Freedom Pods Assessment

1

Are you at least 21?* This field is required.You have to be 21 in certain jurisdictions to consume nicotine, by clicking yes you acknowledge you are over 21.

YESNO

2

Are you interested in quitting nicotine?* This field is required.

Yes

No

3

Do you smoke or vape?* This field is required.

Smoke

Vape

Both

4

How many packs of cigarettes do you smoke in a day?* This field is required.Pack = 20 cigarettes

Less than 1 Pack

1 Pack

2 Packs

3 Packs

4+ Packs

5

How many pods do you vape in a day?* This field is required.Pod = 59mg/mL of nicotine

Less than 1 Pod

1 Pod

2 Pods

3 Pods

4+ Pods

6

How many time(s) have you tried to quit?* This field is required.

First Time

1 Time

2-3 Times

4+ Times

7

What methods have you tried to quit with in the past?* This field is required.Select all the options that apply to you.

Cold turkey

Over-the-counter quit-nicotine aids

Counseling

Prescription treatment

None/Other

8

Then this program isn't for you!

9

What do you want to discuss with your Freedom Pods Quit Coach?* This field is required.Select as many as you like:

Handling triggers

Nicotine withdrawal

Setting a quit date

Treatment options

Support programs

10

What are your top 3 reasons for quitting nicotine?

Reason 1

Reason 2

Reason 3

12

What do you want to learn about Freedom Pods?* This field is required.Select as many as you like:

Nicotine and non-nicotine options

How Freedom Pods work

Smoking/vaping while using Freedom Pods

Side effects

Cost of Freedom Pods

None/other

13

What's your email address?* This field is required.We'll send you an email with the next steps.

example@example.com

14

We need your age and location information to see which regulations apply to your jurisdiction:*Your information will remain private and securely stored.

Country

State

Age

15

How did you find the Freedom Pods Quit Assessment?

16

Interested in quitting nicotine with Freedom Pods?By submitting you're verifying that you are 21+.