The
first five questions ask for some background information about you
How
old are you?
9
years old
10
years old
11
years old
12
years old
13
years old
14
years old
15
years old
16
years old
17
years old
18
years old
19
years old or older
|
What
is your sex?
Male
Female
|
What
grade are you in?
6th
7th
8th
9th
10th
11th
12th
Ungraded
or other grade
|
Are
you Hispanic, Latino/a, or Spanish origin (One or more categories
may be selected)?
No,
not of Hispanic, Latino, Latina,, or Spanish origin
Yes,
Mexican, Mexican American, Chicano or Chicana
Yes,
Puerto Rican
Yes,
Cuban
Yes,
Another Hispanic, Latino/a or Spanish origin
|
What
race or races do you consider yourself to be? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
American
Indian or Alaska Native
Asian
Black
or African American
Native
Hawaiian or Other Pacific Islander
White
|
This
section ask about if you’ll try tobacco that is smoked or
put in your mouth
At
any time during the next 12 months do you think you will use any
form of tobacco?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Do
you think that you will try any form of tobacco soon?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
If
one of your best friends were to offer you any form of tobacco,
would you use it?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
The
next six sections ask about your use of different kinds of tobacco
products
The
next 14 questions are about cigarettes.
Have
you ever
tried
cigarette smoking, even one or two puffs?
Yes
No
|
Do
you think you will smoke a cigarette in the next year?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Do
you think that you will try a cigarette soon?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
If
one of your best friends were to offer you a cigarette, would you
smoke it?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
How
old were you when you first
tried
cigarette smoking, even one or two puffs?
I
have never smoked cigarettes, not even one or two puffs
8
years old or younger
9
years old
10
years old
11
years old
12
years old
13
years old
14
years old
15
years old
16
years old
17
years old
18
years old
19
years old or older
|
About
how many cigarettes have you smoked in your entire
life?
I
have never smoked cigarettes, not even one or two puffs
1
or more puffs but never a whole cigarette
1
cigarette
2
to 5 cigarettes
6
to 15 cigarettes (about 1/2 a pack total)
16
to 25 cigarettes (about 1 pack total)
26
to 99 cigarettes (more than 1 pack, but less than 5 packs)
100
or more cigarettes (5 or more packs)
|
During
the past
30 days,
on how many days did you smoke cigarettes?
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
|
During
the past 30 days, on
the days you smoked,
about how many cigarettes did you smoke per day?
I
did not smoke cigarettes during the past 30 days
Less
than 1 cigarette per day
1
cigarette per day
2
to 5 cigarettes per day
6
to 10 cigarettes per day
11
to 20 cigarettes per day
More
than 20 cigarettes per day
|
When
was the last time you smoked a cigarette, even one or two puffs?
(PLEASE
CHOOSE THE FIRST ANSWER THAT FITS)
I
have never smoked cigarettes, not even one or two puffs
Earlier
today
Not
today but sometime during the past 7 days
Not
during the past 7 days but sometime during the past 30 days
Not
during the past 30 days but sometime during the past 6 months
Not
during the past 6 months but sometime during the past year
1
to 4 years ago
5
or more years ago
|
During
the past 30 days, what brand of cigarettes did you usually smoke?
(CHOOSE
ONLY ONE ANSWER)
I
did not smoke cigarettes during the past 30 days
I
did not smoke a usual brand
American
Spirit
Camel
GPC,
Basic, or Doral
Kool
Lucky
Strike
Marlboro
Newport
Parliament
Virginia
Slims
Some
other brand not listed here
Not
sure
|
Menthol
cigarettes are cigarettes that taste like mint. During the past
30 days, were the cigarettes that you usually smoked menthol?
I
did not smoke cigarettes during the past 30 days
Yes
No
Not
sure
|
During
the past 30 days, how did you get your own cigarettes? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
I
did not get cigarettes during the past 30 days
I
bought a pack of cigarettes myself
I
had someone else buy a pack of cigarettes for me
I
asked someone to give me a cigarette
Someone
offered me a cigarette
I
bought cigarettes from another person
I
took cigarettes from a store or another person
I
got cigarettes some other way
|
During
the past
30 days,
where did you buy
your own cigarettes? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
I
did not buy cigarettes during the past 30 days
A
gas station or convenience store
A
grocery store
A
drugstore
A
vending machine
Over
the Internet
Through
the mail
Some
other place not listed here
|
During
the past
30 days,
did anyone refuse
to sell you cigarettes because of your age?
I
did not try to buy cigarettes during the past 30 days
Yes
No
|
The
next five questions are about smoking cigars.
Have
you ever
tried
smoking cigars, cigarillos, or little cigars, such as Black and
Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies
Blunts, even one or two puffs?
Yes
No
|
How
old were you when you
first tried
smoking a cigar, cigarillo, or little cigar, even one or two
puffs?
I
have never smoked cigars, cigarillos, or little cigars, not even
one or two puffs
8
years old or younger
9
years old
10
years old
11
years old
12
years old
13
years old
14
years old
15
years old
16
years old
17
years old
18
years old
19
years old or older
|
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
|
During
the past
30 days,
how did you get your own cigars, cigarillos, or little cigars?
(You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
I
did not get cigars, cigarillos, or little cigars during the past
30 days
I
bought them myself
I
had someone else buy them for me
I
asked someone to give me one
Someone
offered it to me
I
bought them from another person
I
took them from a store or another person
I
got them some other way
|
During
the past
30 days,
where did you buy
your own cigars, cigarillos, or little cigars? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
I
did not buy cigars, cigarillos, or little cigars during the past
30 days
A
gas station or convenience store
A
grocery store
A
drugstore
A
vending machine
Over
the Internet
Through
the mail
Some
other place not listed here
|
The
next five questions are about using smokeless tobacco. Please do
not think about using snus when you answer these questions.
Have
you ever
used chewing
tobacco, snuff, or dip, such
as
Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or
Copenhagen, even just a small amount?
Yes
No
|
How
old were you when you used
chewing
tobaccos, snuff, or dip for the first time?
I
have never used chewing tobacco, snuff, or dip
8
years old or younger
9
years old
10
years old
11
years old
12
years old
13
years old
14
years old
15
years old
16
years old
17
years old
18
years old
19
years old or older
|
During
the past
30 days,
on how many days did you use chewing tobacco, snuff, or dip?
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
|
During
the past
30 days,
how did you get your own chewing tobacco, snuff, or dip? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
I
did not get chewing tobacco, snuff, or dip during the past 30
days
I
bought it myself
I
had someone else buy it for me
I
asked someone to give me some
Someone
offered it to me
I
bought it from another person
I
took it from a store or another person
I
got it some other way
|
During
the past
30 days,
where did you buy
your own chewing tobacco, snuff, or dip? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
I
did not buy chewing tobacco, snuff, or dip during the past 30
days
A
gas station or convenience store
A
grocery store
A
drugstore
A
vending machine
Over
the Internet
Through
the mail
Some
other place not listed here
|
The
next two questions are about smoking tobacco in a pipe. Please do
not think about smoking tobacco in a waterpipe or hookah when you
answer these questions
Have
you ever
tried
smoking tobacco in a pipe, even one or two puffs?
Yes
No
|
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 three questions are about other forms of tobacco.
Which
of the following tobacco products have you ever
heard
of? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
Roll-your-own
cigarettes
Flavored
cigarettes, such as Camel Crush
Bidis
(small brown cigarettes wrapped in a leaf)
Clove
cigars (kreteks)
Flavored
little cigars (such as mint, clove, spice, alcohol (wine,
cognac), candy, fruit, chocolate, or other sweets)
Smoking
tobacco from a hookah or a waterpipe
Snus,
such as Camel or Marlboro Snus
Dissolvable
tobacco products, such as Ariva, Stonewall, Camel orbs, Camel
sticks, or Camel strips
Electronic
Cigarettes or E-cigarettes, such as Ruyan or NJOY
Some
other new tobacco products not listed here
I
have never heard of any of the products listed above or any new
tobacco product
|
Which
of the following tobacco products have you ever
tried,
even just one time? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
Roll-your-own
cigarettes
Flavored
cigarettes, such as Camel Crush
Bidis
(small brown cigarettes wrapped in a leaf)
Clove
cigars (kreteks)
Flavored
little cigars (such as mint, clove, spice, alcohol (wine,
cognac), candy, fruit, chocolate, or other sweets)
Smoking
tobacco from a hookah or a waterpipe
Snus,
such as Camel or Marlboro Snus
Dissolvable
tobacco products, such as Ariva, Stonewall, Camel orbs, Camel
sticks, or Camel strips
Electronic
Cigarettes or E-cigarettes, such as Ruyan or NJOY
Some
other new tobacco products not listed here
I
have never tried any of the products listed above or any new
tobacco product
|
In
the
past 30 days,
which of the following products have you used on at
least one day?
(You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
Roll-your-own
cigarettes
Flavored
cigarettes, such as Camel Crush
Bidis
(small brown cigarettes wrapped in a leaf)
Clove
cigars (kreteks)
Flavored
little cigars (such as mint, clove, spice, alcohol (wine,
cognac), candy, fruit, chocolate, or other sweets)
Smoking
tobacco from a hookah or a waterpipe
Snus,
such as Camel or Marlboro Snus
Dissolvable
tobacco products, such as Ariva, Stonewall, Camel orbs, Camel
sticks, or Camel strips
Electronic
Cigarettes or E-cigarettes, such as Ruyan or NJOY
Some
other new tobacco products not listed here
I
have not used any of the products listed above or any new
tobacco product in the past 30 days
|
The
next eleven questions ask about different issues related to
tobacco.
How
easy would it be for you to get tobacco products if you wanted
some?
Very
easy
Somewhat
easy
Not
easy at all
|
Do
you believe that tobacco companies try to get young people under
18 to use tobacco products?
Yes
No
|
When
you are using the Internet, how often do you see ads or
promotions for cigarettes or other tobacco products?
I
do not use the Internet
Never
Rarely
Sometimes
Most
of the time
Always
|
When
you read newspapers or magazines, how often do you see ads or
promotions for cigarettes or other tobacco products?
I
do not read newspapers or magazines
Never
Rarely
Sometimes
Most
of the time
Always
|
During
the past 30 days, did you receive coupons from a tobacco company
through… (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
The
mail
E-mail
The
Internet
Social
Networks (such as Facebook and Twitter)
A
text message
On
a cigarette pack or other tobacco product
I
did not receive coupons from a tobacco company
|
When
you go to a convenience store, supermarket, or gas station, how
often do you see ads or promotions for cigarettes or other
tobacco products?
I
never go to a convenience store, supermarket, or gas station
Never
Rarely
Sometimes
Most
of the time
Always
|
During
the past 30 days, how often did you see any ads or promotions for
cigarettes or other tobacco products that were outdoors on a
billboard or could be seen from outside a store?
I
did not see an ad for cigarettes or other tobacco products
during the past 30 days
Never
Rarely
Sometimes
Most
of the time
Always
|
When
you watch TV or go to the movies, how often do you see actors and
actresses using cigarettes or other tobacco products?
I
do not watch TV or go to the movies
Never
Rarely
Sometimes
Most
of the time
Always
|
What
is the name of your favorite cigarette brand? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
American
Spirit
Camel
GPC,
Basic, or Doral
Kool
Marlboro
Newport
Some
other brand not listed here
I
don’t have a favorite cigarette brand
Not
sure
|
Have
you seen or heard advertisements against tobacco with any of the
following? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
A
man who lost his legs from amputations (removal of body parts)
A
woman who lost her fingers and toes from amputations (removal of
body parts)
A
man with a scar on his chest from a heart attack
A
woman putting on a wig and putting in her teeth while getting
dressed
A
son bathing and caring for his mother on her bed because she had
a stroke
A
mom giving her son an inhaler because he has breathing problems
from being around adults who smoke cigarettes
A
man in the shower covering the hole in his neck
A
child scratching because of chicken pox
Don’t
know/Not sure
I
haven’t seen or heard any of these advertisements
|
How
soon after you wake up do you want to use a tobacco product?
I
do not use tobacco
Within
5 minutes
From
6 to 30 minutes
From
more than 30 minutes to 1 hour
After
more than 1 hour but less than 24 hours
I
rarely want to use tobacco
|
Some
cigarette or other tobacco companies make items like sports gear,
T-shirts, hats, jackets,sunglassess or other items that people can
buy or receive for free.
During
the past
12 months,
did you buy or receive anything such as a t-shirt, hat,
sunglasses, that has a tobacco brand name, logo, or picture on
it?
Yes
No
|
How
likely is it that you would ever use or wear something--such as a
t-shirt, hat, or sunglasses --that has a tobacco brand name,
logo, or picture on it?
Very
likely
Somewhat
likely
Somewhat
unlikely
Very
unlikely
|
The
next two questions are about visits to a doctor, dentist, nurse,
or other health professional.
Think
about each time that you visited a doctor, dentist, or nurse in
the past 12 months. During any of these visits were you asked if
you used tobacco that is smoked or put in your mouth?
I
did not see a doctor, dentist, or nurse during the past 12
months
Yes
No
|
During
the past
12 months,
did any doctor, dentist, or nurse give you advice not to use
tobacco that is smoked or put in your mouth?
I
did not see a doctor, dentist, or nurse during the past 12
months
Yes
No
|
The
next six questions are about quitting tobacco products.
Are
you seriously thinking about quitting cigarettes? (PLEASE
CHOOSE THE FIRST ANSWER THAT FITS)
I
do not smoke cigarettes
Yes,
within the next 30 days
Yes,
within the next 6 months
Yes,
within the next 12 months
Yes,
but not within the next 12 months
No,
I am not thinking about quitting cigarettes
|
During
the past
12 months,
how many times have you stopped smoking cigarettes for one
day or longer
because you were trying to quit smoking cigarettes for
good?
I
did not smoke cigarettes during the past 12 months
I
did not try to quit during the past 12 months
1
time
2
times
3
to 5 times
6
to 9 times
10
or more times
|
When
you last
tried to quit
for good, how long did you stay off cigarettes? (PLEASE
CHOOSE THE FIRST ANSWER THAT FITS)
I
have never smoked cigarettes
I
have never tried to quit
Less
than a day
1
to 7 days
More
than 7 days but less than 30 days
More
than 30 days but less than 6 months
More
than 6 months but less than 1 year
1
year or more
|
Are
you seriously thinking about quitting the use of
all tobacco products?
(PLEASE
CHOOSE THE FIRST ANSWER THAT FITS)
I
do not use tobacco products
Yes,
within the next 30 days
Yes,
within the next 6 months
Yes,
within the year
Yes,
but not within the year
No,
I am not thinking about quitting the use of all tobacco products
|
During
the past
12 months,
how many times have you stopped using all
tobacco products
for one
day or longer
because you were trying to quit all tobacco products for
good?
I
did not use tobacco products during the past 12 months
I
did not try to quit all tobacco products during the past 12
months
1
time
2
times
3
to 5 times
6
to 9 times
10
or more times
|
In
the past
12 months,
did you do any of the following to help you quit using tobacco of
any kind for good? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
I
did not use tobacco of any kind during the past 12 months
I
did not try to quit during the past 12 months
Attended
a program in my school
Attended
a program in the community
Called
a telephone help line or telephone 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
Used
another method, such as hypnosis or acupuncture
Tried
to quit on my own or quit “cold turkey”
|
The
next five questions ask about you being around other people’s
tobacco smoke.
During
the past
7 days,
on how many days did someone smoke tobacco products in your home
while you were there?
0
days
1
day
2
days
3
days
4
days
5
days
6
days
7
days
|
During
the past
7 days,
on how many days did you ride in a vehicle were someone was
smoking a tobacco product?
0
days
1
day
2
days
3
days
4
days
5
days
6
days
7
days
|
During
the past
7 days,
on how many days did you breathe the smoke from someone who was
smoking a tobacco product at your school, including school
buildings, school grounds, and school parking lots?
0
days
1
day
2
days
3
days
4
days
5
days
6
days
7
days
|
During
the past
7 days,
on how many days did you breathe the smoke from someone who was
smoking tobacco products in the place where you work?
I
do not have a job
I
did not work during the past 7 days
0
days
1
day
2
days
3
days
4
days
5
days
6
days
7
days
|
During
the past
7 days,
on how many days did you breathe the smoke from someone who was
smoking tobacco products in an indoor or outdoor public place?
Examples of indoor public places are school buildings, stores,
restaurants, and sports arenas. Examples of outdoor public places
are school grounds, parking lots, stadiums and parks.
0
days
1
day
2
days
3
days
4
days
5
days
6
days
7
days
|
The
next five questions ask about smoking and other tobacco use in
your home, your family's cars, and by your friends and family.
Inside
your home (not counting decks, garages, or porches) is smoking…
Always
allowed
Allowed
only at some times or in some places
Never
allowed
|
In
the vehicles that you and family members who live with you own or
lease, is smoking…
Always
allowed
Sometimes
allowed
Never
allowed
|
Does
anyone who lives with you now…? (CHECK
ALL THAT APPLY).
A.
Smoke cigarettes
B.
Use chewing tobacco, snuff, or dip
C.
Use snus
D.
Smoke cigars, cigarillos, or little cigars
E.
Smoke tobacco using a hookah or waterpipe
F.
Smoke tobacco out of a pipe other than a hookah or waterpipe
G.
Smoke bidis (small brown cigarettes wrapped in a leaf)
H.
Smoke clove cigarettes (kreteks)
I.
Use any other form of tobacco
J.
No one who lives with me now uses any form of tobacco
|
How
many of your closest friends use any form of tobacco?
None
One
Two
Three
Four
Five
or more
Not
sure
|
Out
of every 10 students in
your grade
at school, how many do you think smoke cigarettes?
0
1
2
3
4
5
6
7
8
9
10
|
The
next seven questions are about your thoughts about tobacco.
In
your opinion, inside your home, smoking tobacco products should….
Always
be allowed
Be
allowed only at some times or in some places
Never
be allowed
|
In
your opinion, in their vehicles, people should …
Always
allow smoking
Sometimes
allow smoking
Never
allow smoking
|
Do
you think that breathing smoke from other people's cigarettes or
other tobacco products causes…
No
harm
Little
harm
Some
harm
A
lot of harm
|
Do
you believe any of the following are less harmful than smoking
cigarettes? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
Smoking
tobacco from a hookah or waterpipe
Smoking
tobacco from a pipe other than a waterpipe
Smoking
Bidis (small brown cigarettes wrapped in a leaf)
Smoking
Clove cigarettes (kreteks)
Smoking
flavored cigars, little cigars, and cigarillos (such as mint,
clove, spice, alcohol (wine, cognac), candy, fruit, chocolate, or
other sweets)
Smoking
cigars, cigarillos, or little cigars (those that are not
flavored)
Using
electronic cigarettes, such as Ruyan or NJOY
Do
not know
I
do not believe that any of the above products are less harmful
than cigarettes.
|
Do
you believe any of the following are less harmful than smoking
cigarettes? (You
can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
Using
chewing tobacco, snuff, or dip
Using
snus, such as Camel or Marlboro Snus
Using
dissolvable tobacco products, such as Ariva, Stonewall, Camel
orbs, Camel sticks, Marlboro sticks, or Camel strips
Using
electronic cigarettes, such as Ruyan or NJOY
Do
not know
I
do not believe that any of the above products are less harmful
than cigarettes
|
Do
you think smoking cigarettes makes young people look cool or
fit in?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Do
you think young people who smoke cigarettes have more friends?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
The
last six questions are about your experiences at home, in your
community, and at school.
Would
your parents or guardians strongly disapprove if you used tobacco
products?
I
don’t use tobacco products, and my parents would strongly
disapprove if I did
I
don’t use tobacco products, and my parents would not
strongly disapprove if I did
I
use tobacco products, and my parents strongly disapproved when
they first found out
I
use tobacco products, and my parents did not strongly disapprove
when they first found out
I
use tobacco products, but my parents don’t know, and they
would strongly disapprove if they knew
I
use tobacco products, but my parents don’t know, and they
would not strongly disapprove if they knew
|
During
the past
12 months,
have you been involved in any organized activities to keep people
your age from using any form of tobacco product?
Yes
No
|
During
this
school year,
were you taught in any of your classes about why you should not
use tobacco products?
Yes
No
|
During
the past
30 days,
to your knowledge, has anyone, including yourself, smoked a
tobacco product on school property when he or she was not
supposed to?
Yes
No
|
During
the past
30 days,
to your knowledge, has anyone, including yourself, used some
other type of tobacco product (that
is, one that is not smoked)
on school property when he or she was not supposed to?
Yes
No
|
During
the past
30 days,
how many days did you miss at
least one class period
because you skipped or "cut" or just did not want to
be there?
0
days
1
day
2
to 5 days
6
to 10 days
11
or more days
|