USC GETEO STUDY

Genetic Epigenetic & Transcriptomic Effects of E-cig Aerosol on Oral Epithelium

Funded by: National Institutes of Health, National Institute of Dental and Craniofacial Research, Grant No.: 1R01DE026043

Principal Investigator (PI): Ahmad Besaratinia, M.P.H., Ph.D.

If you experience any technical issue with this online survey, please contact us by e-mail or phone: E-mail:geteostudy@gmail.com | Tel: (323)-442-7765

q0_1. First and Last name

q0_2. E-mail

q0_3. Phone:

q0_4. Gender

Male Female

q0_5. Race/Ethnicity

q0_6. Date of Birth:
(mm/dd/YYYY)

q0_7. Height (feet and inches)

q0_8. Weight (lbs)

q0_9. Have you ever tried smoking any tobacco product (i.e. cigarettes / hookah / cigars) even just one or two puffs?

Yes No

q0_10. Which products have you used? (Select all that apply)

Cigarettes Cigars Cigarillos Hookah Little Cigars

q1_0. Section 1: CIGARETTES

q1_1. Have you smoked cigarettes on a regular basis for at least 6 months in your lifetime?

Yes No

q1_2. How often have you smoked cigarettes in the past 6 months? (e.g., 5 times a day, 3 times a week, etc.)

q1_3. How many cigarettes (per day/per week) have you smoked in the past 6 months?

q1_4. Are you currently a cigarette smoker?

Yes No

q1_5. How old were you when you started smoking cigarettes?

q2_0. Section 2: ELECTRONIC CIGARETTE (E-CIG)

q2_1. Have you ever tried e-cigarettes/vaping (even just one or two puffs)?

Yes No

q2_2. Which products have you used? (Select all that apply)

Cig-a-like / Mini e-cig / Slim mode Mid-size e-cig / Vape pen Advanced Personal Vaporizer (APV) / Mod

q2_3. Have you vaped (used e-cig) on a regular basis for at least 6 months in your lifetime?

Yes No

q2_4. How often have you vaped (used e-cig) in the past 6 months? e.g., 5 times a day, 3 times a week, etc.

q2_5. Are you currently using e-cigarettes/vapes?

Yes No

q2_6. When did you start / how long have you been vaping?

q2_7. Have you ever tried smokeless tobacco (even just once)?

Yes No

q2_8. Which products have you used? (Select all that apply)

Chewing Tobacco Snus Snuf Dip

q2_9. Have you used smokeless tobacco products in the past 6 months?

Yes No

q3_0. Section 3: DRUGS: RECREATIONAL/ILLICIT

q3_1. Have you used recreational/illicit drugs on a regular basis in your lifetime?

Yes No

q3_2. How often have you used recreational/illicit drugs in the past 6 months? e.g., 2 times a day, 3 times a week, etc.

q3_3. How old were you when you started using recreational/illicit drugs?

q3_4. Do you currently have any dental problems (i.e. gum disease / tooth decay / inflammation)?

Yes No

q4_0. Section 4: PRESCRIPTION MEDICINE

q4_1. Have you used prescription medicine(s) in the past 5 years?

Yes No

q4_2. Have you taken prescription medicine(s) in the past 6 months?

Yes No

q4_2a. If YES, indicate drug(s), dose and frequency of use (e.g., Lipitor 10 mg 3 times a day).

q4_3. Are you currently taking prescription medicine(s)?

Yes No

q4_3a. If YES, indicate drug(s), dose and frequency of use (e.g., Lipitor 10 mg 3 times a day).

q5_0. Section 5: ADDITIONAL QUESTIONS

q5_1. Are you or have you been pregnant within the past 6 months?

Yes No

q5_2. Have you ever been diagnosed with a chronic disease (i.e. diabetes, heart disease, asthma, cancer)?

Yes No

q5_3. Would you be willing to provide a blood sample?

Yes No

q5_4. How did you hear about this study? (Select all that apply)

Craigslist My USC Facebook Instagram Flyer Reddit ECC Other

q5_4a. Please specify if other:

Thank you for completing this questionnaire. We will review the information you provided and will contact you if you are found eligible to participate in this study. Participation includes a short interview ( max 30 min.) and a painless mouth cheek brushing at a time that is convenient for you. You will be compensated for your participation in this study.