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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.

* Required

*Select the free services you would like to use.

Online: Develop a personalized quit plan and quitting tools which can include patches, gum or lozenges.

Nicotine Replacement Therapy: Learn about and order your quit medications such as patches, gum or lozenges.

Phone: Coaching over the phone to develop a quit plan, which can include patches, gum or lozenges.

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

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. 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.

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

Cigarettes

Chewing 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?
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

The Colorado Quitline welcomes:

All races
All religions
All countries of origin
All sexual orientations
All genders
All ethnicities
All abilities

We stand with you.
To serve you better and meet the needs of all participants, please consider the following optional questions.

Are you Pregnant?
Yes
No

The Colorado 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).

I identify my ethnicity as: (Select all that apply)

American Indian or Native Alaskan

Asian

Black or African American

Hispanic or Latino/Latina

Native Hawaiian or Pacific Islander

White

Not in this list

Do you consider yourself to be gay, lesbian and/or bisexual?
Yes
No

Thanks, please indicate all of the following which apply to you:

Bisexual

Gay or lesbian

Queer

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?

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Tell Us About Yourself

Medical Conditions

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