The
first five questions ask 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? (Select
one or more)
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? (Select
one or more)
American
Indian or Alaska Native
Asian
Black
or African American
Native
Hawaiian or Other Pacific Islander
White
|
The
next six sections of questions ask about your use of particular
kinds of tobacco products, such as cigarettes, cigars, smokeless
tobacco, electronic cigarettes, hookahs, pipes, snus, dissolvable
tobacco, and bidis.
The
first 12 questions are about smoking conventional cigarettes (ones
that have to be lit and burned).
Have
you ever been curious about smoking a cigarette?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Have
you ever
tried
cigarette smoking, even one or two puffs?
Yes
No
|
|
|
|
How
old were you when you first
tried
cigarette smoking, even one or two puffs?
A. 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)
|
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,
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
|
During
the past 30 days, what brand of cigarettes did you usually smoke?
(Choose
only one answer)
A. I
did not smoke cigarettes during the past 30 days
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
|
Do
you think that you will try a cigarette soon?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Do
you think you will smoke a cigarette in the next year?
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
|
The
next five questions are about the use of cigars, cigarillos, or
little cigrars 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?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
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, 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 four questions are about the use of chewing tobacco, snuff,
or dip. Do
not think
about snus or dissolvable tobacco products when you answer these
questions.
Have
you ever been curious about using chewing tobacco, snuff, or dip?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
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 11 questions are about electronic cigarettes or e-cigarettes.
E-cigarettes are battery powered devices that usually contain a
nicotine-based liquid that is vaporized and inhaled. You may also
know them as e-cigs, vape-pens, hookah-pens, e-hookahs, e-cigars,
e-pipes, personal vaporizers, or mods. Some brand examples include
NJOY, Blu, Vuse, MarkTen, Logic, Vapin Plus, eGo, and Halo.
Have
you ever been curious about using an e-cigarette?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Have
you ever
used
an e-cigarette, even once or twice?
Yes
No
|
|
|
|
How
old were you when you first
tried using
an e-cigarette, even once or twice?
I
have never used 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
|
In
total, on how many days have you used e-cigarettes 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
|
During
the past
30 days,
on how many days did you use 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
|
|
During
the past 30 days, where did you get or buy the e-cigarettes that
you have used? (Select
one or more)
I
have never tried an e-cigarette in the past 30 days
A
gas station or convenience store
A
grocery store
A
drugstore
A
mall or shopping center kiosk/stand
On
the Internet
A
vape shop or other store that only sells e-cigarettes
Some
other place not listed here
From
a family member
From
a friend
From
some other person that is not a family member or a friend
|
What
are the reasons you have used e-cigarettes? (Select
one or more)
I
have never tried an e-cigarette
Friend
or family member used them
To
try to quit using other tobacco products, such as cigarettes
They
cost less than other tobacco products, such as cigarettes
They
are easier to get 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 marijuana, marijuana concentrates, marijuana waxes,
THC, or hash oils in an e-cigarette?
A.
I have never used an electronic product
B.
Yes
C.
No
|
Do
you think that you will try an e-cigarette soon?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Do
you think you will use an
e-cigarette in
the next year?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
If
one of your best friends were to offer you an e-cigarette, would
you use it?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
The
next eight questions are about smoking tobacco in a hookah, which
is a type of waterpipe. Shisha (or hookah tobacco) is smoked in a
hookah.
Have
you ever been curious about smoking tobacco in a hookah or
waterpipe?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Have
you ever
tried
smoking tobacco in a hookah or waterpipe, even one or two puffs?
Yes
No
|
|
|
|
How
old were you when you first
tried
smoking tobacco in a hookah or waterpipe, even one or two puffs?
I
have never smoked tobacco from a hookah or waterpipe
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 tobacco in a hookah or waterpipe?
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,
where did you smoke tobacco in a hookah or waterpipe?
(Select
one or more)
A. I
did not smoke tobacco in a hookah or waterpipe during the past 30
days
At
my house
At
a friend’s house
At
a family member’s house, other than my house
At
a hookah bar
At
a café or restaurant
Some
other place not listed here
|
Do
you think that you will try smoking tobacco in a hookah or
waterpipe soon?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
Do
you think you will smoke tobacco in a hookah or waterpipe in the
next year?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
If
one of your best friends were to offer you a hookah or waterpipe
with tobacco, would you try it?
Definitely
yes
Probably
yes
Probably
not
Definitely
not
|
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? (Select
one or more)
Roll-your-own
cigarettes
Pipes
filled with tobacco (not waterpipe)
Snus,
such as Camel, Marlboro, or General Snus
Dissolvable
tobacco products such as Ariva, Stonewall, Camel orbs, Camel
sticks, Marlboro sticks, or Camel strips
Bidis
(small brown cigarettes wrapped in a leaf)
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?
(Select
one or more)
Roll-your-own
cigarettes
Pipes
filled with tobacco (not waterpipe)
Snus,
such as Camel, Marlboro, or General Snus
Dissolvable
tobacco products such as Ariva, Stonewall, Camel orbs, Camel
sticks, Marlboro sticks, or Camel strips
Bidis
(small brown cigarettes wrapped in a leaf)
I
have not used any of the products listed above in the past 30
days
|
Now
thinking about your responses to questions from the last six
sections about past 30 day use of cigarettes, cigars, smokeless
tobacco, e-cigarettes, hookahs, pipes, snus, dissolvable tobacco,
and bidis.
During
the past
30 days,
on how many days did you use any tobacco product(s)?
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 two questions ask 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 any other flavors? (Select
one or more)
Cigars,
cigarillos, or little cigars
Chewing
tobacco, snuff, or dip
E-cigarettes
Tobacco
in a hookah or waterpipe
Pipe
filled with tobacco (not waterpipe)
Snus
Dissolvable
tobacco products
Bidis
(small brown cigarettes wrapped in a leaf)
I
did not use any of the flavored tobacco products listed above in
the past 30 days
|
What
flavors of tobacco products have you used in the past 30 days?
(Select
one or more)
Menthol
or mint
Clove
or spice
Fruit
Chocolate
Alcoholic
drink (such as wine, cognac, margarita or other cocktails)
Candy,
desserts or other sweets
Some
other flavor not listed here
I
did not use flavored tobacco products in the past 30 days
|
|
|
The
next two 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
|
The
next four questions are about quitting 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,
during the next 30 days
Yes,
during the next 6 months
Yes,
during the next 12 months
Yes,
but not during 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
|
Are
you seriously thinking about quitting cigarettes?
(Please
choose the first answer that fits)
I
do not smoke cigarettes
Yes,
during the next 30 days
Yes,
during the next 6 months
Yes,
during the next 12 months
Yes,
but not during 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 four questions are about getting tobacco products.
During
the past
30 days,
how did you get your own tobacco products? (Select
one or more)
I
did not get any 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? (Select
one or more)
I
did not buy tobacco products during the past 30 days
A
gas station or convenience store
A
grocery store
A
drugstore
A
vending machine
On
the Internet
Through
the mail
Some
other place not listed here
|
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
|
How
easy do you think it is for kids your age to buy tobacco products
in a store?
Easy
Somewhat
easy
Not
easy at all
|
The
next four questions are about different issues related to tobacco.
A
warning label tells you if a product is harmful to you and can be
either a picture or words.
During
the past 30 days, how often did you see a warning label on a
cigar, cigarillo, or little cigar package?
I
did not see a cigar, cigarillo, or little cigar package during
the past 30 days
Never
Rarely
Sometimes
Most
of the time
Always
|
During
the past 30 days, how often did you see a warning label on an
e-cigarette package?
I
did not see an e-cigarette package during the past 30 days
Never
Rarely
Sometimes
Most
of the time
Always
|
During
the past 30 days, how often did you see a warning label on a
package of hookah tobacco?
I
did not see a package of hookah tobacco during the past 30 days
Never
Rarely
Sometimes
Most
of the time
Always
|
In
the past 12 months, have you seen or heard The Real Cost, on
television, the internet, social media, or radio as part of ads
about tobacco?
Yes
No
Not
sure
|
The
next nine questions ask about your thoughts on 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 use
chewing tobacco, snuff, dip, or snus,
some days but not every day?
No
harm
Little
harm
Some
harm
A
lot of harm
|
Do
you believe that chewing
tobacco, snuff, dip, or snus
is (LESS ADDICTIVE, EQUALLY ADDICTIVE, or MORE ADDICTIVE) than
cigarettes?
Less
addictive
Equally
addictive
More
addictive
I
have never heard of chewing tobacco, snuff, dip, or snus
I
don’t know enough about these products
|
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
|
Do
you believe that e-cigarettes
are (LESS ADDICTIVE, EQUALLY ADDICTIVE, or MORE ADDICTIVE) than
cigarettes?
Less
addictive
Equally
addictive
More
addictive
I
have never heard of e-cigarettes
I
don’t know enough about these products
|
How
much do you think people harm themselves when they smoke
tobacco in a hookah or waterpipe
some days but not every day?
No
harm
Little
harm
Some
harm
A
lot of harm
|
Do
you believe that smoking
tobacco in a hookah or waterpipe
is (LESS ADDICTIVE, EQUALLY ADDICTIVE, or MORE ADDICTIVE) than
cigarettes?
Less
addictive
Equally
addictive
More
addictive
I
have never heard of smoking tobacco in a hookah or waterpipe
I
don’t know enough about these products
|
How
strongly do you agree with the statement ‘All tobacco
products are dangerous’?
Strongly
agree
Agree
Disagree
Strongly
disagree
|
Not
including the vapor from e-cigarettes, 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
|
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 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 ads or
promotions for 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 e-cigarette
advertisement.
Do not think about cigarettes or other tobacco products.
When
you are using the Internet, how often do you see ads or
promotions for 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 e-cigarettes?
I
do not 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 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
e-cigarettes?
I
do not watch TV
Never
Rarely
Sometimes
Most
of the time
Always
|
The
next three questions ask about you being around other people’s
tobacco smoke. Do not include exposure to vapor from 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 when 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
|
The
next question asks about being around other people’s
e-cigarette vapor. Do not include exposure to smoke from other
tobacco products.
During
the past
30 days,
on how many days did you breathe the vapor from someone who was
using an 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
last three questions ask about your experiences at home and at
school.
Does
anyone who lives with you now…? (Select
one or more)
Smoke
cigarettes
Smoke
cigars, cigarillos, or little cigars
Use
chewing tobacco, snuff, or dip
Use
e-cigarettes
Smoke
tobacco in 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
|
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
|