Make Smoking History
EmailMeForm
Tell us how you quit! Fill out the form below.
Name
*
First
Last
Email
*
Zip Code
*
When did you start smoking?
*
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
When did you quit smoking?
MM
/
DD
/
YYYY
How many cigarettes did you smoke per day?
1-5
6-10
11-15
16-20
21-30
31+
When did you decide to quit?
How many times did you try to quit?
1
2
3
4
5
6
7
8
9
10 or more
What worked for you?
How is your life different now that you quit?
Tell us your story! We'd like to hear anything else you'd like to share about your experience quitting.
*
Can we post your story on our website? We would include your first name and town.
*
Yes
No
Would you be willing to be contacted about your story?
Yes
No