questionnaire (new).docx

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We, the 3rd

year BSN students of Capitol Medical Center Colleges are conducting

a study entitled the use of electronic cigarette. To make our study possible, we are hereby

requesting you to answer our survey questionnaire honestly. Your identity and your

responses will be kept in strict confidentiality. Thank you very much.

Name (optional): _____________________ Age:

Year and Section: ____________________ Course:

Instruction: Check the appropriate space that corresponds to your answer.

I. Demographic Profile

1. Are you a tobacco cigarette smoker?

( ) Yes ( ) No

If yes, how long?

( ) Less than a year ( ) 3 to 4 years ( ) 1- 2 years

( ) 5 to 6 years ( ) Others, please specify _______________

How many sticks of tobacco cigarette do you consume in a day?

( ) 1 to 5 sticks ( ) 11 to 15 sticks

( ) 6 to 10 sticks ( ) Others, please specify _______________

2. Do you use electric cigarette?

( ) Yes ( ) No



If yes, which flavor do you prefer?

( ) Fruity ( ) Vanilla

( ) Mint ( ) Pink Cloud

( ) Others: please specify ____________________________________

How many ml of electronic juice do you consume in one month?

( ) 10 ml ( ) 30 ml

( ) 20 ml ( ) Others, please specify _______________

How many mg of nicotine do you consume in one month?

( ) 0 mg ( ) 6-10 mg ( ) 16-20 mg

( ) 1-5 mg ( ) 10-15 mg

( ) Others, please specify ___________________________________

How long have you been using electronic cigarette?

( ) 1 month – 6 months ( ) 2 years – 3 years

( ) 7 months – 1 year ( ) Others, please specify _______

( ) 1 year – 2 years

3. How much is your monthly allowance?

( ) below Php3000 ( ) Php6000 – 7000

( ) Php 4000 – 5000 ( ) Others, please specify ____________

4. How much money do you spend for electronic cigarette’s nicotine?

( ) Php100 – 200 ( ) Php500 – 600

( ) Php300 – 400 ( ) Others, please specify ____________



II. Perceived Effects

1. What effects do you feel when using tobacco cigarette? Check all that applies.

- It makes me cough - Relaxed

- Irritable - Dizzy

- Depressed - Gain weight

- More focused - Loss of weight

- Alert - Breathing difficulty

- More popular - Light headedness

- Restless - Dehydration

- Causes teeth

discoloration

- Chest pain

- Confident - Nasal relief

- Loss of

concentration

- Regulate bowel

movement

- Feel that I am

impressive to

others

- Digest my food

better

- Headache - “Cool”

- Pressured by peers - Bad breath

- Body aches - Awake

- Fatigue - Relief from stress



2. What effects do you feel when using e-cigarette? Check all that applies.

- It makes me cough - Relaxed

- Irritable - Dizzy

- Depressed - Gain weight

- More focused - Loss of weight

- Alert - Breathing difficulty

- More popular - Light headedness

- Restless - Dehydration

- Causes teeth

discoloration

- Chest pain

- Confident - Nasal relief

- Loss of

concentration

- Regulate bowel

movement

- Feel that I am

impressive to

others

- Digest my food

better

- Headache - “Cool”

- Pressured by peers - Bad breath

- Body aches - Awake

- Fatigue - Relief from stress

III. Reasons for Shifting to E-cigarrete

1. What made you shift from tobacco to electronic cigarette? Check all that applies.



( ) it is cheaper than tobacco

( ) no after taste

( ) healthier

( ) more pleasant odor

( ) more “cool”

( ) it eliminates second-hand smoking

( ) others:

____________________________________________________________

____________________________________________________________

2. Are you satisfied with electronic cigarette?

( ) Yes ( ) No

questionnaire (new).docx

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