Nicotine Use Questionnaire
For all ages
Do you Smoke?
No
Yes
Sometimes
Do you Vape?
No
Yes
Sometimes
Do you use Smokeless Tobacco/Pouches?
No
Yes
Sometimes
Have you ever tried smoking, vaping, or smokeless tobacco?
No
Yes
How often do you smoke, vape, or smokeless tobacco?
A little
A lot
Not at all
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Do you want to quit nicotine (smoke, vape, or smokeless tobacco)?
No
Yes
Maybe
Do you know where to get help quitting nicotine (smoke, vape, or smokeless tobacco)?
No
Yes
Are you around people who use nicotine (smoke, vape, or smokeless tobacco)?
No
Yes
Sometimes
When/If under the age of 21 did someone purchase nicotine products for you?
No
Yes
Did your parents/guardian purchase nicotine products for you?
No
Yes
Were you taught about nicotine in school?
No
Yes
Don't remember
Have you heard of MT reACT?
No
Yes
Don't remember
What is your age?
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Is there any information you would like to find out about nicotine?
Submit
Should be Empty: