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Quitting is a journey. Different paths and routes can get you to your end goal. Tell us about yourself so we can give you the best guidance for your journey.

Tell us a little about yourself.

What is the primary reason you're here today?^*
To quit smoking To quit vaping To quit dipping or chewing tobacco To help my child quit vaping Other
To Improve My Health

For My Family

To Save Money

A Health Condition

Appearance, Smell

I Am Pregnant

I Do Not Smoke
How often do you use tobacco (cigarettes/cigars, chewing tobacco/dip, or e-cigarettes)?^*
Every Day Some Days Not At All
What is your age group?^*
Under 18 18-24 25-30 31-44 45-64 65 or over
What is your gender?^*
Male Female Other / Prefer Not to Say

What's your zipcode?

Zip code^* Zip Code has to have 5 digits

Next, set up your login info and communication preferences

Set up your login!

Username^*
Get creative! Nearly 1 million others have already chosen usernames. You may need some numbers in yours (but not your email address, as usernames are publicly visible) and it must be 15 characters or less.
Password^*
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Email address^*
Confirm email address^*

Sign up for messages with encouragement and advice

Send me emails with tips and strategies straight to my inbox!
Send me texts to keep me on track! Daily messages, tailored to me, for no matter where I am in my quit.

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Check the box below to consent to receive these messages:

I want BecomeAnEX to send me email and/or text messages to help me quit. I understand and agree that: 1) messages to/from BecomeAnEX may have personal details about me, such as protected health information (PHI); 2) these messages won’t be secure and it’s up to me to keep them private; and 3) the contact info I provided is mine and I’ll keep it current on BecomeAnEX.

Who Referred You to EX Program?

If you were referred to EX Program by your employer, health insurance provider, or another sponsor, that means they have paid for you to access premium features. Please provide the information below to access those features.

If you were not referred here, simply check the boxes below each field.

EX Program features are only available to U.S. residents, so please double check your zip code entered above.

Who referred you to the Ex program?

Employer or Sponsor^*
Not referred
Health Insurance Provider (Aetna, Blue Cross, etc)^*
Not referred

Let's begin confirming your identity.

Legal First Name^*
Legal Last Name^*
Legal Birth Date^*
Date format: MM/DD/YYYY
Member ID^*
Relationship^*

Covered Member Info

First Name
Last Name
Birth Date
Date format: MM/DD/YYYY

HIPAA Release

Please give us your permission
Read the full agreement by scrolling through the form above, and then check the box below.

Please give us your permission. Read the full agreement by scrolling through the form above, and then check the box below.

In order to take advantage of EX Program features available to you through your employer or health plan, including any incentive that may be offered by your Sponsor, you must scroll through and agree to the HIPAA Authorization by checking the box next to "I agree…" You are free to decline these features and instead use the free version of the site. To do so, check the "Not Referred" checkboxes below both the Employer/Sponsor and Health Insurance Provider boxes. In order to take advantage of EX Program features available to you through your employer or health plan, including any incentive that may be offered by your Sponsor, you must scroll through and agree to the HIPAA Authorization by checking the box next to "I agree…" You may decline these features and instead use the free version of the site by clicking here: I want to decline the HIPAA Authorization I decline the HIPAA Authorization which would grant me access to premium features and instead I will use the free version of the site. Undo

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