Breathe Free Pledge: I Commit to Quit
By signing this quit-smoking contract, I commit to quit!
As of ______________________, my official "quit date," I commit to breathing free!
My reasons for quitting smoking are:
_______________________________________________________________
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I have found a buddy I will call daily.
I recognize that this may be one of the greatest challenges of my life, but I also know that choosing to quit smoking is the best decision I can make to protect and improve my health.
Upon signing this contract, I make a commitment to myself to breathe free.
I don't know what will happen, or how difficult it will be to quit, but I do know that I can get help from _______________________________________________, and I have decided to (check one):
___ 1. Walk for 30 days and try nicotine patches and bupropion
___ 2. Walk for 30 days and use nicotine patches (or nicotine gum or nicotine oral inhaler) alone
___ 3. Walk for 30 days and use varenicline (Chantix) alone
I also know that staying smoke-free (not having "just one") after the initial breathe free period is important, and I have asked my friends and family to support me and to not smoke around me. I will also continue to talk daily with my buddy for at least 6 months, and then I'll become a buddy to others.
By committing to a life of breathing free, I will ensure a healthier future for myself, and I will protect the well-being of my loved ones and everyone around me who will no longer be exposed to the dangers of secondhand smoke. I am not only motivated but also committed and willing to make the effort to become a nonsmoker.
I deserve to give myself the healthiest life possible -- to breathe free!
| _______________________________________________ Signature/Date |
