Enroll Now

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

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* 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, e.g. Patches, Gum, Lozenges:Learn about and order quit medications.

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

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

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

What is your preferred language?

English Spanish Other

Other Language

What best describes your gender? Why?

Male Female Transgender female/Trans woman Transgender male/Trans man Genderqueer/Gender nonconforming Other

Are you Pregnant?

Yes No

The Utah 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?

Check this box to receive coaching, motivational and other supportive messages from the Quitline. Message frequency varies. Message and data rates may apply. Reply HELP for help. Reply STOP to stop. For more information, please review our SMS Terms/Privacy here: https://helpline.quitlogix.org/en-US/Legal/Privacy

What Type of phone is your preferred phone?

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

I have read and accept the Terms / Privacy Policy

Tell Us About Yourself

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

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* Required

What tobacco products have you used in the past 30 days? This does not include e-cigarettes or vaping products.

Cigarettes

SLT, chew tobacco, snuff, or dip

Cigars, cigarillos, or small cigars

Pipe with tobacco

Have you used an e-cigarette or other electronic “vaping” product in the past 30 days? Why?

Yes No

Do you have health insurance?

What type of insurance do you have?

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

Medical Conditions

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

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* Required

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

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?

Tell Us More About Yourself

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* Required

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? Why?

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? Why?

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? Why?

Yes No

During the past two weeks, have you experienced any emotional challenges that have interfered with your work, family life, or social activities? Why?

Yes No

Do you believe that these mental health conditions or emotional challenges will interfere with your ability to quit?

Yes No

Have you ever or are you currently serving on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

Yes No

How did you hear about the Utah Quitline?

Thank You!

Thank you for enrolling in the quitline. We’ll email you your enrollment details within a business day. We’re glad you’ve taken your first steps toward becoming tobacco free.