 40 days agenda, we need this information to send it over to you.

Street Locality Postal code

Name and surname*

Consent*

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

11. What is your phone number?*

As you asked to be contacted by the Stop-smoking counselling, we need this information to get in contact with you.

Personal Code

Thank you very much for your registration for the Month Without Tobacco 2024. In order to ensure that your data remains anonymous, we kindly request that you create a personal code.

This allows us to anonymise your personal data (e.g. your e-mail address) so that no conclusions can be drawn about you personally.

Please use the following information to create your personal code:

Example:
- Calendar day of your date of birth 7 March 1998 = 7
- First letter of your name: Anna = A
- Third letter of your name: Anna = N
In this case, your personal code would be 7AN

Day of your date of birth:*

First letter of your name:*

Third letter of your name:*

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.

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