Form 2a Household Screener/Field Test

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 2a
PATH Study Data Collection Instruments:
Household Screener
July 23, 2012

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Household Screener
Version 6.1

Section

Number of
questions

Enumeration

17

Tobacco Use -- Short version

5

Tobacco Use -- Long version

14

Relationships and Residential Tenure

4

Contact information -- household respondent

7

Contact information -- sampled person

9

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Household Screener
Version 6.1
OMB Control Number: 0925-XXXX

Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 17 minutes per response,
including the 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: NIH, Project Clearance
Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do
not return the completed form to this address.

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ENUMERATION
PATH ID:

HM0001

Screen ID:

I am going to ask some questions about the people who think of this address as their primary place of
residence. This includes people who usually stay at this address but are temporarily away on business,
on vacation, in a hospital, or living at school in a dorm, fraternity or sorority. It does not include college
students who live in off-campus housing.
Including yourself, how many people live at this address and have no usual place or residence elsewhere?
|__|__|__|

NUMBER OF PEOPLE

ASK: All household.
PROGRAM: Start enumeration timing here. The following variables – name, respondent flag, gender, age,
age range, ethnicity, race, military status, twin flag, and the misreported flag (HM0002 – HM0012) – should
appear as a grid. All enumeration information is entered in this grid.
PATH ID:

HM0002

Screen ID:

[A]
What is the first name of the person, or one of the persons, who is living at this address who owns
or rents this home? ________________________________________
[B]
Next, please tell me the names of all other members of this household (starting with your spouse,
if applicable, and including children). ______________________________________________________
ASK: All households
PROGRAM: The person listed in [A] is the reference person. This variable should appear as the first
nd
column on the grid. For the 1st line on the grid, display text A. For the 2 line, display text B
PATH ID:

HM0003

Screen ID:

[IF NOT OBVIOUS, ASK: Thank you for telling me about all the people who live at this address. Now I
need to ask your name, so I know which person you are. [ENTER ‘1’ NEXT TO THE RESPONDENT]
ASK: All households (if needed, as determined by the interviewer)
PROGRAM: This variable should appear as the 2nd column on the grid. Allow only 1 response to this
question

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PATH ID:

HM0004

Screen ID:

Let me check that I have recorded everything correctly. Here is my list of everyone that lives at this
address: [LIST EVERYONE ON THE GRID]
Is there anyone else who thinks of this address as their primary place of residence? This includes people
who usually stay at this address but are temporarily away on business, on vacation, in a hospital, or living
at school in a dorm, fraternity or sorority. It does not include college students who live in off-campus
housing.
1

YES

2

NO

GO TO HM0002

ASK: All households
PROGRAM: Go through items HM0005 – HM0012 (following appropriate skips), for each household
member. Complete all items for each household member before going to the next household member.
Start with reference person (person A in in HM0002) and proceed to additional household members in the
order in which they were reported by the respondent.
When there are no additional household members, go to HM0013.
PATH ID:

HM0005

Screen ID:

What is {your / NAME’s} sex?
1

MALE

2

FEMALE

ASK: All households about each household member
PROGRAM: This variable should appear as the third column on the grid. Fill in NAME with the first name
of each household member, in turn from HM0002. For {Are you/Is NAME}, if asking about screener
respondent, display “your”. Else display “NAME’s”.
PATH ID:

HM0006

Screen ID:

How old {are you/is NAME}? |__|__|__|
-8

DON’T KNOW

GO TO HM0008

-7

REFUSED

GO TO HM0008

ASK: All households, about each household member.
INTERVIEWER NOTE: IF PERSON IS UNDER 1 YEAR, ENTER “0”
PROGRAM: This variable should appear as the fourth column on the grid. For {are you/is NAME}, if
asking about screener respondent, display “are you”. Else display “is NAME”.
If AGE >= 0 AND AGE < 17 GO TO HM0010, IF AGE >= 17 AND AGE <= 99, GO TO HM0009.
If AGE > 99, GO TO HM0007.

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PATH ID:

HM0007

Screen ID:

I just need to check that {your/NAME’s} age is {HM0006}. Is this right?
1

YES

GO TO HM0009

2

NO

GO TO HM0006

ASK: All households, about each household member whose age was reported as > 99.
PROGRAM: For {your/NAME’s}, if asking about screener respondent, display “your”. Else display “NAME”.
PATH ID:

HM0008

Screen ID:

[Are you/Is NAME] …
1

Under 9 years old,

2

9 to 11 years old,

3

12 to 17 years old,

4

18 to 24 years old,

5

25 to 29 years old, or

6

30 years old or older?

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about any household member for whom exact age was DK or R.
PROGRAM: This variable should appear as the fifth column on the grid. For [Are you/Is NAME], if asking
about screener respondent, display “Are you”. Else display “Is NAME”.
PATH ID:

HM0009

Screen ID:

{Are you/Is NAME} currently serving on active duty in the U.S. Armed Forces, Military Reserves or
National Guard? [READ ONCE] Active duty for the Reserves or National Guard does not include the
regular training for the Reserves or Guard. It does include being activated for deployment such as for the
Iraq War.
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

.

ASK: All households, about each HH member whose AGE is >= 17 years old.
PROGRAM: Active duty military (HM0009 = 1) are ineligible for the study.
This variable should appear as the tenth column on the grid. This item should only be asked if HM0006 is
greater than or equal to 17 or HM0008 is greater than or equal to 4. For [Are you/Is NAME], if asking
about screener respondent, display “Are you”. Else display “Is NAME”.
INTERVIEWER NOTE: If asked: The U.S. Armed Forces are the Army, Navy, Air Force, Marine Corps

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and Coast Guard.
PATH ID:

HM0010

Screen ID:

{Are you/Is NAME} Hispanic, [Latino I Latina], or of Spanish origin?
1

YES

2

NO

GO TO HM0011

-8

DON’T KNOW

GO TO HM0011

-7

REFUSED

GO TO HM0011

ASK: All households, about each HH member.
PROGRAM: For [Are you/Is NAME], if asking about screener respondent, display “Are you”. Else display
“Is NAME”. If male (HM0005 = 1), display “Latino”; if female (HM0005 = 2), display “Latina”
PATH ID:

HM0050

Screen ID:

What is {your/NAME’s} origin? I'm going to read a list. Choose all that apply.
1

Mexican, Mexican American, Chicano or Chicana,

2

Puerto Rican,

3

Cuban, or

4

Another Hispanic, [Latino or Latina], or Spanish origin?

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each HH member where HM0010 = 1.
PROGRAM: For {your/NAME’s}, if asking about screener respondent, display “your”. Else display
“NAME’s”. If male (HM0005=1), display “Latino”; if female (HM0005=2), display “Latina”

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PATH ID:

HM0011

Screen ID:

What is {your/NAME’s} race? I'm going to read a list. Choose all that apply.
1

White

2

Black or African American

3

American Indian or Alaska Native

4

Asian Indian

5

Chinese

6

Filipino

7

Japanese

8

Korean

9

Vietnamese

10

Other Asian

11

Native Hawaiian

12

Guamanian or Chamorro

13

Samoan

14

Other Pacific Islander

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each HH member
PROGRAM: For [your/NAME’s], if asking about screener respondent, display “your”. Else display
“NAME’s”.
PATH ID:

HM0012

Screen ID:

[LEAVE EMPTY UNLESS PERSON WAS MISREPORTED AND IS NOT A HOUSEHOLD MEMBER. IF
MISREPORTED, ENTER ‘X’.]
PROGRAM: This variable should appear as the eleventh column on the grid.
The default for this field is blank – it will only be filled if necessary.

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PATH ID:

HM0013

Screen ID:

We have listed {NUMBER} household member(s): {NAME / GENDER/ AGE}
Have we missed any other …
-

Members of this household who are related to {you/REFERENCE PERSON}?

-

People living here who are not related to {you/REFERENCE PERSON},
including friends or boarders?

-

Household members who usually live here but are not here currently,
such as someone away on vacation, business, in a hospital, or a student living in a dormitory?
1

YES

GO TO HM0002

2

NO

GO TO HM0014

PROGRAM: For {NUMBER}, display the number of household members collected in the enumeration grid.
For member(s), if household contains one person, display “member”. Else display “members”.
For {NAME / GENDER / AGE}, display the name, gender and age of each household member collected in
the grid. For {you/REFERENCE PERSON}, if screener respondent = reference person, display “you”.
Else display the name of first person on grid in “REFERENCE PERSON”. The number of household
members collected in the enumeration grid is the value that should be stored as household size.
PATH ID:

HM0014

Screen ID:

You told me that there are some children who are the same age. Are there any [twins/twins or other
multiple births] between the ages of 9 and 17? Please include any type of [twins/twins or other multiple
births] – identical or non-identical, who are also called fraternal.
1

YES

GO TO HM0015

2

NO

GO TO BOX H3

-8

DON’T KNOW

-7

REFUSED

ASK: Households where two or more household members have AGE = the same value and AGE is >= 9
and <= 17.
PROGRAM: For all HH members with AGE >= 9 and <= 17, compare each age to every other age in this
age range. If two or more ages are the same, display HM0014. . If there are 2 children who are the
same age, fill with “twins.” If there are 3 or more children who are the same age, fill with “twins or other
multiple births”

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PATH ID:

HM0015

Screen ID:

[LEAVE EMPTY UNLESS PERSON WAS IDENTIFIED AS A TWIN OF ANOTHER PERSON WHO IS
ALSO A HOUSEHOLD MEMBER. IF A TWIN, ENTER ‘X’. IF ONE HH MEMBER IS RECORDED AS A
TWIN, ONE OTHER HH MEMBER MUST ALSO BE RECORDED AS A TWIN]
Please tell me which of the children are [twins/twins or multiple births].
ASK: About HH twins (HM0014 = 1) whose AGE is >= 9 and <= 17.
PROGRAM: This variable should appear as the twelfth column on the grid. The default for this field is
blank – it will only be filled if necessary. If there are 2 children who are the same age, fill with “twins” If
there are 3 or more children who are the same age, fill with “twins or multiple births”
BOX H5
There may be multiple sets of twins or multiple births with different ages identified in HM0015. Therefore,
for each set of twins or multiple births identified, loop through items HM0016 – HM0018, following the
appropriate skips. Route according to instruction in BOX H4.
BOX H4
IF TWO CHILDREN ARE IDENTIFIED AS TWINS IN HM0015, GO TO HM0016.
IF THREE OR MORE CHILDREN ARE IDENTIFIED AS MULTIPLE BIRTHS IN HM0015, GO TO HM0017

PATH ID:

HM0016

Screen ID:

[LEAVE EMPTY UNLESS PERSON WAS IDENTIFIED AS A TWIN OF ANOTHER PERSON WHO IS
ALSO A HOUSEHOLD MEMBER. THIS ITEM MUST BE COMPLETED FOR BOTH PERSONS
FLAGGED AS TWINS IN HM0015.]
Are these children identical twins?
1

YES

GO TO BOX H3

2

NO

GO TO BOX H3

-8

DON’T KNOW

GO TO BOX H3

-7

REFUSED

GO TO BOX H3

ASK: About HH twins (HM0015 = X).
PROGRAM: This variable should appear as the thirteenth column on the grid. The default for this field is
blank – it will only be filled if necessary. If there are 2 children in HM0015 who are identified as twins, fill
with “Are these children identical twins”

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PATH ID:

HM0017

Screen ID:

[LEAVE EMPTY UNLESS PERSON WAS IDENTIFIED AS A MEMBER OF A MULTIPLE BIRTH
(TRIPLET, QUAD, ETC.) WITH ANOTHER PERSON WHO IS ALSO A HOUSEHOLD MEMBER. THIS
ITEM MUST BE COMPLETED FOR ALL PERSONS FLAGGED AS MULTIPLE BIRTHS IN HM0015.]
Do any of the multiple births include identical twins?
1

YES

GO TO HM0018

2

NO

GO TO BOX H3

-8

DON’T KNOW

GO TO BOX H3

-7

REFUSED

GO TO BOX H3

ASK: About HH twins (HM0015 = X).
PROGRAM: This variable should appear as the fourteenth column on the grid.
The default for this field is blank – it will only be filled if necessary.
PATH ID:

HM0018

Screen ID:

[LEAVE EMPTY UNLESS PERSON WAS IDENTIFIED AS A MEMBER OF A MULTIPLE BIRTH
(TRIPLET, QUAD, ETC.) WITH ANOTHER PERSON WHO IS ALSO A HOUSEHOLD MEMBER. THIS
ITEM MUST BE COMPLETED FOR ALL PERSONS FLAGGED AS MULTIPLE BIRTHS IN HM0015.]
Please tell me which of the children within the multiple births are identical twins.
ASK: About HH twins (HM0014 = 1) whose AGE is >= 9 and <= 17.
PROGRAM: This variable should appear as the fifteenth column on the grid. The default for this field is
blank – it will only be filled if necessary. If there are 2 children who are the same age, fill with “twins” If
there are 3 or more children who are the same age, fill with “twins or multiple births”

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TOBACCO USE
NOTES:
For the field test, we will test two versions of the tobacco use questions for adults – a short version and a
long version. The difference between the two is the level of detail that is collected about each person’s
tobacco use. The tobacco use definitions don’t have to be precise for screening purposes. It is enough to
know that someone uses tobacco to screen them into the study – we do not need to know which specific
tobacco product they use. However, if we don’t mention all the products, the HH respondent might not
think of them all on their own. A household will be randomly assigned to either the short version or the
long version before the interview. We do not use youth tobacco use status as a sampling criteria, so we
do not ask about youth tobacco use status in the screener.
Tobacco use definitions:
Current-established-tobacco-user: Has smoked a cigarette, cigar, pipe, or used smokeless tobacco { short
version: in the past 30 days | long version: every day, some days, or past 30 days }
Ever-emerging-product-user: Has ever used e-cigarettes, hookah, dissolvables.
BOX H3
Households will be randomly assigned to either the short version or the long version of the tobacco use
questions. The variable SCRNTYPE (1=short version, 2= long version) will be defined in the sample load
file, and will determine which version of the tobacco use questions are administered in a given household.

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TOBACCO USE – SHORT VERSION
PATH ID:

HX0001

Screen ID:

In the past 30 days, {have you/has NAME} smoked a cigarette, a cigar, or a pipe, even one or two puffs?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member whose AGE is >=18 and who is not active duty
military.
PROGRAM: For [your/NAME], if asking about screener respondent, display “Have you”. Else display “Has
NAME”. SHOW GENERIC IMAGE.
PATH ID:

HX0002

Screen ID:

In the past 30 days, {have you/has NAME} used smokeless tobacco, such as chewing tobacco, snuff,
snus or dip, even one or two times? (IF NEEDED: Do not include e-cigarettes or products such as a
nicotine patch, gum, inhaler, nasal spray, lozenge or pill.)
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military AND who
was not previously identified as a tobacco user (HX0001 = 2, -8, -7).
PROGRAM: For [your/NAME], if asking about screener respondent, display “Have you”. Else display “Has
NAME”. SHOW GENERIC IMAGE.
PATH ID:

HX0003

Screen ID:

{Have you/Has NAME} ever smoked cigarettes, cigars, or a pipe, or used smokeless tobacco, such as
chewing tobacco, snuff, snus or dip, even one or two times? (IF NEEDED: Do not include e-cigarettes or
products such as a nicotine patch, gum, inhaler, nasal spray, lozenge or pill.)
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military AND who
was not previously identified as a tobacco user (HX0001 = 2, -8, -7and HX0002 = 2, -8, -7).
PROGRAM: For [your/NAME], if asking about screener respondent, display “Have you”. Else display “Has
NAME”. SHOW GENERIC IMAGE.

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PATH ID:

HX0004

Screen ID:

{Have you/Has NAME} ever used any of the following even one or two times: electronic cigarettes or ecigarettes (such as Smoking Everywhere, NJOY, Blu or Vapor King), a hookah or waterpipe, or a
dissolvable tobacco product (such as Ariva, Stonewall, or Camel Orbs, Sticks, or Strips)?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military AND who
was not previously identified as a tobacco user (HX0001 = 2, -8, -7 and HX0002 = 2, -8, -7).
PROGRAM: For [your/NAME], if asking about screener respondent, display “Have you”. Else display “Has
NAME”. SHOW GENERIC IMAGE.
PATH ID:

HM0021

Screen ID:

I just asked you about the tobacco use of {NUMBER} household member(s): {NAME / GENDER/ AGE}
Have we missed any other …
-

Members of this household who are related to {you/REFERENCE PERSON}?

-

People living here who are not related to {you/REFERENCE PERSON},
including friends or boarders?

-

Household members who usually live here but are not here currently,
such as someone away on vacation, business, in a hospital, or a student living in a dormitory?
1

YES

GO TO HM0002

2

NO

GO TO BOX H2

PROGRAM: For {NUMBER}, display the number of household members collected in the enumeration grid.
For member(s), if household contains one person, display “member”. Else display “members”.
For {NAME / GENDER / AGE}, display the name, gender and age of each household member collected in
the grid. For {you/REFERENCE PERSON}, if screener respondent = reference person, display “you”.
Else display the name of first person on grid in “REFERENCE PERSON”. The number of household
members collected in the enumeration grid is the value that should be stored as household size.

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TOBACCO USE – LONG VERSION
PATH ID:

HC1003

Screen ID:

{Do you/ Does NAME} now smoke cigarettes…
1

Every day

GO TO BOX H2

2

Some days, or

GO TO BOX H2

3

Not at all?

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each household member AGE>=18 who is not active duty military.
PROGRAM: For [Do you/Does NAME], if asking about screener respondent, display “Do you” ELSE
display “Does NAME”
PATH ID:

HC1004

Screen ID:

In the past 30 days, {have you/has NAME} smoked a cigarette, even one or two puffs?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military and who
smokes cigarettes “not at all”, DK or R [IF PATH ID: HC1003 = 3, -8, or -7].
PROGRAM: For {Have you/Has NAME} if asking about screener respondent, display “Have you” ELSE
display “Has NAME”
PATH ID:

HE1002

Screen ID:

{Have you/Has NAME} ever used an electronic cigarette or e-cigarette, such as Smoking Everywhere,
NJOY, Blu or Vapor King, even one or two times?
1

YES

2

NO

-8

REFUSED

-7

DON'T KNOW

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7).
PROGRAM: For {Have you/Has NAME} if asking about screener respondent, display “Have you” ELSE
display “Has NAME”. SHOW GENERIC IMAGE.

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PATH ID:

HG1003

Screen ID:

{Do you/Does NAME} now smoke cigars, cigarillos, or filtered cigars…
1

Every day

GO TO BOX H2

2

Some days, or

GO TO BOX H2

3

Not at all?

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7)]. AND
who is not an ever-emerging-product-user [HE1002 = 2, -7, -8].
PROGRAM: For [Do you/Does NAME], if asking about screener respondent, display “Do you” ELSE
display “Does NAME”. SHOW GENERIC IMAGE.
PATH ID:

HG1004

Screen ID:

In the past 30 days, {have you/has NAME} smoked cigars, cigarillos, or filtered cigars, even one or two
puffs?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7);
(HG1004 = 3, -8, -7)]. AND who is not an ever-emerging-product-user [HE1002 = 2, -7, -8].
PROGRAM: For {Have you/Has NAME} if asking about screener respondent, display “Have you” ELSE
display “Has NAME”. SHOW GENERIC IMAGE.
PATH ID:

HP1003

Screen ID:

{Do you/Does NAME} now smoke a pipe filled with tobacco…
1

Every day

GO TO BOX H2

2

Some days, or

GO TO BOX H2

3

Not at all?

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7);
(HG1003 = 3, -8, -7 AND HG1005 = 2, -8, -7)] AND who is not an ever-emerging-product-user [HE1002 =
2, -7, -8].
PROGRAM: For [Do you/Does NAME], if asking about screener respondent, display “Do you” ELSE

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display “Does NAME”. SHOW GENERIC IMAGE.
PATH ID:

HP1004

Screen ID:

In the past 30 days, {have you/has NAME} smoked a pipe filled with tobacco, even one or two puffs?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003=3, -8, -7 AND HC1004=2, -8, -7);
(HG1003=3, -8, -7 AND HG1004 = 2, -8, -7); HP1003 = 3, -8, -7)] AND who is not an ever-emergingproduct-user [HE1002 = 2, -7, -8]. SHOW GENERIC IMAGE.
PATH ID:

HH1002

Screen ID:

{Have you/Has NAME} ever smoked tobacco in a hookah or waterpipe, even one or two times?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7);
(HG1003 = 3, -8, -7 AND HG1004 = 2, -8, -7); (HP1003 = 3, -8, -7 AND HP1004 = 2, -8, -7)] AND who is
not an ever-emerging-product-user [HE1002 = 2, -7, -8].
PROGRAM: For {Have you/Has NAME} if asking about screener respondent, display “Have you” ELSE
display “Has NAME”. SHOW GENERIC IMAGE.
PATH ID:

HU1002

Screen ID:

{Have you/Has NAME} ever used snus, even one or two times?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7);
(HG1003 = 3, -8, -7 AND HG1004 = 2, -8, -7); (HP1003 = 3, -8, -7 AND HP1004 = 2, -8, -7)] AND who is
not an ever-emerging-product-user [HE1002 = 2, -7, -8 AND HH1002 = 2, -7, -8].
PROGRAM: For [Do you/Does NAME], if asking about screener respondent, display “Do you” ELSE
display “Does NAME”. SHOW GENERIC IMAGE.

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PATH ID:

HS1003

Screen ID:

{Do you/Does NAME} now use smokeless tobacco products, such as snus, moist snuff, dip, spit or chew
… (IF NEEDED: Do not include e-cigarettes or products such as a nicotine patch, gum, inhaler, nasal
spray, lozenge or pill.)
1

Every day

GO TO BOX H2

2

Some days, or

GO TO BOX H2

3

Not at all?

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7);
(HG1003 = 3, -8, -7 AND HG1004 = 2, -8, -7); (HP1003 = 3, -8, -7 AND HP1004 = 2, -8, -7)] AND who is
not an ever-emerging-product-user [HE1002 = 2, -7, -8 AND HH1002 = 2, -7, -8 AND HU1002 = 2, -7, -8].
PROGRAM: For [Do you/Does NAME], if asking about screener respondent, display “Do you” ELSE
display “Does NAME”. SHOW GENERIC IMAGE.
PATH ID:

HS1004

Screen ID:

In the past 30 days, {have you/has NAME} used smokeless tobacco products such as snus, moist snuff,
dip, spit or chew, even one or two times? (IF NEEDED: Do not include e-cigarettes or products such as a
nicotine patch, gum, inhaler, nasal spray, lozenge or pill.)
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO BOX H2

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7);
(HG1003 = 3, -8, -7 AND HG1004 = 2, -8, -7); (HP1003 = 3, -8, -7 AND HP1004 = 2, -8, -7); (HS1003 = 3,
-8, -7] AND who is not an ever-emerging-product-user [HE1002 = 2, -7, -8 AND HH1002 = 2, -7, -8 AND
HU1002 = 2, -7, -8].
PROGRAM: For {Have you/Has NAME} if asking about screener respondent, display “Have you” ELSE
display “Has NAME”

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Household Screener

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Household Screener
Version 6.1

PATH ID:

HD1002

Screen ID:

{Have you/Has NAME} ever used dissolvable tobacco products, such as Ariva, Stonewall, or Camel Orbs,
Sticks, or Strips, even one or two times?
1

YES

GO TO BOX H2

2

NO

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each household member AGE>=18 who is not active duty military and who
has not previously been identified as a tobacco user [(HC1003 = 3, -8, -7 AND HC1004 = 2, -8, -7);
(HG1003 = 3, -8, -7 AND HG1005 = 2, -8, -7); (HP1003 = 3, -8, -7 AND HP1005 = 2, -8, -7); (HS1003 = 3,
-8, -7 AND HS1005 = 2, -8, -7] AND who is not an ever-emerging-product-user [HE1002 = 2, -7, -8 AND
HH1002 = 2, -7, -8 AND HU1002 = 2, -7, -8].
PROGRAM: For {Have you/Has NAME} if asking about screener respondent, display “Have you” ELSE
display “Has NAME”
PATH ID:

HM0020

Screen ID:

I just asked you about the tobacco use of {NUMBER} household member(s): {NAME / GENDER/ AGE}
Have we missed any other …
-

Members of this household who are related to {you/REFERENCE PERSON}?

-

People living here who are not related to {you/REFERENCE PERSON},
including friends or boarders?

-

Household members who usually live here but are not here currently,
such as someone away on vacation, business, in a hospital, or a student living in a dormitory?
1

YES

GO TO HM0002

2

NO

GO TO BOX H2

PROGRAM: For {NUMBER}, display the number of household members collected in the enumeration grid.
For member(s), if household contains one person, display “member”. Else display “members”.
For {NAME / GENDER / AGE}, display the name, gender and age of each household member collected in
the grid. For {you/REFERENCE PERSON}, if screener respondent = reference person, display “you”.
Else display the name of first person on grid in “REFERENCE PERSON”. The number of household
members collected in the enumeration grid is the value that should be stored as household size.

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Household Screener

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Household Screener
Version 6.1

BOX H2
PROGRAM: DEFINE THE FOLLOWING VARIABLES:
SHORT CURRENT ESTABLISHED PRODUCT USER = YES IF HX0001 = 1 OR HX0002 = 1.
SHORT EVER EMERGING PRODUCT USER BUT NOT EVER ESTABLISHED PRODUCT USER = YES
IF HX0004 = 1.
LONG CURRENT ESTABLISHED PRODUCT USER = YES [ IF HC1003=1,2 OR HC1004 = 1 OR
HG1003 = 1, 2 OR HG1004 = 1 OR HP1003 = 1, 2 OR HP1004 = 1 OR HS1003 = 1, 2 OR HS1004 = 1 ]
LONG EVER EMERGING PRODUCT USER = YES IF HE1002 = 1 OR HH1002 = 1 OR HU1002 = 1 OR
HD1002 = 1
Run the sampling algorithm. Eligibility is determined when the enumeration and tobacco use identification
are completed or screens below SP=Sampled Person. If an SP has been selected, GO TO HX0014. Else
GO TO END.

PATH ID:

HX0014

Screen ID:

Based on the information you have provided, we have selected {SP FILL 1}, {SP FILL 2}, {SP FILL 3}, {SP
FILL 4}, {SP FILL 5}, {SP FILL 6}, {SP FILL 7}, {SP FILL 8}, and {SP FILL 9} to participate in the study.
[IF A SHADOW SAMPLE CHILD IS SELECTED, ALSO DISPLAY THE FOLLOWING]
[SHADOW SAMPLE CHILD AGE BETWEEN 9 AND 11 YEARS OLD]
[In addition], we would [also] like to talk to a parent of {APPROPRIATE CHILDREN’S
NAMES} about inviting {him/her/them} to participate in the study when {he/she/they} turn 12.
[PRESS 1 AND ENTER TO CONTINUE]
1

CONTINUE

PROGRAM: For each SP selected, NAME / AGE / GENDER. IF SPs and shadow sampled youth are
selected in this household, display words in brackets. If only shadow sampled youth are selected, omit
words in brackets.

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Household Screener

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Household Screener
Version 6.1

RELATIONSHIP AND RESIDENTIAL TENURE
PATH ID:

HX0015

Screen ID:

Next, I have some questions about the relationships among the people who have been selected to
participate in the study.
What is {NAME’s/your} relationship to {SP/you}? In other words, {NAME/you} is/are {SP’s/your} … IF
NEEDED: For example: wife or husband, son, daughter, son-in-law, sister, foster son, partner, lodger,
etc.
1

Selected Person (SP)

2

Spouse

3

Domestic Partner

4

Fiancé

5

Boyfriend / Girlfriend

6

Son / Daughter (natural or blood)

7

Adopted {son / daughter}

8

Step{son/daughter} / Foster {son/daughter}

9

Son-in-law / Daughter-in-law

10

Grandson / Granddaughter

11

Brother / Sister

12

Step-brother / Step-sister

13

Brother-in-law / Sister-in-law

14

Mother / Father

15

Step-mother / Step-father

16

Mother-in-law / Father-in-law

17

Grandmother / Grandfather

18

Cousin

19

Uncle / Aunt

20

Nephew / Niece

21

Other relative

22

Roommate / Housemate

23

Other non-relative

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each SP and shadow sampled youth.
PROGRAM: Ask HX0015 for each household member reported on enumeration grid in relation to SP #1.

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Household Screener
Version 6.1
Repeat for SP #2, SP #3, SP #4, SP #5, SP #6, SP #7, SP #8, SP #9 as needed.
For {NAME’s/your}, when collecting information about screener respondent’s relationship to any SP,
display “your”. Else display name of each household member collected in enumeration grid in “NAME’s”.
For {SP/you}, if screener respondent = SP, display “you”. Else display SP name in {SP}.
For response options, if HM0005 = 1, then display: 2=Husband; 4=Boyfriend; 5=Son (natural or blood);
6=Adopted son; 7=Stepson/Foster son; 8=Son-in-law; 9=Grandson; 10=Brother; 11=Step-brother;
12=Brother-in-law; 13=Father; 14=Step-father; 15=Father-in-law; 16=Grandfather; 18=Uncle; 19=Nephew.
Else If HM0005 = 2, then display: 1=Wife; 4=Girlfriend; 5=Daughter (natural or blood); 6=Adopted
daughter; 7=Stepdaughter/Foster daughter; 8=Daughter-in-law; 9=Granddaughter; 10=Sister; 11=Stepsister; 12=Sister-in-law; 13=Mother; 14=Step-mother; 15=Mother-in-law; 16=Grandmother; 18=Aunt;
19=Niece.
When collecting information for screener respondent, if screener respondent = SP, assign ‘01’ and go to
next name in enumeration grid.
The second and all subsequent times this question is read, the following text should be in parentheses:
(For example: wife or husband, son, daughter, son-in-law, sister, foster son, partner, lodger, etc )
PATH ID:

HX0018

Screen ID:

Can you tell me who {SP YOUTH NAME}’s parent or guardian is?
DISPLAY LIST OF ALL PEOPLE IN HOUSEHOLD. PICK PARENT OR GUARDIAN (S).
-8

DON’T KNOW

-7

REFUSED

ASK: All households, about sampled youth or shadow sampled youth for whom a mother/father or stepmother/step-father was not identified in HX0015.
PROGRAM: For {SP YOUTH NAME}, display first name of youth SP from enumeration grid.
PATH ID:

HX0016

Screen ID:

Do you own or rent your home?
1

HOME IS OWNED [BY ANY HOUSEHOLD MEMBER]

2

HOME IS RENTED

3

OTHER

-8

DON’T KNOW

-7

REFUSED

ASK: All households

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Household Screener

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Household Screener
Version 6.1

PATH ID:

HX0017

Screen ID:

We want to be sure that every household in this area has been given a chance to participate in this
important study. Is there any other person or group of people you haven’t already told me about who lives
and receives mail {here/at ADDRESS}?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

ASK: All households
PROGRAM: If don’t know house number and/or street name, display “here”. Else display “at ADDRESS”.

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Household Screener

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Household Screener
Version 6.1

CONTACT INFORMATION
PATH ID:

HL0001

Screen ID:

I’d like to take a brief moment and get some of your contact information for my records. In addition, I’d like
your help in getting some basic contact information for {SP FILL 1}, {SP FILL 2}, {SP FILL 3}, {SP FILL 4},
{SP FILL 5}, {SP FILL 6}, {SP FILL 7}, {SP FILL 8}, and {SP FILL 9}
[PRESS 1 AND ENTER TO CONTINUE]
1

1

CONTINUE

PROGRAM: For {SP FILL 1-9}, display the name of each SP selected in HX0014.
SP FILL 1 = display SP #1 NAME.
If second SP selected, display SP FILL 2; else blank. SP FILL 2 = display SP #2 NAME.
If third SP selected, display SP FILL 3; else blank. SP FILL 3 = display SP #3 NAME.
If fourth SP selected, display SP FILL 4; else blank. SP FILL 4 = display SP #4 NAME.
If fifth SP selected, display SP FILL 5; else blank. SP FILL 5 = display SP #5 NAME.
If sixth SP selected, display SP FILL 6; else blank. SP FILL 6 = display SP #6 NAME.
If seventh SP selected, display SP FILL 7; else blank. SP FILL 7 = display SP #7 NAME.
If eighth SP selected, display SP FILL 8; else blank. SP FILL 8 = display SP #8 NAME.
If ninth SP selected, display SP FILL 9; else blank. SP FILL 9 = display SP #9 NAME.
PATH ID:

HL0002

Screen ID:

I would like to confirm your name and street address.
[PROBE FOR APT AS NECESSARY. VERIFY ALL SPELLING.]
NAME: ______________________________________________________________
FIRST

MI

LAST

___________________________________________________________________
STREET

APT #

___________________________________________________________________
CITY

STATE

ZIP

PROGRAM: Pre-populate name (first) field based on info obtained previously.

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Household Screener
Version 6.1
PATH ID:

HL0003

Screen ID:

Do you receive mail at the address you just gave me?
1

YES

2

NO

-8

DON’T KNOW

-7

REFUSED

GO TO HL0005

ASK: All households.
PATH ID:

HL0004

Screen ID:

Can I please have your mailing address? [VERIFY ALL SPELLING.]
__________________________________________________________________
MAILING ADDRESS
__________________________________________________________________
CITY

STATE

ZIP

ASK: All households for household respondents who don’t get mail at their street address (HL0003 =
2,DK,R)

PATH ID:

HL0005

Screen ID:

What is the best telephone number to use to contact you?
__________

______________________________

AREA CODE

PHONE NUMBER

-8

DON’T KNOW GO TO HL0009

-7

REFUSED

GO TO HL0009

ASK: All households

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Household Screener
Version 6.1
PATH ID:

HL0006

Screen ID:

Is this a home phone, cell phone or work number?
1

HOME

2

CELL

3

WORK

4

NOT SURE

-8

DON’T KNOW

-7

REFUSED

ASK: All households who provided a best telephone number in HL0005.
PATH ID:

HL0007

Screen ID:

What is a second telephone number to use to contact you?
__________

______________________________

AREA CODE

PHONE NUMBER

-8

DON’T KNOW GO TO HL0009

-7

REFUSED

GO TO HL0009

ASK: All households who provided a best telephone number in HL0009.
PATH ID:

HL0008

Screen ID:

Is this a home phone, cell phone or work number?
1

HOME

2

CELL

3

WORK

4

NOT SURE

-8

DON’T KNOW

-7

REFUSED

ASK: All households who provided a second telephone number in HL0007.

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Household Screener
Version 6.1
PATH ID:

HL0009

Screen ID:

As I mentioned, the computer has selected [{SP FILL 1}, {SP FILL 2}, {SP FILL 3}, {SP FILL 4}, {SP FILL
5}, {SP FILL 6}, {SP FILL 7}, {SP FILL 8}, {and SP FILL 9}] to be in the study.
I’d like your help in getting some basic contact information for [{SP FILL 1}, {SP FILL 2}, {SP FILL 3}, {SP
FILL 4}, {SP FILL 5}, {SP FILL 6}, {SP FILL 7}, {SP FILL 8}, {and SP FILL 9}]. I’ll use this information only
to contact [{SP FILL 1}, {SP FILL 2}, {SP FILL 3}, {SP FILL 4}, {SP FILL 5}, {SP FILL 6}, {SP FILL 7}, {SP
FILL 8}, {and SP FILL 9}.
[PRESS 1 AND ENTER TO CONTINUE]
1

CONTINUE

PROGRAM: Ask HL0010-HM0027 for each SP selected in HX0014 AND Shadow Sample parent (
HX0018) if Shadow sample parent is not an SP.
PATH ID:

HL0010

Screen ID:

Can I have [SP FILL]’s full name? [VERIFY ALL SPELLING.]
NAME: ___________________________________________________________
FIRST

MI

LAST

PROGRAM: Pre-populate FIRST NAME FIELD BASED ON SP INFO OBTAINED in HX0014.
PATH ID:

HL0011

Screen ID:

What is the best phone number to use to reach [SP FILL]?
__________
AREA CODE

______________________________
PHONE NUMBER

-8
-7

DON’T KNOW
REFUSED

GO TO HL0015
GO TO HL0015

ASK: All households, about each SP.

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Household Screener
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PATH ID:

HL0012

Screen ID:

Is this a home phone, cell phone or work number?
1

HOME PHONE

2

CELL PHONE

3

WORK PHONE

4

NOT SURE

-8

DON’T KNOW

-7

REFUSED

ASK: If household provided an SP Best telephone number in HL0011.
PATH ID:

HL0013

Screen ID:

What is a second telephone number to use to reach [SP FILL]?
__________

______________________________

AREA CODE

PHONE NUMBER

-8

DON’T KNOW

GO TO HL0015

-7

REFUSED

GO TO HL0015

ASK: If household provided an SP best telephone number in HL0011.
PATH ID:

HL0014

Screen ID:

Is this a home phone, cell phone, or work number…
1

HOME PHONE

2

CELL PHONE

3

WORK PHONE

4

NOT SURE

-8

DON’T KNOW

-7

REFUSED

ASK: If household provided an SP second telephone number in HL0013.

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Household Screener
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PATH ID:

HL0015

Screen ID:

Can you please give me [SP FILL]’s e-mail address? [VERIFY ALL SPELLING AND PUNCTUATION.]
_____________________________@_______________
E-MAIL ADDRESS
-8 DON’T KNOW
-7 REFUSED
ASK: All households, about each SP.
PATH ID:

HM0025

Screen ID:

How well [do you/does {SP}] speak English?
1

Very well

GO TO END

2

Well

GO TO END

3

Not well

4

Not at all

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each SP.
PROGRAM: Repeat question for each SP.
PATH ID:

HM0026

Screen ID:

[Are you/Is {SP}] able to speak English well enough to complete an interview in English?
1

Yes

2

No

-8

DON’T KNOW

-7

REFUSED

GO TO END

ASK: All households, about each SP.
PROGRAM: Repeat question for each SP.

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Household Screener
Version 6.1
PATH ID:

HM0027

Screen ID:

In what language would [you/{SP}] be able to complete the interview?
2

Spanish

3

Korean

4

Cantonese

5

Mandarin

6

Vietnamese

91

Other: Specify__________________

-8

DON’T KNOW

-7

REFUSED

ASK: All households, about each SP that does not speak English well enough (HM0026 = 2)
PROGRAM: Repeat question for each SP.

PATH
Household Screener

29