First Name* must provide value
Last name* must provide value
What is your age?* must provide value
years old
Are you male or female?* must provide value
Male
Female
Do you speak and write in English?* must provide value
Yes
No
State* must provide value
Connecticut South Carolina Other
Please select the metro area closest to you. * must provide value
Charleston, SC Columbia, SC Florence, SC Greenville, SC Myrtle Beach, SC Spartanburg, SC Sumter, SC I live outside of South Carolina
Please select the metro area closest to you. * must provide value
New Haven, CT Hartford, CT Bridgeport, CT Stamford, CT Waterbury, CT New London, CT I live outside of Connecticut
Do you currently use e-cigarettes or vapes (JUUL, Kilo, Blu, etc.) containing nicotine? * must provide value
Every Day
Some Days
Not at All
In the past month how often did you use the e-cigarette?* must provide value
0-4 days
5-9 days
10-14 days
15-19 days
20-24 days
25+ days
How long have you currently used an e-cigarette?* must provide value
1 week
1 month
3 months
6 months
> 6 months
Do you have a desire to quit e-cigarettes?* must provide value
Yes
No
Are you agreeing to participate in this program and are you willing to set a quit date and maintain e-cigarette abstinence?* must provide value
Yes
No
Are you currently pregnant?* must provide value
Yes No
Are you currently breastfeeding?* must provide value
Yes No
Are you currently trying to become pregnant?* must provide value
Yes No
Have you smoked any combustible tobacco (cigarettes, cigarillos, cigars, etc.) in the past 30 days?* must provide value
Yes
No
In the past 2 months prior to the last 30 days, how often did you use combustible tobacco products (cigarettes, cigarillos, cigars, etc.)? * must provide value
Not at all
Once per week
Twice per week
> 3 times per week
Every day
Are you currently using any medications to quit smoking including Chantix, Zyban, Wellbutrin, or any nicotine replacement products such as the patch, gum lozenge, nasal spray, or inhaler? * must provide value
Yes No
Have you used any other form of non combustible tobacco such as nicotine pouches, chew/dip, snus, or any other tobacco product not previously mentioned in the past 30 days?* must provide value
Yes No
In the past 2 months prior to the last 30 days, how often did you use non-combustible tobacco products? * must provide value
Not at all
Once per week
Twice per week
> 3 times per week
Every day
Please list any health conditions.* must provide value
How did you hear about this study? * must provide value
Facebook
Instagram
Yale Center for Clinical Investigation (YCCI) Website
Craigslist
Tobacco Treatment Service
From Previous Yale Study
Reddit
Other
Specify* must provide value
To the best of your knowledge, are there any members of your household currently enrolled in this study?* must provide value
Yes No
Do you have an email address?* must provide value
Yes No
Please enter your email address* must provide value
Do you check your email at least one time per day?* must provide value
Yes No
Do you have access to a phone that receives SMS text messages and can access the internet?* must provide value
Yes No
Please enter your phone number* must provide value
Do you have access to the internet on a device* which you can use to virtually meet with us online to provide consent (officially join the study)?* This could be a computer, a smartphone, or any other device on which you can access the internet.* must provide value
Yes No
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