Institute of Social and Preventive Medicine - Faculty of Medicine
- University of Geneva - Switzerland
E-cigarette survey: follow-up
Please answer even if you do not use
Please take a few minutes to answer this
questionnaire. Your participation in this follow-up survey is very
important for the quality of this study.
Your answers will be stored on a computer file to conduct
statistical analysis, they will not be transmitted to any third parties.
If you do not want your answers to be stored, please do
Are you currently using the electronic cigarette?
Do you currently smoke tobacco (cigarettes, cigars or pipe)?
Do you currently use smokeless tobacco (snuff or snus or chewing tobacco)?
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
One question for EX-smokers and
EX-users of smokeless tobacco :
When did you quit smoking or stop using smokeless tobacco?
I quit smoking or stopped using smokeless tobacco on:
Questions for current smokers:
(Non-smokers, please click here to continue)
Currently, how many cigarettes (tobacco) do you smoke per day, on average?
I currently smoke
Usually, how soon after waking do you smoke your first cigarette
of the day?
Please rate your addiction to tobacco cigarettes on a scale of 0 to 100:
- I am NOT addicted to tobacco cigarettes at all =
- I am extremely addicted to tobacco cigarettes =
Addiction to tobacco cigarettes (0-100)
If you've already tried to quit smoking, how long did your most
recent quit attempt last?
My most recent quit attempt lasted:
If you have gone back to smoking after trying to quit, when
did you start smoking again?
I started smoking again on:
Do you intend to quit smoking?
If you tried to quit smoking, are you sure that you could actually quit?
Is it likely that, in one month from today, you will have quit
Please rate yourself for TODAY:
Desire or craving to smoke
Angry, irritable, frustrated
Depressed mood, sad
Insomnia, sleep problems, awakening at night
Increased appetite, hungry, weight gain
Want to hold a cigarette between your fingers
Questions on past and current e-cigarette
When did you last use an electronic cigarette ?
I used an e-cig for the last time on :
How long did your current or most recent episode of electronic
cigarette use last?
In the morning, usually, how soon after waking up do you use the electronic
Currently, on how many days per week do you use the electronic cigarette
I use the e-cig on
days per week
Currently how many puffs per day do you draw on you relectronic
cigarette, on average?
puffs per day
Does the refill liquid or cartridges that you currently use contain nicotine?
What is the concentration of nicotine in the e-liquid or cartridge that
you are currently using?
mg nicotine per mL
How much do you spend monthly for your electronic cigarettes
(purchase, refills, liquids,
cartridges, batteries, components, etc..)
For how much longer do you intend to use the electronic
For still another
Reasons for using the e-cigarette:
I use the electronic cigarette
Not at all true
Not very true
... because I enjoy it
... to deal with my craving for tobacco
... to quit smoking or avoid relapsing to smoking
... to deal with tobacco withdrawal symptoms
... to deal with situations or places where I cannot smoke
(e.g. at home, at work, during business meetings, when visiting non-smoking
friends, in a plane, bus or train, etc.)
... because in spite of my efforts, I am unable to stop using
the electronic cigarette
...because I am addicted to the electronic cigarette
Other purpose or reason:
Not at all true
Not very true
Urge to use the e-cigarette:
For you, stopping using the electronic cigarette for good would be:
Please rate your addiction to the electronic cigarette on a scale of
0 to 100:
- I am NOT addicted to the electronic cigarette at all =
- I am extremely addicted to the electronic cigarette =
Addiction to the e-cigarette (0-100)
How much of the time have you felt the urge to vape (=to use an electronic
How strong have the urges been today?
Questions for all:
Are you the same person who answered our similar questionnaire, a few
How old are you?
What is your body weight ?
We will contact you by e-mail in a few months, to ask you
a few questions about your use of e-cigarettes and of tobacco. If you
have a new e-mail address (in addition to the address that we already have
from you), please indicate it here.Your e-mail address is kept
confidential and will not be transmitted to anyone. Your participation in the follow-up surveys is very important for the
quality of this study.
Please click below to send your answers and to continue
Principal investigator: Jean-Francois Etter,
is senior lecturer at the Faculty of Medicine of the University of Geneva,
Switzerland. He is in charge of the Stop tabac.ch website and is the author
publications. Consultant: Thomas Eissenberg, PhD
is Professor of psychology, director of the Clinical Behavioral Pharmacology
Laboratory at the Virginia Commonwealth University, Richmond, VA, USA. He
is the author of numerous
[Created by JF Etter, version 1, 10 September 2012]