• Ÿcomplete a brief survey now;
• Ÿmeet the basic health eligibility requirements;
• Ÿprovide a ground address and an email address

Using nicotine patches or gum for the full 8-weeks boosts your ability to quit smoking.

Read the information below about the surveys, then click the AGREE button if you agree to take part. The order form, the eligibility questions, and the survey will automatically appear.

Reasons and Methods for Information Collection

Why is information collected from me?

Leave The Pack Behind collects information to better understand and serve the young adults who use its services. To receive your free nicotine patch or gum, you must complete the initial health screening and smoking history surveys. Six months from now, you can complete the final, optional survey that is emailed to you.

How is my information stored and maintained?

When you submit the initial surveys, a personal identification number (PIN) appears on your screen. This number, along with your answers, but not your name, is downloaded into “Database 1.” (There is no personally-identifiable information in Database 1). This database is used by Leave The Pack Behind to evaluate its services. It is retained for up to 15 years.

Completely separate from Database 1, your PIN, name, and contact information are downloaded into “Database 2.” This database is used by Leave The Pack Behind to send you emails. Database 2 is retained for up to 15 years. Your information remains in this database if you agree to receive emails from Leave The Pack Behind about other quit-smoking aides and/or surveys. If you decline this opportunity, your information is deleted from this database one year after the last use of your contact information.

How is my privacy protected?

All data are encrypted and protected with numerous security features during data collection and transmission to the databases. Both databases are securely maintained under strict password protection, and both are kept confidential as required by applicable privacy laws.

Brock University (where Leave The Pack Behind is housed) protects your privacy and your personal information. The personal information requested in this survey is collected under the authority of The Brock University Act, 1964, and in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA). The information collected is used to improve service provision, and to understand young adults’ smoking and quitting experiences. Reports include aggregate data; no personally-identifying information is included.

How can I withdraw my information from the databases?

You can withdraw your information at any time, for any reason with no penalty. To withdraw now, click DECLINE. To withdraw your information any time after submitting the initial surveys, send an email to [email protected] stating your PIN and your desire to withdraw. (The Administrative Assistant who receives your email will delete your name and contact information from Database 2, then forward your PIN (not your name) to staff who maintain Database 1 so they can delete your answers. The Administrative Assistant will permanently erase your email request. It may take up to 10 business days to process your request to stop receiving emails.)

What else should I know?

This service is funded by the Ontario Ministry of Health and Long Term Care. Obtaining the patch or gum through Leave The Pack Behind should in no way be taken as a form of or substitute for medical consultation.

If you have general questions about this service or how your information is collected, stored and used, please contact Leave The Pack Behind:

T 905-688-5550 x4992
E [email protected]