Tobacco Usage Survey

We are conducting focus groups with people smoking cigarettes, using moist smokeless tobacco / dip, and/or E-Cigs/E-Vapes. Please answer the questions below to see if you qualify.

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* 1. Please provide the following information so that we may contact you:

Name

ZIP/Postal Code

Email Address

Phone Number

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* 2. What is your Gender?

Male

Female

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* 3. Which category below includes your age?

under 21

21-29

30-39

40-49

50-54

55+

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* 4. What is your marital status?

Single living alone

Single w/roommate(s)

Cohabitating with partner

Married

Divorced

Living with parents

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* 5. What of the following best describes your employment status ?

Working Full-time

Working Part-time

Homemaker

FT/PT Student

Retired

Unemployed

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* 6. If you are employed, what is your occupation and industry?

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* 7. What is your ethnicity?

Caucasian

African-American

Hispanic

Asian

Other

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* 8. Which of the following, if any, do you use?

Soft Drinks (Pop)

Coffee

Decaf Coffee

Cigarettes

Cigars

E-cigarettes

E-vapor products, including refillable devices and vaporizers

Moist Smokeless Tobacco/Dip

Beer

Snus

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* 9. When was the last time, if ever, you used either an E-Cigarette or E-Vapor product?

within the last 7 days

more than 7 days ago, but within the last 14 days

more than 14 days ago, but within the last month

1-3 months ago

4-6 months ago

7-9 months ago

10-12 months ago

over a year ago

Never

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* 10. If you are using multiple tobacco products which one do you use most often ?

Cigarettes

Cigars

E-cigarettes

E-vapor products, including refillable devices and vaporizers

Moist Smokeless Tobacco/Dip

Snus

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* 11. Which of the following best describes the e-cigarette/e-vapor product(s) you use?

A disposable device without a replaceable cartridge or a rechargeable battery

A rechargeable device with replaceable cartridge

A rechargeable device with a tank that is NOT intended to be refilled

A rechargeable device with a tank that you refill with e-Liquie

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* 12. What brand(s) of e-cigarette or e-vapor product(s) do you use?

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* 13. What flavors do you use with your e-smoking products?

Non-menthol taste

Menthol taste

Flavors

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* 14. What is your regular brand of cigarettes, that is, the brand you purchase and smoke most often ?

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* 15. How would you ask the clerk for your pack of cigarettes ?

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* 16. How many packs of cigarettes do you smoke in an average week?

Less than 1 pack

1 Pack

1-2 Packs

2 packs or more

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* 17. Do you have any food allergies?

Yes

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* 18. Are you pregnant, nursing, or planning to become pregnant in the next 9 months?

Yes

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* 19. Which one smokeless tobacco products, if any, do you typically use most often?

	Long Cut	Extra Long Cut	Fine Cut	Pouch	Snus
Copenhagen	Copenhagen Long Cut	Copenhagen Extra Long Cut	Copenhagen Fine Cut	Copenhagen Pouch	Copenhagen Snus
Grizzly	Grizzly Long Cut	Grizzly Extra Long Cut	Grizzly Fine Cut	Grizzly Pouch	Grizzly Snus
Skoal	Skoal Long Cut	Skoal Extra Long Cut	Skoal Fine Cut	Skoal Pouch	Skoal Snus
Longhorn	Longhorn Long Cut	Longhorn Extra Long Cut	Longhorn Fine Cut	Longhorn Pouch	Longhorn Snus
Kodiak	Kodiak Long Cut	Kodiak Extra Long Cut	Kodiak Fine Cut	Kodiak Pouch	Kodiak Snus
TimberWolf	TimberWolf Long Cut	TimberWolf Extra Long Cut	TimberWolf Fine Cut	TimberWolf Pouch	TimberWolf Snus
General	General Long Cut	General Extra Long Cut	General Fine Cut	General Pouch	General Snus
Camel	Camel Long Cut	Camel Extra Long Cut	Camel Fine Cut	Camel Pouch	Camel Snus
Other	Other Long Cut	Other Extra Long Cut	Other Fine Cut	Other Pouch	Other Snus

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* 20. What variety or taste do you use with your smokeless tobacco products ?

Wintergreen

Mint / Smooth Mint Spearmint

Natural

Straight

Other (please specify)

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* 1. Please provide the following information so that we may contact you:

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* 2. What is your Gender?

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* 3. Which category below includes your age?

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* 4. What is your marital status?

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* 5. What of the following best describes your employment status ?

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* 6. If you are employed, what is your occupation and industry?

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* 7. What is your ethnicity?

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* 8. Which of the following, if any, do you use?

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* 9. When was the last time, if ever, you used either an E-Cigarette or E-Vapor product?

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* 10. If you are using multiple tobacco products which one do you use most often ?

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* 11. Which of the following best describes the e-cigarette/e-vapor product(s) you use?

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* 12. What brand(s) of e-cigarette or e-vapor product(s) do you use?

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* 13. What flavors do you use with your e-smoking products?

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* 14. What is your regular brand of cigarettes, that is, the brand you purchase and smoke most often ?

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* 15. How would you ask the clerk for your pack of cigarettes ?

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* 16. How many packs of cigarettes do you smoke in an average week?

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* 17. Do you have any food allergies?

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* 18. Are you pregnant, nursing, or planning to become pregnant in the next 9 months?

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* 19. Which one smokeless tobacco products, if any, do you typically use most often?

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* 20. What variety or taste do you use with your smokeless tobacco products ?

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* 21. Which of these dates and times are you available ?