This form is to attest whether you use or do not use nicotine or tobacco products, and are tobacco-free. Pitkin County's Health & Well-Being Program is intended to encourage and assist employees in helping to quit their tobacco use.  We are collecting this information to know how to best provide resources to employees.

To earn the 2023 Health Insurance Premium Discount / Wellness Rate, you must participate in a Tobacco-Free Success Plan if you are a tobacco-user.

Quitting tobacco is one of the most impactful things you can do for your health. Within 24 hours of quitting, chances of a heart attack goes down significantly!

Tobacco use is defined as using any product that contains any tobacco or nicotine including cigarettes, cigars, chew, snuff, spit tobacco, e-cigarettes, vaping devices, and other forms that tobacco is used.

FDA approved nicotine replacement therapy, including nicotine gum, lozenges, and patches are allowed, and encouraged to use if helpful.

Pitkin County reserves the right to test for tobacco use at any time. An employee or spouse/partner who intentionally falsifies their non-tobacco use status on this form will be subject to immediate revocation of the employee's Health Insurance Premium Discount, and the employee may also face disciplinary action.