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

Tell Us About Yourself

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

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

All fields required At least one selection is required

* Required

*In which program(s) would you like to participate?

Phone: Coaching over the phone to develop a quit plan.

Online: Develop a personalized quit plan and quitting tools.

Nicotine Replacement Therapy: Learn about and order quit medications.

Text: Receive motivational, informational, coaching and other types of text messages.

Standard text messaging rates may apply.
Message frequency will vary.
Reply STOP to opt out.

Email: Get motivational, informational, coaching and other types of email messages.

Next we need to collect some information to create your personalized profile.

What is your preferred language?
English
Spanish
Hawaiian
Other

Are you Pregnant?
Yes
No

The Hawai'i Tobacco Quitline offers a special program just for pregnant and postpartum people. If you are currently pregnant and would like to learn more about this program or to enroll, call 1-800-QUIT-NOW (1-800-784-8669).

Please enter your first name.

Please enter your last name.

What is your preferred phone number?

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

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What types of tobacco have you used in the past 30 days? Please do not include e-cigarettes or vaping use.

Cigarettes

Cigars, cigarillos, or small cigars

Pipe with tobacco

Chewing tobacco, snuff, or dip

Do you currently 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 currently 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 currently 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 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 chewing tobacco, snuff or chew?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Have you used an e-cigarette or other electronic “vaping” product such as JUUL, NJOY, blu or other brands in the past 30 days? This does not include vaping of other substances such as cannabis.
Yes
No

How many days did you use an e-cigarette or electronic “vaping” product in the last 30 days?

People use e-cigarette/e-vaping products for a variety of reasons, are you currently using e-cigarettes/e-vaping products to quit smoking?
Yes
No

Do you intend to completely quit using e-cigarettes/e-vaping products within the next 30 days?
Yes
No

Because of the COVID-19 pandemic, has your motivation to quit using tobacco or vaping increased, decreased, or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer

Because of the COVID-19 pandemic, has the amount you use tobacco or vape increased, decreased, or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer

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?

What is the highest level of education you have completed?
Less than grade 9
Grade 9 to 11, no degree
GED
High school degree
Some college or university (includes some technical or trade school)
College or university degree (includes AA, BA, Masters, and PH.D.)
Technical/Trade School Degree
Don't know/unsure
Prefer not to answer

Do you have any mental health conditions, such as an anxiety disorder, depression disorder, bipolar disorder, schizophrenia, Attention-Deficit/Hyperactivity Disorder (ADHD), Posttraumatic Stress Disorder (PTSD) or substance use disorder?
Yes
No

Anxiety Disorder

Depression

Bipolar Disorder

Schizophrenia and Schizoaffective Disorders

Attention-Deficit/Hyperactivity Disorder (ADHD)

Posttraumatic Stress Disorder (PTSD)

Substance use disorder

Other

During the past two weeks, have you experienced any emotional challenges such as excessive stress, feeling depressed or anxious?
Yes
No

During the past two weeks, have you experienced any emotional challenges that have interfered with your work, family life, or social activities?
Yes
No

Do you believe that these mental health conditions or emotional challenges will interfere with your ability to quit?
Yes
No

What is your race?

American Indian or Native Alaskan

Asian

Black or African American

Native Hawaiian or Pacific Islander

Please share your ethnicity or race:

White

Not in this list

What identity fits you better?

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Tell Us About Yourself

Medical Conditions

Tell Us More About Yourself

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