Form F STUDENTS 2009 AND 2011 NATIONAL YOUTH TOBACCO SURVEYS
2009 and 2011 National Youth Tobacco Survey (NYTS)
Appendix F. NYTS Questionnaire
STUDENTS 2009 AND 2011 NATIONAL YOUTH TOBACCO SURVEYS
OMB: 0920-0621
Appendix F. National Youth Tobacco Survey Questionnaire
Form Approved
OMB No.: 0920-0621
Expiration Date: XXXX
National Youth
Tobacco
Survey (NYTS)
2006 Questionnaire
This
survey is about tobacco. We would like to know about you and things
you do that may affect your health. Your answers will be used for
programs for young people like yourself.
DO
NOT write your name on this survey. The answers you give will be
kept private.
NO
one will know what you write. Answer the questions based on what
you really do and know.
Completing
the survey is voluntary. Whether or not you answer the questions
will not affect your grade in this class. Try to answer all the
questions. If you do not want to answer a question, just leave it
blank. There are no wrong answers.
The
questions that ask about your background will only be used to
describe the types of students completing this survey. The
information will not be used to find out your name. No names will
ever be reported.
Please
read every question. Try to answer all the questions. Fill in the
circles in the booklet completely. When you are finished, follow
the instructions of the person giving you the survey.
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-0621).
Thank You Very Much For Your Help.
-
TODAY’S DATE
Month
Day
O January
O 0
O 1
O February
O 1
O 2
O March
O 2
O 3
O April
O 3
O 4
O May
O 5
O June
O 6
O 7
O 8
O 9
The first questions ask for some background information about you.
1. How old are you?
a. 9 years old
b. 10 years old
c. 11 years old
d. 12 years old
e. 13 years old
f. 14 years old
g. 15 years old
h. 16 years old
i. 17 years old
j. 18 years old
k. 19 years old
l. 20 years old
21 years old
2. What is your sex?
Female
Male
3. What grade are you in?
a. 6th
b. 7th
c. 8th
d. 9th
e. 10th
f. 11th
g. 12th
h. Ungraded or other grade
Are you Hispanic or Latino?
Yes
b. No
5. What race or races do you consider yourself to be? (Please select one or more than one category) Would you say:
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
6. During an average week, how much money do you get from a job and other sources (allowance, etc.)?
a. None
b. Less than $1
c. $1 to $5
d. $6 to $10
e. $11 to $20
f. $21 to $50
g. $51 to $100
h. $101 to $150
i. $151 or more
7. During the past 30 days, how many days did you miss school for any reason, with or without permission?
a. 0 days
b. 1 day
c. 2 to 5 days
d. 6 to 10 days
e. 11 or more days
The next questions ask about your use of tobacco.
The first group of questions is about cigarette smoking.
8. Have you ever tried cigarette smoking, even one or two puffs?
Yes
No
9. How old were you when you smoked a whole cigarette for the first time?
a. I have never smoked a whole cigarette
b. 8 years old or younger
c. 9
d. 10
e. 11
f. 12
g. 13
h. 14
i. 15
j. 16
17 years old or older
10. About how many cigarettes have you smoked in your entire life?
a. None
b. 1 or more puffs but never a whole cigarette
c. 1 cigarette
d. 2 to 5 cigarettes
e. 6 to 15 cigarettes (about ½ a pack total)
f. 16 to 25 cigarettes (about 1 pack total)
g. 26 to 99 cigarettes (more than 1 pack but less than 5 packs)
h. 100 or more cigarettes (5 or more packs)
11. Now think back 12 months ago. At this time last year, about how much were you smoking?
a. I have never smoked cigarettes
b. I have smoked in my life, but I wasn’t smoking at this time last year
c. I smoked on some days at this time last year
d. I smoked on most days at this time last year
e. I smoked every day at this time last year
12. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
a. Yes
b. No
13. During the past 30 days, on how many days did you smoke cigarettes?
a. 0 days
b. 1 or 2 days
c. 3 to 5 days
d. 6 to 9 days
e. 10 to 19 days
f. 20 to 29 days
g. All 30 days
14. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
a. I did not smoke cigarettes during the past 30 days
b. Less than 1 cigarette per day
c. 1 cigarette per day
d. 2 to 5 cigarettes per day
e. 6 to 10 cigarettes per day
f. 11 to 20 cigarettes per day
g. More than 20 cigarettes per day
During the past 30 days, what brand of cigarettes did you usually smoke? (Choose only one answer)
a. I did not smoke cigarettes during the past 30 days
b. I do not have a usual brand
c. American Spirit
d. Camel
e. GPC, Basic, or Doral
f. Kool
g. Lucky Strike
h. Marlboro
i. Newport
j. Parliament
k. Virginia Slims
l. Some other brand
16. What type of cigarette did you usually smoke in the past 30 days?
a. I have never smoked
b. I have smoked but not in the past 30 days
I do not have a usual type
Regular/Full flavor
Light
f. Ultra Light
17. Are the cigarettes you usually smoke menthol cigarettes?
a. I do not smoke cigarettes
b. Yes
c. No
18. When was the last time you smoked a cigarette, even one or two puffs?
a. I have never smoked even one or two puffs
b. Earlier today
c. Not today but sometime during the past 7 days
d. Not during the past 7 days but sometime during the past 30 days
e. Not during the past 30 days but sometime during the past 6 months
f. Not during the past 6 months but sometime during the past year
g. 1 to 4 years ago
h. 5 or more years ago
Where do you smoke cigarettes?
(Choose one or more answers)
a. I do not smoke now
b. At home
c. At school
d. At work
e. In the car
f. At friends’ houses
g. At sports events, parties, dances, raves, or other social events
h. In public buildings (restaurants, fast food places, shopping malls, or other hangouts)
i. Outdoors (sidewalks, parking lots, parks, or other places)
20. Have you ever tried any of these tobacco products? (Choose one or more answers)
a. Eclipse cigarettes
b. Omni
c. Advance Lights
d. Accord
e. Ariva
f. I have not tried any of these products
21. During the past 30 days, how did you usually get your own cigarettes? (Choose only one answer)
I did not smoke cigarettes during the past 30 days
I bought them in a store such as a convenience store, supermarket, or gas station
I bought them from a vending machine
I gave someone else money to buy them for me
I borrowed them from someone else
I stole them
A person 18 years old or older gave them to me
I got them some other way
22. During the past 30 days, where did you buy the last pack of cigarettes you bought? (Choose only one answer)
a. I did not buy a pack of cigarettes during the past 30 days
b. A gas station
c. A convenience store
d. A grocery store
e. A drugstore
f. A vending machine
g. I bought them over the Internet
h. Other
23. When you bought or tried to buy cigarettes in a store during the past 30 days, were you ever asked to show proof of age?
a. I did not try to buy cigarettes in a store during the past 30 days
b. Yes, I was asked to show proof of age
c. No, I was not asked to show proof of age
24. During the past 30 days, did anyone ever refuse to sell you cigarettes because of your age?
a. I did not try to buy cigarettes in a store during the past 30 days
b. Yes, someone refused to sell me cigarettes because of my age
c. No, no one refused to sell me cigarettes because of my age
25. During the past 30 days, on how many days did you smoke cigarettes on school property?
a. 0 days
b. 1 or 2 days
c. 3 to 5 days
d. 6 to 9 days
e. 10 to 19 days
f. 20 to 29 days
g. All 30 days
26. Do you want to stop smoking cigarettes?
a. I do not smoke now
b. Yes
c. No
27. Are you seriously thinking about quitting smoking?
a. I have never smoked
b. I do not smoke now
c. Yes, within the next 30 days
d. Yes, within the next 6 months
e. Yes, but not within the next 6 months
f. No, I am not thinking of quitting smoking
Not sure
28. How many times during the past 12 months have you stopped smoking for one day or longer because you were trying to quit smoking?
I have not smoked in the past 12 months
I have not tried to quit
c. 1 time
d. 2 times
e. 3 to 5 times
f. 6 to 9 times
g. 10 or more times
29. When you last tried to quit, how long did you stay off cigarettes?
a. I have never smoked cigarettes
b. I have never tried to quit
c. Less than a day
d. 1 to 2 days
e. 3 to 7 days
f. More than 7 days but less than 30 days
g. 30 days or more but less than 6 months
h. 6 months or more but less than a year
i. 1 year or more
30. During the past 12 months, did a medical doctor, dentist, or nurse ask you whether you smoke cigarettes?
Yes
No
I don’t know/I can’t remember
31. During the past 12 months, did a medical doctor, dentist, or nurse tell you to stop smoking?
I have never smoked
Yes
No
I don’t know/I can’t remember
32. In the past 12 months, did you do any of the following to help you stop smoking? (Choose one or more answers)
I have never smoked
I have not smoked in the past 12 months
I did not try to quit in the past 12 months
Attended a program in my school
Attended a program in the community
Called a help line or quit line
Used nicotine gum
Used nicotine patch
Used any medicine to help quit
Visited an internet quit site
Got help from family or friends
I tried to quit but did something else
I tried to quit but did not do any of these things
33. In the past 12 months, did you have to go to a stop smoking class because you were caught smoking?
I have never smoked
I have not smoked in the past 12 months
Yes, I had to go to a stop smoking class
No, I did not have to go to a stop smoking class
34. Do you think you would be able to quit smoking cigarettes now if you wanted to?
I do not smoke now
Yes
No
35. How long can you go without smoking before you feel like you need a cigarette?
I have never smoked cigarettes
I do not smoke now
Less than 1 hour
1 to 3 hours
More than 3 hours but less than a day
A whole day
Several days
A week or more
36. How true is this statement for you? After not smoking for a while, I feel restless and irritable.
I have never smoked cigarettes
I don’t smoke now
Not at all true
Not very true
Fairly true
Very true
37. How true is this statement for you? When I go without a smoke for a few hours, I experience craving.
a. I have never smoked cigarettes
b. I don’t smoke now
c. Not at all true
d. Not very true
e. Fairly true
f. Very true
The next questions are about smokeless tobacco—chewing tobacco, snuff, or dip.
38. Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?
a. Yes
b. No
39. How old were you when you used chewing tobacco, snuff, or dip for the first time?
a. I have never used chewing tobacco, snuff, or dip
b. 8 years old or younger
c. 9
d. 10
e. 11
f. 12
g. 13
h. 14
i. 15
j. 16
17 years old or older
40. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?
a. 0 days
b. 1 or 2 days
c. 3 to 5 days
d. 6 to 9 days
e. 10 to 19 days
f. 20 to 29 days
g. All 30 days
41. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip on school property?
a. 0 days
b. 1 or 2 days
c. 3 to 5 days
d. 6 to 9 days
e. 10 to 19 days
f. 20 to 29 days
g. All 30 days
T
he
next questions are about cigars and pipes.
42. Have you ever tried smoking cigars, cigarillos, or little cigars, even one or two puffs?
a. Yes
b. No
43. How old were you when you smoked a cigar, cigarillo, or little cigar for the first time?
I have never smoked a cigar, cigarillo or little cigar
8 years old or younger
9
10
11
12
13
14
15
16
17 years old or older
44. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
45. Have you ever tried smoking tobacco in a pipe, even one or two puffs?
Yes
No
46. During the past 30 days, on how many days did you smoke tobacco in a pipe?
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
The next questions are about bidies and kreteks. Bidis (or “beedies”) are small brown cigarettes from India made of tobacco wrapped in a leaf tied with a thread. They can taste like vanilla, chocolate, cherry or other flavors. Kreteks (or “clove cigarettes”) are cigarettes containing tobacco and clove extract.
47. Have you ever tried smoking any of the following:
Bidis
Kreteks
I have tried both bidis and kreteks
I have never smoked bidis or kreteks
48. During the past 30 days, on how many days did you smoke bidis?
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
49. During the past 30 days, on how many days did you smoke kreteks?
a. 0 days
b. 1 or 2 days
c. 3 to 5 days
d. 6 to 9 days
e. 10 to 19 days
f. 20 to 29 days
g. All 30 days
The next questions ask about other people smoking and using tobacco around you.
50. During the past 7 days, on how many days were you in the same room with someone who was smoking cigarettes?
a. 0 days
b. 1 or 2 days
c. 3 or 4 days
d. 5 or 6 days
e. 7 days
51. During the past 7 days, on how many days did you ride in a car with someone who was smoking cigarettes?
a. 0 days
b. 1 or 2 days
c. 3 or 4 days
d. 5 or 6 days
e. 7 days
52. Do you think the smoke from other people’s cigarettes is harmful to you?
a. Definitely yes
b. Probably yes
c. Probably not
d. Definitely not
53. Does anyone who lives with you now smoke cigarettes?
a. Yes
No
54. Does anyone who lives with you now use chewing tobacco, snuff, or dip?
a. Yes
b. No
55. How many of your four closest friends smoke cigarettes?
a. None
b. One
c. Two
d. Three
e. Four
f. Not sure
56. How many of your four closest friends use chewing tobacco, snuff, or dip?
a. None
b. One
c. Two
d. Three
e. Four
f. Not sure
57. Which statement best describes the rules about smoking inside your home?
Smoking is not allowed anywhere inside my home
Smoking is allowed in some places or at some times
Smoking is allowed anywhere in my home
There are no rules about smoking in my home
The next questions ask about your thoughts about tobacco.
58. Do you think you will smoke a cigarette at anytime during the next year?
Definitely yes
Probably yes
Probably not
Definitely not
59. Do you think you will be smoking cigarettes 5 years from now?
I definitely will
I probably will
I probably will not
I definitely will not
60. If one of your best friends offered you a cigarette, would you smoke it?
Definitely yes
Probably yes
Probably not
Definitely not
61. Do you think that you will try a cigarette soon?
I have already tried smoking cigarettes
Yes
No
62. During the past 12 months, has either of your parents (or guardians) told you not to smoke cigarettes?
Mother (female guardian) only
Father (male guardian) only
Both
Neither
63. In the past 12 months, how often have your parents or guardians discussed the dangers of tobacco use with you?
Never
Rarely
Sometimes
Often
Very often
64. Do you think it is safe to smoke for only a year or two, as long as you quit after that?
Definitely yes
Probably yes
Probably not
Definitely not
65. Do you think smoking cigarettes makes young people look cool or fit in?
a. Definitely yes
b. Probably yes
c. Probably not
d. Definitely not
Some tobacco companies make items like sports gear, t-shirts, lighters, hats, jackets, and sunglasses that people can buy or receive free.
66. During the past 12 months, did you buy or receive anything that has a tobacco company name or picture on it?
a. Yes
b. No
67. Would you ever use or wear something that has a tobacco company name or picture on it such as a lighter, t-shirt, hat, or sunglasses?
a. Definitely yes
b. Probably yes
c. Probably not
d. Definitely not
The next questions ask about events you may have attended or what you have seen or heard on the TV, radio, movies, billboards, signs, newspapers, magazines, stores, or the Internet.
68. During the past 12 months, have you participated in any community activities to discourage people your age from using cigarettes, chewing tobacco, snuff, dip, or cigars?
a. Yes
No
I did not know about any activities
69. During the past 30 days, how many times did you see anti-smoking messages on TV?
a. I did not watch TV in the past 30 days
b. None
c. 1 to 3 times in the past 30 days
d. 1 to 3 times per week
Daily or almost daily
More than once a day
70. During the past 30 days, how many times did you hear anti-smoking messages on the radio?
a. I did not listen to the radio in the past 30 days
b. None
c. 1 to 3 times in the past 30 days
1 to 3 times per week
Daily or almost daily
More than once a day
71. During the past 30 days, how many times did you see anti-smoking messages on the Internet?
I did not use the Internet in the past 30 days
None
1 to 3 times in the past 30 days
1 to 3 times per week
Daily or almost daily
More than once a day
72. During the past 30 days, how many times have you seen anti-smoking messages on billboards or outdoor signs?
None in the past 30 days
1 to 3 times in the past 30 days
1 to 3 times per week
Daily or almost daily
More than once a day
73. During the past 30 days, how many times did you see anti-smoking messages in magazines or newspapers?
I did not read magazines or newspapers
None in the past 30 days
1 to 3 times in the past 30 days
1 to 3 times per week
Daily or almost daily
More than once a day
74. When you watch TV or go to movies, how often do you see actors using tobacco?
I don’t watch TV or go to movies
Most of the time
Some of the time
Hardly ever
Never
75. When you are using the Internet, how often do you see ads for tobacco products?
I do not use the Internet
Most of the time
Some of the time
Hardly ever
Never
76. When you read newspapers or magazines, how often do you see ads or promotions for cigarettes and other tobacco products?
I do not read newspapers or magazines
All of the time
Most of the time
Some of the time
Hardly ever
Never
77. When you go to a convenience store, supermarket, or gas station, how often do you see ads for cigarettes and other tobacco products or items that have tobacco company names or pictures on them?
I never go to a convenience store, supermarket, or gas station
All of the time
Most of the time
Some of the time
Hardly ever
Never
The last questions ask if you were taught about tobacco in your classes.
78. During this school year, did you practice ways to say “No” to tobacco in any of your classes (for example, by role playing)?
a. Yes
b. No
c. Not sure
79. During this school year, were you taught in any of your classes the reasons why people your age smoke?
a. Yes
b. No
c. Not sure
80. During this school year, were you taught in any of your classes that most people your age do not smoke cigarettes?
Yes
No
Not sure
81. During this school year, were you taught in any of your classes about the dangers of tobacco use?
Yes
No
Not sure
Thank you for participating in this survey.
| File Type | application/msword |
| File Title | The first questions ask for some background information about you |
| Author | abb1 |
| Last Modified By | DASH |
| File Modified | 2008-05-30 |
| File Created | 2008-05-30 |
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