Tyler Smoker’s Petition
What type of tobacco product do use
(check all that apply)
Cigarettes Cigars Chew Vape Hookah
What age were you when you started using tobacco product
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 WHY
How often do you use tobacco product daily
1 2 3 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 more
How long after awakening before your first use of tobacco product
Immediately 1-2 mins 3-5 mins 6-10 mins 11-20 mins 21-30 mins >1hour
Do you use tobacco product Before or After coffee N/A
How many years have you been using tobacco products
<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 30 40 50 WOW
How many times have you attempted to quit
None 1 2 3 4 5 6 7 8 9 10 multiple
Do you experience shortness of breath
Yes No
Are you currently experiencing any health issues
Yes No
Complete the sentence
Ciggerates_____________________________________________________________
Vaping________________________________________________________________
Chewing tobacco________________________________________________________
Tobacco_______________________________________________________________
I want/need to quit because_______________________________________________
RescueMeFromTobacco,Inc hereby petitions you to quit using tobacco
Do you want to be Rescued from tobacco
Yes No
To learn more about tobacco cessation and post cessation support visit:
RescueMeFromTobacco.com
#ReleaseYourself