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): _____________________ Year and Section: ____________________

Age: Course:

Instruction: Check the appropriate space that corresponds to your answer. I. Demographic Profile 1. Are you a tobacco cigarette smoker? ( ) Yes If yes, how long? ( ) Less than a year ( ) 5 to 6 years ( ) 3 to 4 years ( ) 1- 2 years ( ) No

( ) Others, please specify _______________

How many sticks of tobacco cigarette do you consume in a day? ( ) 1 to 5 sticks ( ) 6 to 10 sticks ( ) 11 to 15 sticks ( ) Others, please specify _______________

2. Do you use electric cigarette? ( ) Yes ( ) No

If yes, which flavor do you prefer? ( ) Fruity ( ) Mint ( ) Vanilla ( ) Pink Cloud

( ) Others: please specify ____________________________________ How many ml of electronic juice do you consume in one month? ( ) 10 ml ( ) 20 ml ( ) 30 ml ( ) Others, please specify _______________

How many mg of nicotine do you consume in one month? ( ) 0 mg ( ) 1-5 mg ( ) 6-10 mg ( ) 10-15 mg ( ) 16-20 mg

( ) Others, please specify ___________________________________ How long have you been using electronic cigarette? ( ) 1 month 6 months ( ) 7 months 1 year ( ) 1 year 2 years 3. How much is your monthly allowance? ( ) below Php3000 ( ) Php 4000 5000 ( ) Php6000 7000 ( ) Others, please specify ____________ ( ) 2 years 3 years ( ) Others, please specify _______

4. How much money do you spend for electronic cigarettes nicotine? ( ) Php100 200 ( ) Php300 400 ( ) Php500 600 ( ) Others, please specify ____________

II.

Perceived Effects 1. What effects do you feel when using tobacco cigarette? Check all that applies. It makes me cough Irritable Depressed More focused Alert More popular Restless Causes teeth discoloration Confident Loss of concentration Feel that I am impressive to others Headache Pressured by peers Body aches Fatigue Cool Bad breath Awake Relief from stress Nasal relief Regulate bowel movement Digest my food better Relaxed Dizzy Gain weight Loss of weight Breathing difficulty Light headedness Dehydration Chest pain

2. What effects do you feel when using e-cigarette? Check all that applies. It makes me cough Irritable Depressed More focused Alert More popular Restless Causes teeth discoloration Confident Loss of concentration Feel that I am impressive to others Headache Pressured by peers Body aches Fatigue Cool Bad breath Awake Relief from stress Nasal relief Regulate bowel movement Digest my food better Relaxed Dizzy Gain weight Loss of weight Breathing difficulty Light headedness Dehydration Chest pain

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