Welcome to your Online Quit Program. As you proceed your personal information will be stored here.

I'd like to Sign Up!

Step 4 out of 4

You may not be ready or committed to give up smoking right now - that's okay. Or, you may have already given up smoking.

No matter where you are in your journey, signing up will get you started on preparing for that important quit date! If you've already given up smoking, the information in this programme will help increase your chances of success! Take a big step toward independence by signing up.

If you are concerned about how your information will be used you might like to review our Privacy Policy.

Now let's get started. We will use this information to begin creating your Personalised Treatment Programme:

My Smoking History:

Please Note: You are required to fill in ALL FIELDS to continue...

1. The number of cigarettes I smoke per day is:

2. My year of birth is:  (e.g. "1952")

3. The number of years I've smoked for is:

4. The amount of money per day I spend on cigarettes is:  (example: 3.00)

5. The number of other smokers I live with is:
If you would like to help someone quit please click here.

6. The city or town I live in is:

7. The country I live in is:

8. I am a:   

9. My email address is:
Please confirm your email address:

You'll use this email address to login to the programme. Please also use this email address when you redeem your voucher or order the NicoTest. For security purposes we will be sending your password to the email address you provide.

10. The Nickname I'd like to use for this programme. This will also be the Nickname that you will use in the *Support Group:

* Please note that others in the Support Group and your Quitting Buddies will see your Nickname. Please choose a Nickname that is different from your real name.

11. The number of times I've tried to quit is:

12. In past quit attempts, I've used the following methods: (please select all that you have tried)

No NRT or Prescription Medication

Over-the-Counter (Non-Prescription) Products:


Prescription Products:

13. My height:   
   

14. My weight:  

15 . Please select the ethnic background which best describes you:

a. White
 
 
 
b. Black or Black British
 
 
 
c. Asian or Asian British
 
 
 
 
d. Mixed
 
 
 
 
e. Other ethnic groups
 
 
 

16. Marital status

17. Employment status

18. Highest educational qualification

Please Note: By clicking "Sign Up" you acknowledge that the NicoTest is for educational purposes only and is not be used as a substitute for a consultation or visit with your GP or other healthcare provider.

Statistical data collected throughout the site is used for research purposes only. Individual statistics are not collected or distributed and we do not collect or distribute email addresses or any other personal information. You may access our Privacy Policy and read important legal information at any time by following the links at the bottom of every page..

Please check this box to acknowledge that your non-personal information will be used for purposes of improving this programme. Your use of this programme is subject to your data being used for research purposes. We do not collect or analyse individual statistics and no one will contact you at any time.

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NicoTest.com does not replace the advice of your GP or other health care provider. NicoTest Version 5.0 is licensed to g-Nostics Ltd. Copyright 2004-2010 by Evolution Health Systems Inc. All rights reserved including related methods and software. All worldwide patent rights reserved.