Type to search

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 Brian.Clark@ucsf.edu (full credit goes to Tulsi Jose for the development of this questionnaire).

Brian Clark
Brian Clark
+ posts

Brian Clark is the senior data and project analyst at the Smoking Cessation Leadership Center. He manages and oversees coordination of SCLC’s various projects while providing analysis of campaign metrics.

Catherine Saucedo
Catherine Saucedo
+ posts

Catherine Saucedo is the deputy director of the Smoking Cessation Leadership Center. She provides oversight and executive level management for the Center.

Christine Cheng
Christine Cheng
+ posts

Christine Cheng is the partner relations director at the Smoking Cessation Leadership Center. She is responsible for the provision of outreach to accomplish SCLC’s objectives across its local, state, and national network of partners.

Steven Schroeder
Steven Schroeder, MD
+ posts

Steven Schroeder, MD, is the director of the Smoking Cessation Leadership Center, which began in 2003. He founded the SCLC after serving as president and CEO of the Robert Wood Johnson Foundation.