Day 1 Quit Pledge

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* 1. I Pledge, that today marks the first day I am smoke/vape free

Name *

Email Address

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* 2. My former tobacco product of choice was

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* 3. I began using tobacco at the age of

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* 4. I have tried to quit ____ times (on average it may take 8-10 tries to quit for good)

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* 5. My reason for quitting is ____