{{ step + 1 }}
When you enroll in the American Indian Commercial Tobacco Program you will have access to free phone and online support. Please complete the form to get started.
* Required
Tobacco plays an important role for many tribes for ceremonial and spiritual purposes. Some American Indian people use tobacco for spiritual or cultural reasons and others do not.
This program respects the individual relationship to the tobacco plant and allows further examination of the cultural aspects of that relationship, as desired.
This program honors all parts of the medicine wheel and believes to promote wellness, one needs harmony between mind, body and spirit. We are here to assist individuals in finding this balance and harmony.
Are you interested in enrolling in this special program?
Choose
Yes
No
What is your preferred language?
English
Spanish
Other
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
Please enter your Phone Extension if you have one:
Please enter your zip code.
Please tell us when you were born.
What best describes your gender?
Male
Female
Transgender female/Trans woman
Transgender male/Trans man
Genderqueer/Gender nonconforming
Other
In which program would you like to participate?
Online Only
Phone + Online
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. !, $, #, %)
Display Password
Confirm Password
Display Password
I have read and accept the
Terms / Privacy Policy
{{PPError}}
By checking the box you agree to receive motivational, informational, coaching and other types of messages from the Quitline to support you. Message frequency will vary. Reply HELP for help. Reply STOP to stop (or cancel). Message and data rates may apply.
Please select text, email, or both below:
Text
Email
There are some questions that we would like to ask so that we can better understand your commercial tobacco use and your personal goals for being in this program. This information is only for our use and will not be shared with anyone or any organization without your permission.
Will you share whether you culturally identify with a tribe?
Choose
Yes
No
Please specify the name of enrolled or principal tribe:
Choose
Apache
Arapahoe
Assiniboine
Blackfeet
Cherokee
Chickasaw
Chippewa- Cree
Choctow
Creek
Crow Tribe
Gros Ventre
Indigenous Peoples of the Great Basin
Kootenai
Lakota (Sioux)
Little Shell Band of Chippewas
Martis people
Mohave people
Navajo
Northern Cheyenne
No response
Paiute
Pend d'Oreille
Quoeech
Other
Salish
Shoshone
Sioux
Southern Ute
Swan Creek and Black River Chippewa
Ute Mountain Ute
Washoe Tribe of Nevada and California
Wind River Indian Reservation
If your enrolled or principal tribe is not represented, please type the name here:
What types of commercial tobacco have you used in the past 30 days?
Commercial Cigarettes:
Commercial chewing tobacco, snuff, or dip:
Commercial Cigars, cigarillos, or small cigars:
Pipe with commercial tobacco:
Other commercial tobacco products:
Have you used an e-cigarette or other electronic “vaping” product in the past 30 days?
Yes
No
Don't know
Refused
How would you like your commercial tobacco use to change as a result of participating in this program?
Choose
Quit
Cut down
Remain the same
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?
Choose
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
{{defaultThankYou.header}}
{{thankYou.header}}
{{thankYouNRT.header}}
{{youthRedirect.header}}