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About the Quitline
About the Quitline Programs
How The Program Works
Helping Friends & Family
Program FAQs
Resources
About Quitting
Podcast
Proven Strategies for Quitting
Success Stories
Benefits of Quitting
Tobacco's Health Effects
Tobacco and You
Interactive Tools
Health Professionals
Education
Make a Referral
Community Organizations
Quitline FAQs
Resources
Enroll Now
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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
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All fields required
All questions are 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.
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
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
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 Wyoming Quit Tobacco Program 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?
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Cell
Home
Work
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What types of tobacco have you used in the past 30 days? This does not include e-cigarettes or vaping products.
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
Chewing 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 with tobacco
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
Have you used an e-cigarette or other electronic “vaping” product in the past 30 days?
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
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
Which of these groups would you say best describes you?
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?
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
High school degree
Some college or university (includes some technical or trade school)
College or university degree (includes AA, BA, Masters, and PH.D.)
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 annual household income?
Choose
Less than $25,000
$25,000 - $50,000
More than $50,000
Prefer not to answer
Don't know
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