MLMQ (CT) - Start My Quit Page 2

Personalize Your Program

Congratulations! You're ready to get help with quitting. Please complete the form below to choose your program.

All form fields are required.

Select the services you would like to use on your quitting journey.

CREATE A QUIT PLAN:

Develop your personalized quit plan by utilizing effective tools including coaching, interactive activities.

TRACK MY PROGRESS:

Track how many days you've gone without tobacco. Receive check ins, motivational messages, and other support.

COACHING:

Coaching over phone, web, or chat to develop a quit plan.

What is your preferred method of contact?

Phone

Text

What is your preferred language?

English

Spanish

Other

Other Language

What best describes your gender?

Help

Tobacco impacts gender differently. Answering this will help us provide you the most accurate information.

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?

Confirm Phone Number

What Type of phone is your preferred phone?

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.

Confirm Email Address

Create Password

Passwords must include at least 8 characters with at least 1 of each of the following: uppercase letter, lowercase letter, number, and non-alphanumeric character (e.g. @, $, !, %, *, #, ?, ., &).

Confirm Password

I have read and accept the Terms / Privacy Policy

Tell Us About Yourself

We'll provide more specific resources based on the product(s) you use.

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

How did you hear about the QuitLine?

Have you used an e-cigarette, JUUL, smart vape, 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

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

Nicotine pouches such as Zyn, Rogue, or FRE

Cigarettes

Chewing tobacco, snuff, or dip

Cigars, cigarillos, or small cigars

Pipe

Other tobacco products:

What other products do you use?

Water pipes or hookahs:

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

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

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

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

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?

What is your medical history?

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

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

None of these apply

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?

What is your personal background?

These questions are not required, but help us understand how our program is helping participants of different backgrounds.

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 (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 and/or bisexual?

Help

LGBT communities are disproportionately impacted by tobacco. We have information that is specific to these communities related to quitting.

Yes

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 does not prevent enrollment. We will be more careful about how we send you information to protect your privacy.

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