Sabish FACT Mini Grant Adult Survey

Adult Survey E-Cigarette (Electronic Delivery Devices)
(12 Survey Questions Total)

Question Title

* 1. It is very difficult for kids to get E-Cigarettes (Vapes, JUULs. etc.) in
our community

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Question Title

* 2. Kids are attracted to E-Cigarettes, (JUULs, Vapes) because they
come in candy flavors such as (Cotton Candy/Watermelon) and many other flavors.

Strongly Agree

Agree

Neither agree nor disagree

Disagree

Strongly Disagree

Question Title

* 3. I am aware of the following brands of E-Cigarettes (vape products).
Please choose all that apply.

JUUL

Smoke Badge

Suorin

All of the above

None of the above

Other (please specify)

Question Title

* 4. I am aware that substances other than liquid nicotine can be used in many of the E-Cigarettes (Vapes JUUL's).

Strongly agree

Agree

Neither agree not disagree

Disagree

Strongly disagree

Question Title

* 5. Unlike Conventional Cigarettes, E-Cigarettes (Vape Products) can be adevertised on radio, TV, billboards, newspaper, and social media.

True

False

Question Title

* 6. Currently anyone interested in selling only E-Cigarettes or liquid nicotine could do so in Wisconsin without a tobacco retail license.

True

False

Question Title

* 7. Currently there is not a Federal or State of Wisconsin requirement to list the ingredients in liquid used in E-Cigarettes, (JUUL's, Vapes), or bottles of the liquid nicotine/E-Juice.

True

False

Question Title

* 8. I am concerned that the aerosol (vapor) coming from a E-Cigarette
(JUUL, Vape), contains some heavy metals such as lead and nickel
as well as formaldehyde.

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Question Title

* 9. I feel anywhere you can't smoke a cigarette (workplaces, restaurants, bars,) no one should be allowed to use (E-cigarettes, JUULs, Vapes)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Question Title

* 10. I use the following Tobacco or Nicotine Products. Please choose all
that apply.

Cigarettes

Smokeless Tobacco (Dip, Snuff, Chew)

Little Cigars (e.g. swisher sweets, Black and Mild, other)

E-Cigarettes (Vapes)

I do not use any Smokeless Tobacco, Cigarettes, Little Cigars or E-Cigarettes

Other Tobacco (please specify)

Question Title

* 11. If you answered question Q10 as using E-Cigarettes, choose all that
apply from the following statements below that best describe why
you use E-Cigarettes. If you do not use E-Cigarettes skip Q11.

I use E-Cigarettes to stop smoking conventional cigarettes

I use E-cigarettes hoping I will eventually quit all nicotine

I use E-Cigarettes because I can use them at home without concerns of secondhand exposure

I use E-Cigarettes because I can use them in public places where conventional cigarettes are ban

I use E-Cigarettes because many of my friends use E-Cigarettes

I use E-Cigarettes because I never smoked conventional cigarettes and believe the liquid coming from the E-Cigarette is mostly water vapor

Other (please specify)

Sabish FACT Mini Grant Adult Survey

Adult Survey E-Cigarette (Electronic Delivery Devices) (12 Survey Questions Total)

Question Title

* 1. It is very difficult for kids to get E-Cigarettes (Vapes, JUULs. etc.) in our community

Question Title

* 2. Kids are attracted to E-Cigarettes, (JUULs, Vapes) because they come in candy flavors such as (Cotton Candy/Watermelon) and many other flavors.

Question Title

* 3. I am aware of the following brands of E-Cigarettes (vape products). Please choose all that apply.

Question Title

* 4. I am aware that substances other than liquid nicotine can be used in many of the E-Cigarettes (Vapes JUUL's).

Question Title

* 5. Unlike Conventional Cigarettes, E-Cigarettes (Vape Products) can be adevertised on radio, TV, billboards, newspaper, and social media.

Question Title

* 6. Currently anyone interested in selling only E-Cigarettes or liquid nicotine could do so in Wisconsin without a tobacco retail license.

Question Title

* 7. Currently there is not a Federal or State of Wisconsin requirement to list the ingredients in liquid used in E-Cigarettes, (JUUL's, Vapes), or bottles of the liquid nicotine/E-Juice.

Question Title

* 8. I am concerned that the aerosol (vapor) coming from a E-Cigarette (JUUL, Vape), contains some heavy metals such as lead and nickel as well as formaldehyde.

Question Title

* 9. I feel anywhere you can't smoke a cigarette (workplaces, restaurants, bars,) no one should be allowed to use (E-cigarettes, JUULs, Vapes)

Question Title

* 10. I use the following Tobacco or Nicotine Products. Please choose all that apply.

Question Title

* 11. If you answered question Q10 as using E-Cigarettes, choose all that apply from the following statements below that best describe why you use E-Cigarettes. If you do not use E-Cigarettes skip Q11.

Question Title

* 12. In the text box below please enter the City, Village, or Township that you currently reside in (live in).

Adult Survey E-Cigarette (Electronic Delivery Devices)
(12 Survey Questions Total)

* 1. It is very difficult for kids to get E-Cigarettes (Vapes, JUULs. etc.) in
our community

* 2. Kids are attracted to E-Cigarettes, (JUULs, Vapes) because they
come in candy flavors such as (Cotton Candy/Watermelon) and many other flavors.

* 3. I am aware of the following brands of E-Cigarettes (vape products).
Please choose all that apply.

* 8. I am concerned that the aerosol (vapor) coming from a E-Cigarette
(JUUL, Vape), contains some heavy metals such as lead and nickel
as well as formaldehyde.

* 10. I use the following Tobacco or Nicotine Products. Please choose all
that apply.

* 11. If you answered question Q10 as using E-Cigarettes, choose all that
apply from the following statements below that best describe why
you use E-Cigarettes. If you do not use E-Cigarettes skip Q11.