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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?
Yes
No

When you are using them regularly, how many pods do you use per week?

When you are using them regularly, how many cartridges do you use per week?

On the days in which you use e-cigarettes, how many milliliters of fluid do you use?

Do you intend to quit using e-cigarettes/e-vaping products within the next 30 days?
Yes
No

Do you smoke cigarettes every day or some days?
Every day
Some days

How many cigarettes do you smoke per day on the days that you smoke?

How soon after you wake, do you smoke your first cigarette?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Chewing tobacco, snuff, or dip

Do you use chewing tobacco, snuff or dip every day or some days?
Every day
Some days

How many pouches or tins do you use per week, on the weeks that you use tobacco?

How soon after you wake, do you first use spit tobacco, snuff or chew?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Cigars, cigarillos, or small cigars

Do you smoke cigars every day or some days?
Every day
Some days

How many cigars, cigarillos or little cigars do you smoke per week on the weeks that you smoke?

How soon after you wake, do you first smoke a cigar, cigarillo, or little cigar?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Do you smoke a pipe with tobacco every day or some days?
Every day
Some days

How many pipes do you smoke per week, on the weeks that you smoke?

How soon after you wake, do you first smoke a pipe?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Other tobacco products:

How much other tobacco do you use per week, on the weeks that you use tobacco?

How old were you when you started using tobacco products, including vaping?

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

Emphysema, Chronic Bronchitis, or COPD

Heart disease, irregular heart rate, or angina

Heart attack within the last 12 months

Stroke within the last 12 months

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

Currently breastfeeding Yes No

Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?

What grade are you in? If you are not currently in school, what grade did you last complete?
Less than grade 9
Grade 9 to 11, no degree
GED
High school degree
Don't know
Refused

Black or African American

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Hispanic or Latino/Latina

Do you consider yourself to be gay, lesbian and/or bisexual?
Yes
No

Tell Us About Yourself

Medical Conditions

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