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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

Quit Partner needs to collect some personal information to provide you with free quit nicotine services. We will also use your information to help evaluate how well our programs work and for research. The information we are collecting about you is private under Minnesota state law. Your private information will only be shared with MDH, its vendors, the Centers for Disease Control and Prevention, and other people or entities as authorized by law. If your information is shared with other external partners for program evaluation or research purposes, your name and other information that could identify you will be removed.
You will be asked some required and optional questions. You do not have to answer any of these questions, but if you do not answer the required ones, you will not be able to receive services from Quit Partner. You may be able to receive services elsewhere.

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?
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?

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. !, $, #, %)

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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:

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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:

Are you ever exposed to secondhand smoke?

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?

Are the commercial cigarettes you usually smoke menthol cigarettes?

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?

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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