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

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Does your parent or guardian know that you are enrolling in a program to stop using nicotine?
This does not prevent enrollment. We will be more careful about how we send you information to protect your privacy.

In which program would you like to participate? Why?

Online Only Phone + Online

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

The Phone + Online program requires consent from your parent or legal guardian before you can participate. Consent can be provided to us either verbally over the phone by your parent or guardian, or we can email them a consent form that they can send back to us allowing you to participate in coaching. A coach will call you to talk about these steps.

What is your preferred language?

English Spanish Other

Other Language

What best describes your gender? Why?

Male Female Transgender 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?

My Life My Quit offers text messages to keep you on track. We send you a message about every 1-2 days and you can also text with a live Coach for help quitting.

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.

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. !, $, #, %)

Confirm Password

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?

How did you hear about My Life My Quit?

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 such as 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 pods, 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

Smokeless tobacco, chew 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?

Bidis:

Kreteks or clove cigarettes:

Tobacco pouches or 'snus':

Tobacco 'orbs:'

Tobacco strips:

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?

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. Please remember that your answers are completely confidential.

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 (General Educational Development) 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, bisexual, and/or transgender? Why?

Yes No

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

Bisexual

Gay or lesbian

Queer

Transgender or gender variant and assigned male at birth

Transgender or gender variant and assigned female at birth

Have you ever been told by a doctor or nurse that you have Asthma?

Do you live with someone who uses tobacco or vapes?

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.