Form 2e Tobacco Use Form/Field Test

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

Attachment 2e
PATH Study Data Collection Instruments:
Tobacco Use Form
July 23, 2012

PATH

PATH Study Tobacco Use Form

Population Assessment
of Tobacco and Health

OMB Control Number: 0925-XXXX

Expiration Date:

Have you used any of the following products today, yesterday, or the day before yesterday?
(If you don’t know an answer or don’t want to provide one, you may leave the question blank.)

1 Cigarettes?

YES
NO

2 E-cigarettes?

YES
NO

3 Cigars?

YES
NO

4 Cigarillos?

YES
NO

5 Little filtered
cigars?

YES

6 Regular pipe filled
with tobacco?

YES

7 Hookah?

YES

NO

NO

NO

8 Snus pouches?

YES
NO

9 Smokeless tobacco
(such as chew,
snuff, or dip)?

YES
NO

When did you last smoke a cigarette?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last smoke a cigarette?
Morning
Evening
Afternoon

During the day you last smoked a
cigarette, how many did you smoke?

When did you last use an e-cigarette?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use an e-cigarette?
Morning
Evening
Afternoon

During the day you last used an
e-cigarette, how many times did
you use it?

When did you last smoke a cigar?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last smoke a cigar?
Morning
Evening
Afternoon

During the day you last smoked a
cigar, how many did you smoke?

When did you last smoke cigarillos?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last smoke cigarillos?
Morning
Evening
Afternoon

During the day you last smoked
cigarillos, how many did you smoke?

When did you last smoke little filtered cigars?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last smoke little filtered cigars?
Morning
Evening
Afternoon

During the day you last smoked little
filtered cigars, how many did you
smoke?

When did you last smoke a regular pipe filled with tobacco?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last smoke a regular pipe
filled with tobacco?
Morning
Evening
Afternoon

During the day you last smoked a
regular pipe filled with tobacco,
how many bowls did you smoke?

When did you last smoke a hookah?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last smoke a hookah?
Morning
Evening
Afternoon

During the day you last smoked a
hookah, how many times did you
smoke it?

When did you last use snus pouches?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use snus pouches?
Morning
Evening
Afternoon

During the day you last used snus
pouches, how many did you use?

When did you last use smokeless tobacco?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use smokeless tobacco?
Morning
Evening
Afternoon

During the day you last used
smokeless tobacco, how many times
did you use it?
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PATH

PATH Study Tobacco Use Form

Population Assessment
of Tobacco and Health

Have you used any of the following products today, yesterday, or the day before yesterday?
(If you don’t know an answer or don’t want to provide one, you may leave the question blank.)

10 Dissolvable
tobacco?

YES

11 Nicotine patch?

YES

NO

NO

12 Nicotine gum?

YES
NO

13 Nicotine inhaler?

YES
NO

14 Nicotine nasal
spray?

YES

15 Nicotine lozenge
or pill?

YES

16 Prescription drug
to stop smoking?

YES

NO

NO

NO

(such as Chantix,
varenicline, Wellbutrin,
Zyban, or bupropion)

When did you last use dissolvable tobacco?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use dissolvable tobacco?
Morning
Evening
Afternoon

During the day you last used
dissolvable tobacco, how many
pieces did you use?

When did you last use a nicotine patch?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use a nicotine patch?
Morning
Evening
Afternoon

During the day you last used a
nicotine patch, how many did you
use?

When did you last use nicotine gum?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use nicotine gum?
Morning
Evening
Afternoon

During the day you last used
nicotine gum, how many pieces
did you use?

When did you last use a nicotine inhaler?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use a nicotine inhaler?
Morning
Evening
Afternoon

During the day you last used a
nicotine inhaler, how many times
did you use it?

When did you last use a nicotine nasal spray?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use a nicotine nasal spray?
Morning
Evening
Afternoon

During the day you last used a
nicotine nasal spray, how many
times did you use it?

When did you last use a nicotine lozenge or pill?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last use a nicotine lozenge
or pill?
Morning
Evening
Afternoon

During the day you last used a
nicotine lozenge or pill, how many
times did you use it?

When did you last take a prescription drug to stop smoking?

In the past hour
Yesterday

Sometime today
Day before yesterday

What time of day did you last take a prescription drug
to stop smoking?
Morning
Evening
Afternoon

During the day you last took a
prescription drug to stop smoking,
how many did you take?

Public reporting burden for this collection of information is estimated to average 2 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 (XXXX-XXXX). Do not return the completed form to this address.

Date:
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0
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Time:
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Participant ID:
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