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Welcome! Begin your quit journey by selecting the programs you would like to enroll in.

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What is your preferred language?

English Spanish Other

Other Language

What best describes your gender? Why?

Male Female Transgender female/Trans woman Transgender male/Trans man Genderqueer/Gender nonconforming Other

Please enter your first name.

Please enter your last name.

What is your preferred phone number?

What Type of phone is your preferred phone?

Please enter your Phone Extension if you have one:

By checking the box you agree to receive motivational, informational, coaching and other types of messages from My Life My Quit to support you. Message frequency will vary. Reply HELP for help. Reply STOP to stop (or cancel). Message and data rates may apply.

Please enter your zip code.

Please tell us when you were born.

In which program would you like to participate? Why?

Online Only Phone + Online

Please enter your email address.

Password Criteria

Include a minimum of 8 characters, with at least 1 of each of the following: uppercase & lowercase characters, digits, and non-alphabetic characters (e.g. @, $, !, %, *, #, ?, ., &)

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I have read and accept the Terms / Privacy Policy

Tell Us About Yourself

The following questions help us to understand you and find the right tools to help you quit using tobacco.

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What is your preferred method of contact?

Participant feedback helps us improve our services. Providing feedback is voluntary and does not impact your participation in the program. You can choose what you want to share and when you want to share it. After you complete the program, may we contact you about your experience?

Yes No

Have you used an e-cigarette, Puff Bars, Smok, JUUL, Suorin, or other electronic “vaping” product in the past 30 days?

Do you use e-cigarettes every day, some days or not at all?

Do you use e-cigarette pod, cartridges or a tank system?

When you are using them regularly, how many pods do you use per week?

When you are using them regularly, how many cartridges do you use per week?

On the days in which you use e-cigarettes, how many milliliters of fluid do you use?

How soon after you wake, do you use e-cigarette or other electronic vaping products?

Do you intend to quit using e-cigarettes/e-vaping products within the next 30 days?

Yes No

What types of tobacco have you used in the past 30 days?

Cigarettes

Do you smoke cigarettes every day or some days?

Every day Some days

How many cigarettes do you smoke per day on the days that you smoke?

How soon after you wake, do you smoke your first cigarette?

Within five minutes 6 to 30 minutes 31 to 60 minutes More than 60 minutes

Chewing tobacco, snuff, or dip

Do you use chewing tobacco, snuff or dip every day or some days?

Every day Some days

How many pouches or tins do you use per week, on the weeks that you use tobacco?

How soon after you wake, do you first use spit tobacco, snuff or chew?

Within five minutes 6 to 30 minutes 31 to 60 minutes More than 60 minutes

Cigars, cigarillos, or small cigars

Do you smoke cigars every day or some days?

Every day Some days

How many cigars, cigarillos or little cigars do you smoke per week on the weeks that you smoke?

How soon after you wake, do you first smoke a cigar, cigarillo, or little cigar?

Within five minutes 6 to 30 minutes 31 to 60 minutes More than 60 minutes

Pipe

Do you smoke a pipe with tobacco every day or some days?

Every day Some days

How many pipes do you smoke per week, on the weeks that you smoke?

How soon after you wake, do you first smoke a pipe?

Within five minutes 6 to 30 minutes 31 to 60 minutes More than 60 minutes

Other tobacco products:

What other products do you use?

Water pipes or hookahs:

Do you currently use other types of tobacco every day, some days, or not at all?

How much other tobacco do you use per week, on the weeks that you use tobacco?

How soon after you wake, do you use other tobacco?

Do you usually smoke/chew/vape/JUUL a particular flavor?

What flavor?

How old were you when you started using tobacco products, including vaping?

Do you have a promo code?

Promo Code:

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

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Disclaimer : We do not provide medical care. Talk to your doctor about your plan to quit tobacco and use of nicotine replacement or other quit smoking medicine if you have any questions or problems.

Read Disclaimer? Yes

Do you have a history of any of the following? Check all that apply.

Asthma

Emphysema, Chronic Bronchitis, or COPD

History of seizures

Diabetes

Cancer

Heart disease, irregular heart rate, or angina

Heart attack within the last 12 months

Stroke within the last 12 months

High blood pressure

High blood pressure is controlled with medication

Skin condition (eczema, psoriasis, etc.) or allergies to adhesives

Use dentures or have sensitive gums

Currently pregnant

Yes

Due Date?

Currently breastfeeding

Yes

Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?

Tell Us More About Yourself

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* Required

Several communities have been targeted by the tobacco industry or have higher smoking rates. We'd like to ask you some demographic questions.

What grade are you in? If you are not currently in school, what grade did you last complete?

Less than grade 9 Grade 9 to 11, no degree GED High school degree Don't know Refused

What race or ethnicity do you identify with most?

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Hispanic or Latino/Latina

Do you consider yourself to be gay, lesbian and/or bisexual? Why?

Yes No

Thanks, indicate all of the following which apply to you:

Bisexual

Gay or lesbian

Queer

Does your parent or guardian know that you are enrolling in a program to stop using nicotine? This service is confidential. What you share, including your participation in the program is kept between you and your coach. We will not tell anyone what you share with us about your smoking or vaping or even that you contacted us.

Is anyone requiring you to call the quitline? (Parent/guardian, school, law enforcement, other)

Thank You!

Thank you for enrolling in the quitline. We’ll email you your enrollment details within a business day. We’re glad you’ve taken your first steps toward becoming tobacco free.