Smoker Adoption Papers

Great American Smokeout

November 15, 2007

I,________________________________, will do all that is within my power to

help you, __________________________________,

not to smoke during the American Cancer Society Great American Smokeout on November 15, 2007. On my honor and as my part of the bargain, I promise to do
the following to accomplish our goal:

• Praise you for having the willpower to give up nicotine for a day.

• Reassure you that there are still only 24 hours in a day.

• Help you remember your commitment to not smoke.

• Bribe you with food, money, and/or other incentives.

• Be there when you need me.

You, on your part, will make it through the day if you:

• Hide your cigarettes, ashtrays, lighters, and matches.

• Tell your friends you have been adopted and will not smoke during the Great American Smokeout.

• Call me when you feel you can’t resist the desire to smoke.

• Refrain from visiting smoke-filled rooms.

• Remember that today, you are SETTING YOURSELF FREE!

I will do what it takes to help set my friend FREE.

___________________________                       ________________
     (Nonsmoker’s Signature)                                             Date

I promise not to smoke during the American Cancer Society Great American Smokeout.

___________________________                       ________________
     (Temporary Smoker’s Signature)                                    Date

For tobacco cessation information and resources in Jefferson and Keokuk Counties, Iowa, call 1-800-QUIT-NOW (1-800-784-8669) or visit www.chokesmokes.org