Survey for users of nicotine chewing-gums

  • Please answer only if you are currently using nicotine chewing-gums.  
  • You will need only 2 minutes to answer this survey.
  • Thank you + + for taking time to answer.

Important: please answer ALL questions, even if there are some repetitions :
Do you currently smoke tobacco?
During the past 31 days, on how many days did you smoke?  I smoked on days
Are you currently trying to quit smoking?
Have you ever used nicotine chewing-gums ?
Do you currently use nicotine replacement products (i.e. nicotine gums, patches, tablets or inhalers)?
Currently, what type of nicotine replacement product do you use? Currently, I use:
-Nicotine chewing-gums: Yes /  No
-Nicotine patches: Yes /  No
-Nicotine tablets: Yes /  No
-Nicotine inhalers: Yes /  No
Currently, on how many days per week do you chew nicotine chewing-gums? I currently use nicotine gums on days per week
For how long have you been chewing nicotine gums at this frequency? For
Currently, how many nicotine chewing-gums do you use per day? I use nicotine gums / day
What dosage do you use? I use gums containing  milligrams (mg) of nicotine
What flavor of nicotine gum do you use?
(e.g. - Neutral (nicotine), Fruit, Mint, Citrus, etc)		 Flavor:
What brand of nicotine chewing-gum are you currently using? (e.g. Habitrol, Nicorette, Nicotinell) Brand:
In packages of how many gums do you buy your nicotine gums? In packages of gums
Where do you buy your nicotine gums? (e.g. drugstore, pharmacist, internet, etc.)
For which purpose(s) do you use nicotine gums?
Please write a synonymous of "I feel nervous":
Question for ex-smokers:
When did you quit smoking?		 I stopped smoking on:
Day:
Month:
Year:

Finally, here are some questions about yourself:
Are you?
How old are you? I am years old
In which country do you live?


Important: please check that you have answered ALL questions.

Thank you + + + for your participation !

Created by JF Etter, last modified 21 May + 23 June 2004