OMB# 0910-0796 | Exp.
6/30/2018
Background Assessment:
Age: I am _____ years old
How many times have you used an electronic nicotine product in your entire life?
1 time, even just a few puffs
2 to 10 times
11 to 20 times
21 to 50 times
51 to 99 times
100 or more times
Don’t know
On how many of the past 30 days did you use an electronic nicotine product?
________ days
Don’t know
At the time you started using electronic nicotine products, were you also using some other type of tobacco product(s)?
Yes (If yes, go to 4.1)
No (If no, go to 4.2)
4.1 Please select which tobacco product(s) you were using when you started using electronic nicotine products. Choose all that apply:
Cigarettes
Cigars (including traditional cigars, cigarillos, or little filtered cigars)
Pipes
Hookah
Smokeless tobacco (including chewing tobacco, snuff, or dip)
Snus
Other, please specify_________________
4.2 Was your electronic nicotine product the first experience you had with a product containing nicotine?
Yes
No (If no, go to 4.3.a)
4.2.a What other tobacco products have you tried? Choose all that apply:
Cigarettes
Cigars (including traditional cigars, cigarillos, or little filtered cigars)
Pipes
Hookah
Smokeless tobacco (including chewing tobacco, snuff, or dip)
Snus
How old were you when you first started using an electronic nicotine product?
____ Years old
When you first started using electronic nicotine products, was it flavored to taste like menthol, mint, clove, spice, candy, fruit, chocolate, or other sweets? (Please do not include tobacco flavor)
Yes
No
Don’t know
6.1 In the past 30 days, which flavors have you used in your electronic nicotine product?
Choose all that apply:
Tobacco-flavored
Menthol or mint
Clove or spice
Fruit
Chocolate
An alcoholic drink (such as wine, cognac, margarita or other cocktails)
A non-alcoholic drink (such as coffee, soda, energy drinks, or other beverages)
Candy, desserts or other sweets
Some other flavor, specify: __________________
Don’t know
What do you call the electronic nicotine device you use most often…?
_______________________________
Is the device you just described the same type as the device you used when you started using electronic nicotine products?
Yes
No
If not, please describe the first device type you used:____________________________
Where do you buy your electronic nicotine product most of the time?
A vape shop or vapor lounge
Online
A mall kiosk
A convenience store or gas station
A supermarket, grocery store, or drug store
A bar, pub, restaurant or casino
A friend or relative
A liquor store
Somewhere else, specify: ____________
What brand of electronic nicotine product do you own?
__________________
Don’t know
How addicted to your electronic nicotine product do you feel?
not at all
somewhat addicted
very addicted
11.1 On the days that you use an electronic nicotine product, how soon after you wake up do you typically take your first puff of the day? Please enter the number of minutes or hours.
_________ minutes after waking
_________ hours after waking
Don’t know
What concentration of nicotine do you usually use?
I don’t know the concentration
0mg or 0%
1-12mg or 0.1-1.2%
13-17 mg or 1.3-1.7%
18-24mg or 1.8-2.4%
25+mg or 2.5+%
Other (please specify): __________________________________
About how much did you pay for your device? Do not include the cost of additional cartridges or accessories unless they were included in a starter kit.
Less than $10
$10 to $20
$21 to $100
More than $100
Don’t know
Have you smoked at least 100 cigarettes in your entire life?
Yes
No
14.1 Do you now smoke cigarettes every day, some days, or not at all?
Every day (go to 14.1.a & 14.1.b)
Some days(go to 14.1.a & 14.1.b)
Not at all (If no to 14. and currently uses not at all, go to 14.1.c; If yes to 14. and currently uses not at all, go to 14.1.d.i & 14.1.d.ii)
14.1.a How addicted to cigarettes do you feel?
not at all
somewhat addicted
very addicted
14.1.b On the days that you smoke cigarettes, how soon after you wake up do you typically take your first puff of the day? Please enter the number of minutes or hours.
_________ minutes after waking
_________ hours after waking
Don’t know
14.1.c Have you ever tried cigarette smoking, even one or two puffs?
Yes
No
14.1.d.i At any time during the past 12 months, did you completely switch from smoking traditional cigarettes to using e-cigarettes?
Yes
No
14.1.d.ii How long has it been since you completely stopped smoking cigarettes?
[_] [_] days/ months/ years
Have you ever used a nicotine replacement therapy product, such as nicotine patches, gum, or lozenge?
Yes
No
15.1Are you currently using a nicotine replacement therapy product, such as nicotine patch, gum, or lozenge?
Yes
No
In the past 12 months, have you tried to quit using electronic nicotine products completely?
Yes
No
16.1 Are you thinking about quitting the use of electronic nicotine products for good?
Yes (If yes, go to 16.1.a)
No
Don’t know/ not sure
16.1.a How soon are you likely to quit using electronic nicotine products?
Within the next 30 days
Within the next 6 months
Within the year
Longer than a year
Don’t know/ Not sure
16.2 (Among dual e-cigarette/ cigarette users) Are you thinking about quitting the use of all tobacco products for good?
Yes (If yes, go to 16.2.a)
No
Don’t know/ not sure
16.2.a (Among dual e-cigarette/ cigarette users) How soon are you likely to quit using tobacco/ nicotine products?
Within the next 30 days
Within the next 6 months
Within the year
Longer than a year
Don’t know/ Not sure
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Coleman, Blair |
File Modified | 0000-00-00 |
File Created | 2021-01-26 |