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

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?

What is your preferred language?

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How did you hear about the ASHline?

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What Type of phone is your preferred phone?

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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

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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. @, $, !, %, *, #, ?, ., &)

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Tell Us About Yourself

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

By checking the box you agree to receive motivational, informational, coaching and other types of messages from the ASHLine 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?

Please specify the name of enrolled or principal tribe:

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?

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?

Medical Conditions

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

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

No

Due Date?

Currently breastfeeding

Yes

No

Tell Us More About Yourself

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.