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About the Quitline
About the Quitline Programs
How The Program Works
Helping Friends & Family
Program FAQs
Resources
About Quitting
Proven Strategies for Quitting
Success Stories
Benefits of Quitting
Tobacco's Health Effects
Tobacco and You
Interactive Tools
Health Professionals
Education
Make a Referral
Quitline FAQs
Resources
Sign Up
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Tell Us About Yourself
Medical Conditions
Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.
Tell Us More About Yourself
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All questions are required
At least one selection is required
To enroll in the program, we need to get some information from you. The next several pages will ask you questions about you and your tobacco history. Once you have completed the questions, we will begin this journey together!
* Required
Quit Partner needs to collect some personal information to provide you with free quit nicotine services. We will also use your information to help evaluate how well our programs work and for research. The information we are collecting about you is private under Minnesota state law. Your private information will only be shared with MDH, its vendors, the Centers for Disease Control and Prevention, and other people or entities as authorized by law. If your information is shared with other external partners for program evaluation or research purposes, your name and other information that could identify you will be removed. You will be asked some required and optional questions. You do not have to answer any of these questions, but if you do not answer the required ones, you will not be able to receive services from Quit Partner. You may be able to receive services elsewhere.
In which program(s) would you like to participate? Please choose at least one of the following checkboxes:
Individuals who sign up for coaching and quit medications together are twice as likely to quit successfully.
Phone –
Free coaching over the phone to develop a quit plan and get extra quit medications. Sign up for our standard program or learn more about our specialized programs for American Indians, people with behavioral health conditions, & pregnant/postpartum people.
Online –
Sign up to get a starter kit of quit medications (two weeks), chat with a coach by using the live chat function, or design your quit plan. For the full coaching program, please select the phone option.
Nicotine Replacement Therapy –
Check this box to get a starter kit of two weeks of a quit medications(patches, gum, lozenges) as part of your online program to help you quit.
Email –
Sign up for motivational emails, quit medication updates, appointment reminders, and more.
What is your preferred language?
English
Spanish
Other
Other Language (Translation services available for phone coaching)
Choose
Acholi
Afrikaans
Akan
Albanian
American Sign Lang
Amharic
Arabic
Arakanese
Armenian
Ashanti
Assyrian
Azerbaijani
Azeri
Bakunin
Barbara
Basque
Behdini
Belorussian
Bengali
Berber
Bosnian
Bulgarian
Burmese
Cantonese
Catalan
Chaldean
Chaochow
Chavacano
Cherokee
Chin
Chuukese
Cree
Croatian
Czech
Danish
Dari
Dinka
Diula
Dutch
English
Estonian
Ewe
Farsi (Persian)
Fijian Hindi
Finnish
Flemish
French
French Canadian
Fukienese
Fula
Fulani
Fuzhou
Ga
Gaddang
Gaelic
Georgian
German
Greek
Gujarati
Haaka
Haaka - China
Hassaniyya
Haitian Creole
Hebrew
Hindi
Hmong
Hokkien
Hunanese
Hungarian
Ibanag
Ibo
Icelandic
Igbo
Ilocano
Indonesian
Inuktitut
Italian
Jakartanese
Japanese
Javanese
Kanjobal
Karen
Kashmiri
Kazakh
Khmer (Cambodian)
Kinyarwanda
Kirghiz
Kirundi
Korean
Kosovan
Krio
Kurdish
Kurmanji
Laotian
Latvian
Lingala
Lithuanian
Luganda
Luo
Luxembourgeois
Maay
Macedonian
Malagasy
Malay
Malayalam
Maltese
Mandarin
Mandingo
Mandinka
Marathi
Marshallese
Mexican Sign Lang
Mien
Mina
Mirpuri
Mixteco
Moldavan
Mongolian
Montenegrin
Moroccan Arabic
Navajo
Neapolitan
Nepali
Nigerian Pidgin English
Norwegian
Nuer
Oromo
Other
Pahari
Pampangan
Pangasinan
Pashto
Patois
Pidgin English
Polish
Portuguese
Portuguese Creole
Pothwari
Pulaar
Punjabi
Quichua
Romani, Vlach
Romanian
Russian
Samoan
Serbian
Shanghainese
Sichuan
Sicilian
Sindhi
Sinhalese
Slovak
Somali
Soninke
Sorani
Spanish
Sudanese Arabic
Sundanese
Susu
Swahili
Swedish
Sylhetti
Tagalog
Taiwanese
Tajik
Tamil
Telugu
Thai
Tibetan
Tigrinya
Toishanese
Tongan
Tshiluba
Turkish
Twi
Ukrainian
Urdu
Uyghur
Uzbek
Vietnamese
Visayan
Wenzhou
Wolof
Yiddish
Yoruba
Yupik
What best describes your gender?
Male
Female
Transgender female/Trans woman
Transgender male/Trans man
Genderqueer/Gender nonconforming
Other
Quit Partner offers a phone coaching program just for pregnant and postpartum people. If you are currently pregnant and would like to learn more about this program or enroll, call 1-800-QUIT-NOW.
Please enter your first name.
Please enter your last name.
What is your preferred phone number?
What Type of phone is your preferred phone?
Choose
Cell
Home
Work
Check this box to receive coaching, motivational and other supportive messages from the Quitline. Message frequency varies. Message and data rates may apply. For more information, please review our SMS Terms/Privacy here: https://helpline.quitlogix.org/en-US/Legal/Privacy
Please enter your zip code.
Please tell us when you were born.
Please enter your email address.
To what extent, if any, do you believe that continued smoking affects the risk of getting coronavirus or having a more serious case?
Choose
Definitely increases
Might increase
Does not change
Might reduce
Definitely reduces
Don't know
Prefer not to answer
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. !, $, #, %)
Display Password
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What tobacco product(s) are you currently using?
Cigarettes
Smokeless tobacco, chew tobacco, snuff, or dip
Cigars, cigarillos, or small cigars
Pipe with tobacco
None
Have you used an e-cigarette or other electronic “vaping” product in the past 30 days?
Yes
No
Because of COVID-19, has your motivation to quit cigarettes increased, decreased or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer
Because of COVID-19, has the amount you smoke increased, decreased or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer
Do you smoke cigarettes every day or some days?
Every day
Some days
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
Are the cigarettes you usually smoke menthol cigarettes?
Yes, I usually smoke menthol cigarettes
No, I usually smoke other types of cigarettes
Don't know
Refused
Quit Partner offers an incentive program for participants who complete phone coaching and use menthol tobacco. If you would like to learn more, call 1-800-QUIT-NOW.
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
Because of COVID-19, has your motivation to quit e-cigs/Vaping increased, decreased or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer
Because of COVID-19, has the amount you use e-Cigs or vape increased, decreased, stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer
To what extent, if any, do you believe that continued vaping affects the risk of getting coronavirus or having a more serious case?
Choose
Definitely increases
Might increase
Does not change
Might reduce
Definitely reduces
Don't know
Prefer not to answer
How many days did you use an e-cigarette or electronic “vaping” product in the last 30 days?
Do you intend to completely quit using e-cigarettes/e-vaping products within the next 30 days?
Yes
No
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
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.
None
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
No
Due Date?
Currently breastfeeding
Yes
No
Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?
Please select one
No
Yes
How did you hear about Quit Partner?
Choose
Animal Shelters
Billboard(s)
Booth at an event
Brochure/Newsletter/Flyer
Bus ad
Community Organization
County Health Department
Court Referral Youth
Dentist
Direct mail
Door Hanger
Employer
Family/Friends
Gas Station Ads
Health Care Professional
Insurance company
Internet
Newspaper/Magazine
Online Ad
Other
Outdoor Ad
Pharmacy/Pharmacist
Post Card
Quit Card
Radio
SAGE Program
School
Social media
Tiktok
Television
Text To Quit
Theater ad, before movie
Unknown
Veterinary Clinics
Which of these groups would you say best describes you?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/Latina
Native Hawaiian or Pacific Islander
White
Do you consider yourself to be gay, lesbian, bisexual and/or queer?
Yes
No
Bisexual
Gay or lesbian
Queer
What is the highest level of education you have completed?
Less than grade 9
Grade 9 to 11, no degree
GED (General Educational Development)
High school degree
Some college or university (includes some technical or trade school)
College or university degree (includes AA, BA, Masters, and PH.D.)
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