Order a Quit Pack or get patches, gum and lozenges

Please note: patches, gum and lozenges are only available to New Zealand residents

patches, gum and lozenges information

Nicotine patches, gum and lozenges can double your chances of quitting. Fill out the online form, and we will send you a Quit Card for patches, gum and lozenges. Take the card to a pharmacy where there will be a cost of $10-20 for eight-weeks supply of patches, gum and lozenges.

Click here for information sheets about patches, gum and lozenges.

If you have certain medical conditions you may need to get clearance from your doctor to use nicotine patches, gum and lozenges. Diabetics on insulin should inform their doctor of their intention to quit. Please call the Quitline on 0800 778 778 if you:

• have had a heart attack, stroke or severe angina in the last two weeks
• are pregnant or breast feeding
• are taking medication for a mental health condition
• weigh less than 45 kilos or 7 stone.

What do you want us to send?

Please tick which package you would like to receive. You may choose both if you like.

• Quit Pack with printed information about quitting smoking.
• Quit Card for nicotine patches, gum and lozenges.

Personal Information

Title Choose one Mr Mrs Miss Ms Dr

First Name *

Middle Name

Last Name *

Email address

Date of Birth * (Day) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (Month) 01 02 03 04 05 06 07 08 09 10 11 12 (Year) 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918

Gender * Choose One Female Male

Ethnicity * Which ethnic group do you belong to? Tick the space or spaces that apply to you.

  NZ Māori

  New Zealand European

  Samoan

  Cook Island Māori

  Tongan

  Niuean

  Chinese

  Indian

  Other (such as Dutch, Tokelauan)

Please state:  

  Don't want to give my ethnicity

Postal (delivery) Address

Street Address *

Suburb *

City *

Postcode

Phone numbers

Please specify at least one *

Home number

Mobile number

Work number

Preferred Contact Number * Choose one Home Mobile Work

Okay to leave a message? * Choose one No Yes

Smoking details

How much do you smoke? *

Tailor-made cigarettes per day 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150

Roll your own grams per week 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150

Pipe grams per week 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150

Cigars per week 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

Time to first smoke * Choose one Less than 30 minutes after waking 30 Minutes or More After Waking

How deeply do you inhale? * Choose one Lightly Moderately Heavily

Which do you prefer? Patches Gum Lozenges

Research

The Quit Group conducts research about the Quit Online Community and quitting. If you decide you would like to participate in our research. Information will be kept confidential.

Would you be interested in participating in future research projects about quitting online or quitting in general. *

Yes, I would like to make myself available for research.

No, I would not like to make myself available for research.

From time-to-time The Quit Group conducts research about the Quit Online Community and quitting. If you decide you would like to participate in our research:

• Your details may get passed on to our researchers.
• Our researchers may, or may not, contact you.
• You have the right to refuse participation in any research project you are invited to be part of.
• Our researchers will keep your information confidential.

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