How old are you? (Must be
18+)
____ years old
What is your occupation? __________
What is the highest level
of education that you have achieved?
Less than High School Diploma
High School Diploma or GED
Some College / Technical School
College Degree
Graduate Degree
Which of
these best describes your current employment status?
Full-time employment
Part-time employment
A full-time homemaker / stay at home caregiver
A full-time student
Part-time student
Retired
Unemployed / Laid off
Unable to work due to long term disability / sickness
Do you know or have you heard of electronic
cigarette?
No, I never read anything about it and nobody told me about it.
Yes, I read a bit about it or someone told me about it.
Yes, I am informed on the e-cig, but I have never used it.
Yes, and I have already used it.
Are you currently using electronic cigarette?
No, I have never used it.
No, but I have used it in the past.
Yes, occasionally (not daily).
Yes, I use it every day.
In the future, do you intend to
use electronic cigarette?
I have no intention. at all to use it
I don’t know.
I strongly want to use it.
I plan to use it.
Do you currently smoke tobacco (cigarettes,
cigars or pipe)?
Yes, occasionally (NOT every day).
Yes, I smoke every day.
No, I am an EX-smoker.
No, I never was a smoker.
Do you currently use smokeless
tobacco (snuff or snus or chewing tobacco)?
Yes, I use smokeless tobacco every day.
Yes, occasionally (NOT every day).
No, I am an EX-user of smokeless tobacco.
No, I never was a user of smokeless tobacco.
Before you first used the
electronic cigarette, were you a smoker or a user of smokeless tobacco?
I was an ex-smoker or an ex-user of smokeless tobacco.
I was a DAILY smoker or use of smokeless tobacco.
I was an NON-daily smoker or user of smokeless tobacco.
I had never smoked or used smokeless tobacco.
The first time that you ever used
nicotine, in which product was the nicotine?
In a cigarette, cigar or pipe (tobacco),
In a smokeless tobacco.
In a nicotine medication(patch,gum, tablet, inhaler)
In an electronic cigarette.
Have you smoked any tobacco
(even one puff of cigarette, cigar, pipe, etc.), or used smokeless tobacco in
the past 7 days?
During the past 31 days, on how
many days did you smoke or use smokeless
tobacco? ____ days / 31
How old were you when you first started to smoke daily or to use smokeless tobacco daily? I was ____ years old
What kind of smoker you are ?
Current Smoker.
EX-smokers and EX-users of smokeless tobacco
Never Smoke
Four
questions for EX-smokers and EX-users of smokeless tobacco
When did you quit smoking or
stop using smokeless tobacco?
____ / ____ / ____ (dd / mm / yy)
Before you quit smoking, how many cigarettes (tobacco) did you smoke per day, on average?
I smoked ____cig./day before I quit smoking
Before you quit smoking, how soon after waking up did you smoke your first cigarette of the
day, usually? ____ minutes
Please rate your addiction to
tobacco cigarettes when you were a smoker, on a scale of 0 to 100: ____
Addiction to tobacco cigarettes when you were a smoker
(0-100)
- I was NOT addicted to tobacco cigarettes at all = 0
- I was extremely addicted to tobacco cigarettes = 100
Questions for current smokers
Currently, how many
cigarettes (tobacco) do you smoke per day, on average?
I currently smoke ____ cig./day (tobacco)
Usually, how soon after
waking up do you smoke your first cigarette of the day?
____ minutes
Please rate your addiction to
tobacco cigarettes on a scale of 0 to 100:
____ Addiction to tobacco cigarettes (0-100)
-
I am NOT addicted to tobacco cigarettes at all = 0
- I am extremely addicted to tobacco cigarettes = 100
If you’ve already tried to quit
smoking… how long did you most recent quit attempt last?
My most recent quit attempt lasted__________
How long did your longest
quit attempt last?
My longest quit attempt lasted: ____
If you have gone back to
smoking after trying to quit, when did you start smoking again the last time?
I started smoking again the last
time on: ____ / ____ / ____ (dd / mm / yy)
Are you currently trying
to reduce your smoking?
Do you
intend to quit smoking?
I have NO intention to quit smoking
I plan to quit, but I haven’t set a quit date
I plan to quit in the next 6 months
I have decided to quit in the next 30 days
I have decided to quit immediately
If you
tried to quit smoking, are you sure that you could actually quit?
Not at all sure
Not very sure
Somewhat sure
Very sure
Is it likely that, in one
month from today, you will have quit smoking?
It is very likely
It is rather likely
It is rather unlikely
It is very unlikely
If you
have decided to quit smoking, have you set a quit date?
If you have, what is your
target quit date?
I have decided to quit smoking on:
____ / ____ / ____ (dd / mm / yy)
Do your
relatives / friends / colleagues ask you to quit smoking?
Never
Seldom
Some times
Many times
All the time