Text2Quit Enrollment Form

Text2quit is a new interactive program designed to help you kick the habit for good. Text2quit sends personalized text messages and emails timed to your quit date to help support you through the quitting process. Complete the questions below to subscribe.

Activation Code

*
Yes
No
 

Contact Information

Message Frequency: varies by user participation. Minimum 1 message/week.
Message Pricing: Message and data rates may apply.
*
Your cell phone number is used to send you regular text messages to coach you through the process of quitting.
*

By entering your cell phone number you agree to enroll into the program and receive Text2Quit text messages from 311411. The content is NOT available across all carriers. For currently supported carriers for Text2Quit text messages, click here. Opt-out: You can cancel at any time by texting STOP to 311411. For help, text HELP to 311411. For support, email support@voxiva.com


*
Your e-mail address is used to send you occasional e-mail messages with guidance on quitting smoking and links to other resources.
*

Personal Information

*
Your first name will appear on text and e-mail messages we send you.
*
*
Male
Female
We will use your gender (and age) to assign you a "Quit Coach" that you will be able to relate to.
*
  Select date
Your birth date is used to calculate savings and life expectancy and assign you a "Quit Coach" you will be able to relate to.
*
Your ZIP Code is used to assign you to a time zone so you receive messages at the right time of day.

Smoking Habits and Information

*
cigarettes
Your cigarette intake is used to calculate savings from quitting.
*
$ per pack
The cost of a packet of cigarettes is used to calculate savings from quitting.
*
  • To improve my health
  • For my family and/or friends
  • To save money
  • Just tired of smoking
  • Doctor told me to
  • For religious reasons
  • To be a role model
  • More and more places going smoke-free
  • To feel more in control of my life
  • Because of my children (grandkids)
  • Dirty/bad habit
  • For a healthy pregnancy
  • Because of the smell
  • To increase my endurance (e.g. basketball/jogging/dancing etc.)
  • Other
You will be regularly reminded by text message and e-mail of your main reasons for quitting.
*
*
  • When I get up in the morning
  • When I am in the car
  • When I am in a bad mood (e.g. angry and upset)
  • When I am bored
  • When I am drinking coffee
  • When others are smoking around me
  • When I am socializing
  • When I want to concentrate
  • When I want to celebrate
  • When I am anxious or stressed
  • When I am drinking alcohol
  • When I am talking on the phone
  • When I take work breaks
  • Other
*

Quitting Plans

*
  Select date
Your quit date will be used to determine what coaching messages to send you on a given day.

It is best to pick a quit date that is within the next 4 weeks. Choose a date that is not too stressful and when you tend to smoke a little less.

Mondays are usually good for quitting.
*
Yes
No
Undecided
If you tell us that you plan to use NRT or another medication, we will send you information on how best to use these products.

Note: Smoking cessation medications are not generally recommended for use by pregnant or breastfeeding women. Talk to your doctor about the benefits and possible risks before taking any medication to assist you stopping smoking.
*
  • Nicotine Gum
  • Nicotine Patch
  • Nicotine Nasal Spray
  • Nicotine Lozenge
  • Nicotine Inhaler
  • Chantix
  • Zyban
  • Other
The NRT or medication(s) you select will be used to send you information on how best to use these products.

Account Set-up


Password must be minimum 8 characters with at least 1 letter and 1 number.
*

*
*