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Mayo Clinic Comprehensive Questionnaire Intake Questions Related to E-Cigarette Use (Tobacco-Free Recovery Sidebar)
- Have you ever used an e-cigarette even one time?
- How old were you when you first tried an e-cigarette?
- Have you ever used an e-cigarette daily for a month or more?
- What e-cigarette product(s) have you tried? Select all that apply.
- A disposable e-cigarette (nonrechargeable)
- An e-cigarette device that uses replaceable and prefilled cartridges/pods (rechargeable)
- An e-cigarette with a tank that you refill with liquids (you use your own combination of separate devices: batteries, atomizers, etc.) (rechargeable)
- A heat not burn tobacco device
- Other
- Does the e-cigarette that you use or used contain any of the following items?
- Nicotine
- Cannabis
- Other
- While using an e-cigarette, do you mix your own e-liquids for refills?
- Yes
- No
- Do not know
- Name the brand(s) of e-cigarette(s) that you currently use or have used in the past.
- What is/was your primary reason for using an e-cigarette? Select all that apply.
- To quit smoking cigarettes
- To cut down smoking cigarettes
- To use when I cannot or am not allowed to smoke cigarettes
- To avoid returning to smoking cigarettes
- Because I enjoy(ed) it
- Curiosity or just wanted to try them
- Other
- In your opinion, how harmful is using an e-cigarette to your health?
- No harm
- Little harm
- Some harm
- A lot of harm
- Do not know
- How often do you currently use an e-cigarette? Select all that apply.
- Daily or almost daily
- Less than daily, but at least once a week
- Less than weekly, but at least once a month
- Less than monthly
- Not at all
- In the last 30 days, how often had you used e-cigarettes?
- Every day
- Some days
- Not at all
- How many times per day do you usually use your e-cigarette? (Assume that “one time” consists of around 15 puffs or lasts around 10 minutes)
- 0–4 times/day
- 5–9 times/day
- 10–14 times/day
- 15–19 times/day
- 20–29 times/day
- 30+ times/day
- What is the amount of nicotine that you typically use?
- 0 mg
- 3 mg
- 6 mg
- 12 mg
- 18 mg
- 24 mg
- ≥30 mg
- Do not know
- When do you usually use an e-cigarette? Select all that apply.
- Emotional (e.g., anger, sadness, anxiety, etc.)
- Pattern/habit (e.g., driving, talking on the phone, after meals, first thing in the morning, etc.)
- Social (e.g., going to a bar, social event, concert, around other smokers)
- Withdrawal (e.g., craving the taste of a cigarette, smelling cigarette smoke, handling cigarettes, lighters, and matches)
- While not using an e-cigarette, do you experience the following? Select all that apply.
- Feeling down or sad
- Having trouble sleeping
- Feeling irritable, on edge, or grouchy
- Having trouble thinking clearly and concentrating
- Feeling restless and jumpy
- Feeling hungrier or gaining weight
- Other
To gain access to the complete questionnaire, please contact Brian Clark at [email protected] (full credit goes to Tulsi Jose for the development of this questionnaire).
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