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About the Quitline
About the Hawai‘i Tobacco Quitline Programs
How The Hawai‘i Tobacco Program Works
For Ohana and Friends
Program FAQs
About Quitting
Proven Strategies for Quitting
Benefits of Quitting
Tobacco's Health Effects
Interactive Tools
Resources
Health Professionals
Education
Make a Referral
Quitline FAQs
Print Resources
Resources for Patients
Enroll Now
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About the Quitline
About the Hawai‘i Tobacco Quitline Programs
How The Hawai‘i Tobacco Program Works
For Ohana and Friends
Program FAQs
About Quitting
Proven Strategies for Quitting
Benefits of Quitting
Tobacco's Health Effects
Interactive Tools
Resources
Health Professionals
Education
Make a Referral
Quitline FAQs
Print Resources
Resources for Patients
Enroll Now
Home
Enroll Now
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
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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.
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
Other Language
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
Chamorro
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
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?
What Type of phone is your preferred phone?
Choose
Cell
Home
Work
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Please enter your zip code.
Please tell us when you were born.
Please enter your email address.
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Getting feedback about this program is important to the people who fund the program. It lets them know what is going well and what can be improved. May someone contact you at a later date to ask about your satisfaction with the program and your progress towards quitting?
Choose
Yes
No
Do you have health insurance?
Choose
Yes
No
What type of insurance do you have?
Choose
Commercial - HMAA
Commercial - HMSA
Commercial - Kaiser Permanente
Commercial - Other
Commercial - TriCare/VA
Commercial - UHA Health Insurance
Commercial - United Health Care
Don't Know
Medicaid - 'Ohana Health Plan
Medicaid - Aloha Care
Medicaid - Fee for Service
Medicaid - Hawai`i QUEST Program
Medicaid - HMSA QUEST
Medicaid - Kaiser QUEST
Medicaid - Other
Medicaid - UHC Community Plan
Medicare
Prefer not to answer
How did you hear about the Hawai`i Tobacco Quitline?
Choose
A poster at a convenience store
AM/FM Radio Station
Cable TV or local television station
Don’t Know/Don’t Remember
Facebook
From a friend or family member
From a healthcare professional
Google Search
Instagram
Other
Streaming audio (such as Spotify)
Streaming TV Service (Hulu, etc.)
Twitter
YouTube
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
Currently, when you smoke cigarettes, how often do you smoke menthol cigarettes?
Choose
All of the time
Most of the time
Some of the time
Rarely
Never
Don't know
Prefer not to answer
Do you intend to quit smoking cigarettes in the next 30 days?
Choose
Yes
No
Don't know
Prefer not to answer
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 intend to quit smoking cigars, cigarillos, or little cigars in the next 30 days?
Choose
Yes
No
Don't know
Refused
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 intend to quit smoking a pipe in the next 30 days?
Choose
Yes
No
Don't know
Refused
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
Do you intend to quit using chewing tobacco, snuff, or dip in the next 30 days?
Choose
Yes
No
Don't know
Refused
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
Have you set a quit date?
Choose
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?
Please select one
No
Yes
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
Which specific Asian ethnicity or race do you identify with the most?
Choose
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Indonesian
Japanese
Korean
Laotian
Pakistani
Taiwanese
Thai
Vietnamese
Other
Don't know/unsure
Prefer not to answer
Black or African American
Native Hawaiian or Pacific Islander
Which specific ethnicity or race do you identify with more?
Choose
Native Hawaiian
Fijian
Guamanian or Chamorro
Maori
Samoan
Tahitian
Tongan
Other Micronesian
Other Pacific Islander
I don’t know
Prefer not to answer
Please choose from options below:
Choose
Marshallese
Palauan
Pohnpeian
Chuukese
Yapese
Saipanese
Kosraean
Please share your ethnicity or race:
White
Not in this list
Are you of Hispanic or Latino/Latina origin?
Choose
Yes
No
Don't know/unsure
Prefer not to answer
What specific heritage?
Choose
Central American
Cuban
Mexican
Other
Puerto Rican
Refused
South American
Do you consider yourself to be:
Choose
A. Heterosexual or Straight
B. Gay or Lesbian
C. Bisexual
D. An identity not listed
E. Prefer not to answer
What identity fits you better?
On average, how many alcoholic drinks do you consume in a week? (Sunday to Saturday)
Choose
1-2
2-3
3-4
4-5
5-6
6-7
7+
I do not drink alcohol
Don't know/unsure
Prefer not to answer
What is your employment status?
Choose
Employed for pay or self-employed
Stay-at-home parent
Retired
Student
Out of work
Unable to work
Don't know
Prefer not to answer
Which of the following income categories best describes your total household income last year?
Choose
$0 to less than $15,000
$15,000 to less than $25,000
$25,000 to less than $35,000
$35,000 to less than $50,000
$50,000 to less than $75,000
$75,000 or more
Prefer not to answer
Don't know/unsure
Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
Choose
Yes
No
Prefer not to answer
Have you ever been diagnosed with diabetes?
Choose
Yes
No
If yes, which type:
Choose
Type 1 Diabetes
Type 2 Diabetes
Don't know/unsure
Prefer not to answer
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