Ready to Quit?  

The Waianae Coast Comprehensive Health Center is offering free access to an app that will teach you new ways to deal with the urge to smoke or use tobacco.

To help you quit tobacco we would like to learn about your tobacco use. Please answer these questions. This should take less than ten minutes to complete. Your answers will only be grouped together with other participants’ answers. This information will be used by the evaluator for program improvement purposes.

Once you have completed this survey, you will receive free access to a smoking cessation app. If you have questions, please contact WCCHC at quitnow@wcchc.com or (808) 697-3599.

Get Started Today! 
(Note: All questions are required.)


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1)
2) How soon after you wake up do you smoke your first cigarette or use tobacco? (check one):
3) What type of nicotine containing products do you use? (check all that apply):
4) Are you currently? (check all that apply):
5) What is your race? Which one or more of these groups would you say best describes you? (check all that apply)
6) What is your average total household income?
7) Do you have any health insurance, including pre-paid or government programs?
8) Are you homeless/houseless or at-risk of homelessness? (living outside, in a public space, emergency shelter, transitional housing program, or at-risk of losing current housing)
9) Do you have any mental health conditions, such as (check all that apply)
10) What is your gender identity? (check all that apply)
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12)
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