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, Latina, or of 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, Latina, 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
|
The
next five sections of questions ask about your use of particular
kinds of tobacco products.
The
first eleven questions are about smoking conventional cigarettes
(ones that have to be lit and burned).
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
|
The
next seven questions are about the use of cigars, cigarillos or
little cigars such as Black and Mild, Swisher Sweets, Dutch
Masters, White Owl, or Phillies Blunts.
Have
you ever been curious about smoking a cigar, cigarillo, or little
cigar such as Black and Mild, Swisher Sweets, Dutch Masters,
White Owl, or Phillies Blunts?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Have
you ever
tried
smoking cigars, cigarillos, or little cigars, such as Black and
Mild, Swisher Sweets, Dutch Masters, White Owl, or Phillies
Blunts, even one or two puffs?
Yes
No
|
Do
you think that you will try a cigar, cigarillo or little cigar
soon?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
If
one of your best friends were to offer you a cigar, cigarillo or
little cigar, would you smoke it?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
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, on
the days that you smoked,
about how many cigars, cigarillos, or little cigars did you smoke
per day?
I
did not smoke cigars, cigarillos, or little cigars during the
past 30 days
Less
than 1 cigar, cigarillo or little cigar per day
1
per day
2
to 5 per day
6
to 10 per day
11
to 20 per day
More
than 20 per day
|
The
next three questions are about the use of chewing tobacco, snuff
or dip. Do not think about 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
tobacco, 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
|
The
next twelve questions are about electronic cigarettes or
e-cigarettes. E-cigarettes are electronic devices that usually
contain a nicotine-based liquid that is vaporized and inhaled. You
may also know them as vape-pens, hookah-pens, electronic hookahs
(e-hookahs),electronic cigars (e-cigars), electronic pipes
(e-pipes), or e-vaporizers. Some look like cigarettes and others
look like pens or small pipes. These are battery-powered devices
that produce vapor instead of smoke. Some brands examples are
NJOY, Blu, VUSE, MarkTen, Finiti, Starbuzz, and Fantasia.
Have
you ever been curious about using an electronic cigarette or
e-cigarette, even once or twice?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Have
you ever
used
an electronic cigarette or e-cigarette,
even once or twice?
Yes
No
|
Do
you think that you will try an electronic
cigarette or e-cigarette
soon?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
If
one of your best friends were to offer you an electronic
cigarette or e-cigarette,
would you use it?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
How
old were you when you first tried using an electronic cigarette
or e-cigarette, even once or twice?
I
have never used electronic cigarettes or e-cigarettes
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 electronic cigarettes or
e-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
|
In
total, on how many days have you used an electronic cigarette or
e-cigarette in your entire life?
0
days
1
day
2
to 10 days
11
to 20 days
21
to 50 days
51
to 100 days
Over
100 days
|
What
brands of electronic cigarettes or e-cigarettes have you ever
tried?
(CHOOSE
ALL THAT APPLY)
I
have never tried electronic cigarettes or e-cigarettes
Blu
NJOY
MarkTen
Logic
VUSE
Finiti
Starbuzz
Fantasia
Some
other brand not listed here
I
do not know the brand name
|
Thinking
about all types of electronic cigarettes or e-cigarettes, have
you used the disposable kind or rechargeable/refillable tank
kind?
I
have never tried an electronic cigarette or e-cigarette
Only
the disposable kind
Only
the rechargeable/refillable tank kind
Both
the disposable kind and rechargeable/refillable tank kind
|
Which
of the following statements best applies to your cigarette or
electronic cigarette use?
I
have never tried cigarettes or electronic cigarettes
I
have only tried cigarettes
I
have only tried electronic cigarettes
I
tried cigarettes before I ever tried electronic cigarettes
I
tried electronic cigarettes before I ever tried cigarettes
|
What
are the reasons why you have used electronic cigarettes or
e-cigarettes? (CHOOSE
ALL THAT APPLY)
I
have never tried an electronic cigarette
Friend
or family member used them
To
try to quit using tobacco products, such as cigarettes
They
cost less than other tobacco products, such as cigarettes
Famous
people on TV or in movies use them
They
are less harmful than other forms of tobacco, such as cigarettes
They
are available in flavors, such as mint, candy, fruit, or
chocolate
They
can be used in areas where other tobacco products, such as
cigarettes, are not allowed
I
used them for some other reason
|
Have
you ever used an electronic cigarette device for any other
substance other than for nicotine?
Yes
No
|
The
next two questions are about the use of other tobacco products,
not described in the previous sections.
Which
of the following tobacco products have you ever
tried,
even just one time? (CHOOSE
ALL THAT APPLY)
Roll-your-own
cigarettes
Flavored
cigarettes, such as clove, alcohol (wine, cognac), candy, fruit,
chocolate, or other sweets (DO NOT include menthol cigarettes)
Bidis
(small brown cigarettes wrapped in a leaf)
Flavored
cigars, cigarillos, and little cigars (such as mint, clove,
alcohol (wine, cognac), candy, fruit, chocolate, or other sweets)
Hookah
or a waterpipe used with tobacco
Pipe
filled with tobacco (not waterpipe)
Snus,
such as Camel or Marlboro Snus
Dissolvable
tobacco products, such as Ariva, Stonewall, Camel orbs, Camel
sticks, or Camel strips
I
have never tried any of the products listed above
|
In
the
past 30 days,
which of the following products have you used on at
least one day?
(CHOOSE
ALL THAT APPLY)
Roll-your-own
cigarettes
Flavored
cigarettes, such as clove, alcohol (wine, cognac), candy, fruit,
chocolate, or other sweets (DO NOT include menthol cigarettes)
Bidis
(small brown cigarettes wrapped in a leaf)
Hookah
or a waterpipe used with tobacco
Pipe
filled with tobacco (not waterpipe)
Snus,
such as Camel or Marlboro Snus
Dissolvable
tobacco products, such as Ariva, Stonewall, Camel orbs, Camel
sticks, or Camel strips
I
did not use any of the products listed above in the past 30 days
|
The
next question asks about flavors in tobacco products.
Which
of the following tobacco products that you used in the past 30
days were flavored to taste like menthol (mint), alcohol (wine,
cognac), candy, fruit, chocolate or other sweets? (CHOOSE
ALL THAT APPLY)
Cigars,
such as Macanudo, Romeo y Julieta, or Arturo Fuente
Cigarillos,
such as Black and Mild, Swisher Sweets, Dutch Masters, or
Phillies Blunts
Little
cigars, such as Prime Time little filtered cigars or Winchester
little filtered cigars
Chewing
tobacco, snuff, or dip
Electronic
cigarettes or e-cigarettes
Hookah
or a waterpipe used with tobacco
Pipe
filled with tobacco (not waterpipe)
Snus,
such as Camel or Marlboro Snus
Dissolvable
tobacco products,
such as Ariva, Stonewall, Camel orbs, Camel sticks, or Camel
strips
I
did not use any of the flavored products listed above in the past
30 days
|
The
next question asks about the first tobacco product you ever tried.
Which
of the following tobacco products did you try first? (CHOOSE
ONLY ONE ANSWER)
Cigarettes
Cigars,
cigarillos, or little cigars
Electronic
cigarettes or e-cigarettes
Chewing
tobacco, snuff, or dip
Hookah
or a waterpipe used with tobacco
Pipe
filled with tobacco (not waterpipe)
Snus,
such as Camel or Marlboro snus
Bidis
(small brown cigarettes wrapped in a leaf)
Dissolvable
tobacco products, such as Ariva, Camel orbs, Camel sticks, or
Camel strips
Not
sure about the product I tried first
I
have never tried any of the products listed above
|
The
next four questions are about getting tobacco products.
During
the past
30 days,
how did you get your own tobacco products? (CHOOSE
ALL THAT APPLY)
I
did not get any of my own tobacco products during the past 30
days
I
bought them myself
I
had someone else buy them for me
I
asked someone to give me some
Someone
offered them 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 tobacco products? (CHOOSE
ALL THAT APPLY)
I
did not buy my own tobacco products 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,
where did you get or buy the electronic
cigarettes
that you have used?
(CHOOSE
ALL THAT APPLY)
I
have never tried an electronic cigarette
A
gas station or convenience store
A
grocery store
A
drugstore
A
mall or shopping center kiosk/stand
Over
the Internet
A
store that sells electronic cigarettes, such as a “vape
shop ”
Some
other place
From
a family member
From
a friend
Some
other person that is not a family member or a friend
|
During
the past
30 days,
did anyone refuse
to sell you any tobacco products because of your age?
I
did not try to buy any tobacco products during the past 30 days
Yes
No
|
The
next four questions are about issues related to urges or needs to
use tobacco products.
During
the past 30 days, have you had a strong craving or felt like you
really needed to use a tobacco product of any kind?
Yes
No
|
How
soon after you wake up do you want to use a tobacco product?
I
do not want to 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
|
How
true is this statement for you? I feel restless and irritable
when I don’t use tobacco for a while.
I
do not use tobacco
Not
at all true
Sometimes
true
Often
true
Always
true
|
How
true is this statement for you? When I go without using a
tobacco product for a few hours, I experience cravings
I
do not use tobacco
Not
true at all
Sometimes
true
Often
true
Always
true
|
The
next two questions are about quitting conventional cigarettes.
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
|
The
next three questions are about quitting all types of tobacco
products
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 next 12 months
Yes,
but not within the next 12 months
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 questions ask about your thoughts on different types of
tobacco products.
How
much do you think people harm themselves when they smoke
cigarettes some days but not every day?
No
harm
Little
harm
Some
harm
A
lot of harm
|
How
much do you think people harm themselves when they smoke cigars,
cigarillos or little cigars
some days but not every day?
No
harm
Little
harm
Some
harm
A
lot of harm
|
How
much do you think people harm themselves when they use chewing
tobacco, snuff, dip, or snus,
some days but not every day?
No
harm
Little
harm
Some
harm
A
lot of harm
|
How
much do you think people harm themselves when they use
e-cigarettes
some days but not every day?
No
harm
Little
harm
Some
harm
A
lot of harm
|
How
strongly do you agree with the statement ‘All tobacco
products are dangerous’?
Strongly
agree
Agree
Disagree
Strongly
disagree
|
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 think the minimum age to buy tobacco products should be 21?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
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 four questions ask about issues related to tobacco
advertisement. Do not think of electronic cigarettes.
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 use read newspapers or magazines
Never
Rarely
Sometimes
Most
of the time
Always
|
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
|
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
|
The
next four questions ask about issues related to electronic
cigarette advertisement.
When
you are using the Internet, how often do you see ads or
promotions for electronic cigarettes or e-cigarettes?
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 electronic cigarettes or e-cigarettes?
I
do not use read newspapers or magazines
Never
Rarely
Sometimes
Most
of the time
Always
|
When
you go to a convenience store, supermarket, or gas station, how
often do you see ads or promotions for electronic cigarettes or
e-cigarettes?
I
never go to a convenience store, supermarket, or gas station
Never
Rarely
Sometimes
Most
of the time
Always
|
When
you watch TV, how often do you see ads or promotions for
electronic cigarettes or e-cigarettes?
I
do not watch TV
Never
Rarely
Sometimes
Most
of the time
Always
|
The
next four questions ask about you being around other people’s
tobacco smoke or vapor from electronic cigarettes or e-cigarettes.
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
30 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
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 how many days did you breathe the vapor from someone who was
using an electronic cigarette or e-cigarette 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
or 2 days
3
to 5 days
6
to 9 days
10
to 19 days
20
to 29 days
All
30 days
|
The
next question asks about your experiences at home.
Does
anyone who lives with you now…? (CHECK
ALL THAT APPLY).
Smoke
cigarettes
Smoke
cigars, cigarillos, or little cigars
Use
chewing tobacco, snuff, or dip
Use
electronic cigarettes or e-cigarettes
Smoke
tobacco out of a hookah or waterpipe
Smoke
pipes filled with tobacco (not waterpipes)
Use
snus
Use
dissolvable tobacco products
Smoke
bidis (small brown cigarettes wrapped in a leaf)
No
one who lives with me now uses any form of tobacco
|
The
last four questions are about your experiences at home and at
school.
Out
of every 10 students in your grade at school, how many do you
think use electronic
cigarettes or
e-cigarettes?
0
1
2
3
4
5
6
7
8
9
10
|
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
to10 days
11
or more days
|
Do
you speak a language other than English at home?
Yes
No
|
Because
of a physical, mental, or emotional condition, do you have
serious difficulty concentrating, remembering, or making
decisions?
Yes
No
|