Form 0920-0621 National Youth Tobacco Survey (NYTS) 2019 Questionnaire

National Youth Tobacco Surveys (NYTS) 2015-2017

Attachment_I-1_2019_NYTS_NS_Change_Request

National Youth Tobacco Survey (NYTS) 2019 Questionnaire

OMB: 0920-0621

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Form Approved

OMB No. 0920-0621

Exp. Date: 04/30/2021




National Youth

Tobacco Survey (NYTS)

2019 Questionnaire

Shape2 Shape1

This survey is about tobacco. We would like to know about you and things you do that may affect your health. Your answers will be used for programs for young people like yourself.

The answers you give will be kept private.

NO one will know what you answered. Answer the questions based on what you really do and know.

Completing the survey is voluntary. Whether or not you answer the questions will not affect your grade in this class. Try to answer all the questions. If you do not want to answer a question, just leave it blank. There are no wrong answers.

The questions that ask about your background will only be used to describe the types of students completing this survey. The information will not be used to find out your name. No names will ever be reported.

Please read every question. Try to answer all the questions. Select the squares next to the response you choose. When you are finished, follow the instructions of the person giving you the survey.

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including 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: CDC Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30329, ATTN: PRA (0920-0621).























Thank You Very Much For Your Help.




INSTRUCT_1: The first five questions ask some background information about you.



  1. How old are you?

  1. 9 years old

  2. 10 years old

  3. 11 years old

  4. 12 years old

  5. 13 years old

  6. 14 years old

  7. 15 years old

  8. 16 years old

  9. 17 years old

  10. 18 years old

  11. 19 years old or older



  1. What is your sex?

  1. Male

  2. Female



  1. What grade are you in?

  1. 6th

  2. 7th

  3. 8th

  4. 9th

  5. 10th

  6. 11th

  7. 12th

  8. Ungraded or other grade



  1. Are you Hispanic, Latino, Latina, or of Spanish origin? (Select one or more)

  1. No, not of Hispanic, Latino, Latina, or Spanish origin [EXCLUSIVE]

  2. Yes, Mexican, Mexican American, Chicano, or Chicana

  3. Yes, Puerto Rican

  4. Yes, Cuban

  5. Yes, Another Hispanic, Latino, Latina, or Spanish origin



  1. What race or races do you consider yourself to be? (Select one or more)

  1. American Indian or Alaska Native

  2. Asian

  3. Black or African American

  4. Native Hawaiian or Other Pacific Islander

  5. White



INSTRUCT_2: The next seven sections of questions ask about your use of particular kinds of tobacco products, such as cigarettes, cigars, smokeless tobacco, electronic cigarettes, hookahs, roll-your own-cigarettes, pipes, snus, dissolvable tobacco, bidis, and heated tobacco products.



INSTRUCT_2a: The next several questions are about smoking cigarettes (ones that have to be lit and burned).



  1. Have you ever tried cigarette smoking, even one or two puffs?

  1. Yes

  2. No [SKIP TO QN14]



  1. How old were you when you first tried cigarette smoking, even one or two puffs?

  1. 8 years old or younger

  2. 9 years old

  3. 10 years old

  4. 11 years old

  5. 12 years old

  6. 13 years old

  7. 14 years old

  8. 15 years old

  9. 16 years old

  10. 17 years old

  11. 18 years old

  12. 19 years old or older



  1. About how many cigarettes have you smoked in your entire life?

  1. 1 or more puffs but never a whole cigarette

  2. 1 cigarette

  3. 2 to 5 cigarettes

  4. 6 to 15 cigarettes (about 1/2 a pack total)

  5. 16 to 25 cigarettes (about 1 pack total)

  6. 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)

  7. 100 or more cigarettes (5 or more packs)



  1. When was the last time you smoked a cigarette, even one or two puffs? (Please choose the first answer that fits)

  1. Earlier today

  2. Not today but sometime during the past 7 days

  3. Not during the past 7 days but sometime during the past 30 days

  4. Not during the past 30 days but sometime during the past 6 months

  5. Not during the past 6 months but sometime during the past year

  6. 1 to 4 years ago

  7. 5 or more years ago


IF QN9 EQ (1-3 [A-C]) [CONTINUE TO QN10]

IF QN9 EQ (4-7 [D-G]) [SKIP TO INSTRUCT_3]



  1. During the past 30 days, on how many days did you smoke cigarettes?


Specify: |__|__| (Range: 1 – 30)


[PROGRAMMING: RANGE (1 – 30) ALLOWED]



  1. During the past 30 days, on the days you smoked, about how many cigarettes did you smoke per day? A pack usually has 20 cigarettes in it.

  1. Less than 1 cigarette per day

  2. 1 cigarette per day

  3. 2 to 5 cigarettes per day

  4. 6 to 10 cigarettes per day

  5. 11 to 20 cigarettes per day

  6. More than 20 cigarettes per day



  1. During the past 30 days, what brand of cigarettes did you usually smoke? (Choose only one answer)

  1. I did not smoke a usual brand

  2. American Spirit

  3. Camel

  4. GPC, Basic, or Doral

  5. Kool

  6. Marlboro

  7. Newport

  8. L&M

  9. Pall Mall

  10. Winston

  11. Some other brand not listed here (Please specify: _____________________)

  12. Not sure



  1. Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?

  1. Yes

  2. No

  3. Not sure


  • [ALL RESPONSES SKIP TO INSTRUCT_3]



  1. Have you ever been curious about smoking a cigarette?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think that you will try a cigarette soon?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think you will smoke a cigarette in the next year?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. If one of your best friends were to offer you a cigarette, would you smoke it?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



INSTRUCT_3: The next several questions are about the use of cigars, cigarillos, or little cigars such Swisher Sweets, Black and Mild, Garcia y Vega, Cheyenne, White Owl, or Dutch Masters.



  1. Have you ever tried smoking cigars, cigarillos, or little cigars, such as Swisher Sweets, Black and Mild, Garcia y Vega, Cheyenne, White Owl, or Dutch Masters, even one or two puffs?

  1. Yes

  2. No [SKIP TO QN23]



  1. How old were you when you first tried smoking a cigar, cigarillo, or little cigar, even one or two puffs?

  1. 8 years old or younger

  2. 9 years old

  3. 10 years old

  4. 11 years old

  5. 12 years old

  6. 13 years old

  7. 14 years old

  8. 15 years old

  9. 16 years old

  10. 17 years old

  11. 18 years old

  12. 19 years old or older



  1. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?


Specify: |__|__| (Range 0 – 30)


[PROGRAMMING: RANGE (0 – 30) ALLOWED]


IF RESPONSE EQ (0) SKIP TO INSTRUCT_4.

ELSE IF RESPONSE EQ (1-30) CONTINUE TO QN 21.



  1. During the past 30 days, on the days that you smoked, about how many cigars, cigarillos, or little cigars did you smoke per day?

  1. Less than 1 cigar, cigarillo, or little cigar per day

  2. 1 per day

  3. 2 to 5 per day

  4. 6 to 10 per day

  5. 11 to 20 per day

  6. More than 20 per day


  1. During the past 30 days, which of the following types of cigars have you smoked? (Select one or more)

  1. Regular cigars

  2. Cigarillos

  3. Little Cigars

  4. Don’t Know [EXCLUSIVE]


  • [ALL RESPONSES SKIP TO INSTRUCT_4]



  1. Have you ever been curious about smoking a cigar, cigarillo, or little cigar?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think you will try a cigar, cigarillo, or little cigar soon?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think you will smoke a cigar, cigarillo, or little cigar in the next year?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. If one of your best friends were to offer you a cigar, cigarillo, or little cigar, would you smoke it?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



INSTRUCT_4: The next several 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.



  1. Have you ever used chewing tobacco, snuff, or dip, such as Copenhagen, Grizzly, Skoal, or Longhorn, even just a small amount?

  1. Yes

  2. No [SKIP TO QN30]



  1. How old were you when you used chewing tobacco, snuff, or dip for the first time?

  1. 8 years old or younger

  2. 9 years old

  3. 10 years old

  4. 11 years old

  5. 12 years old

  6. 13 years old

  7. 14 years old

  8. 15 years old

  9. 16 years old

  10. 17 years old

  11. 18 years old

  12. 19 years old or older



  1. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?


Specify: |__|__| (Range 0 – 30)


[PROGRAMMING: RANGE (0 – 30) ALLOWED]


  • [ALL RESPONSES SKIP TO INSTRUCT_5]



  1. Have you ever been curious about using chewing tobacco, snuff, or dip?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think you will try chewing tobacco, snuff, or dip, soon?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think you will use chewing tobacco, snuff, or dip in the next year?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. If one of your best friends were to offer you chewing tobacco, snuff, or dip, would you use it?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



INSTRUCT_5: The next several questions are about electronic cigarettes or e-cigarettes. Some brand examples include JUUL, Vuse, MarkTen, and blu.


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, e-hookahs, vapes, or mods.



  1. Have you ever used an e-cigarette, even once or twice?

  1. Yes

  2. No [SKIP TO QN43]



  1. How old were you when you first tried using an e-cigarette, even once or twice?

  1. 8 years old or younger

  2. 9 years old

  3. 10 years old

  4. 11 years old

  5. 12 years old

  6. 13 years old

  7. 14 years old

  8. 15 years old

  9. 16 years old

  10. 17 years old

  11. 18 years old

  12. 19 years old or older



  1. In total, on how many days have you used e-cigarettes in your entire life?

  1. 1 day

  2. 2 to 10 days

  3. 11 to 20 days

  4. 21 to 50 days

  5. 51 to 100 days

  6. Over 100 days



  1. When was the last time you used an e-cigarette, even one or two times? (Please choose the first answer that fits)

  1. Earlier today

  2. Not today, but sometime during the past 7 days

  3. Not during the past 7 days, but sometime during the past 30 days

  4. Not during the past 30 days, but sometime during the past 6 months

  5. Not during the past 6 months, but sometime during the past year

  6. 1 to 4 years ago

  7. 5 or more years ago


IF QN37 EQ (1-3 [A-C]) [CONTINUE TO QN38]

IF QN37 EQ (4-7 [D-G]) [SKIP TO QN42]


  1. During the past 30 days, on how many days did you use e-cigarettes?


Specify: |__|__| (Range 1 – 30)


[PROGRAMMING: RANGE (1 – 30) ALLOWED]



  1. Which of the following best describes the type of e-cigarette you have used in the past 30 days? If you have used more than one type, please think about the one you use most often.

  1. A disposable e-cigarette

  2. An e-cigarette that uses pre-filled pods or cartridges (e.g. JUUL)

  3. An e-cigarette with a tank that you refill with liquids

  4. A mod system (a mod system is customized by the user with their own combination of batteries, atomizers, etc.)

  5. I don’t know the type



  1. During the past 30 days, what brand of e-cigarettes did you usually use?

  1. I did not use a usual brand

  2. Blu

  3. JUUL

  4. Logic

  5. MarkTen

  6. NJOY

  7. Vuse

  8. Some other brand not listed here (specify): ______________________________



  1. During the past 30 days, where did you get or buy the e-cigarettes that you have used? (Select one or more)

  1. A gas station or convenience store

  2. A grocery store

  3. A drugstore

  4. A mall or shopping center kiosk/stand

  5. On the Internet

  6. A vape shop or other store that only sells e-cigarettes

  7. Some other place not listed here

  8. From a family member

  9. From a friend

  10. From some other person that is not a family member or a friend



  1. What are the reasons you have used e-cigarettes? (Select one or more)

  1. Friend or family member used them

  2. To try to quit using other tobacco products, such as cigarettes

  3. They cost less than other tobacco products, such as cigarettes

  4. They are easier to get than other tobacco products, such as cigarettes

  5. I’ve seen people on TV, online, or in movies use them

  6. They are less harmful than other forms of tobacco, such as cigarettes

  7. They are available in flavors, such as mint, candy, fruit, or chocolate

  8. I can use them unnoticed at home or at school

  9. I was peer pressured into using them

  10. I can use them to do tricks

  11. I was curious about them

  12. I used them for some other reason (specify: _____________________)


ALL RESPONSES SKIP TO INSTRUCT_6.



  1. Have you ever been curious about using an e-cigarette?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think that you will try an e-cigarette soon?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think you will use an e-cigarette in the next year?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. If one of your best friends were to offer you an e-cigarette, would you use it?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



INSTRUCT_6: The next several questions are about smoking tobacco in a hookah, which is a type of waterpipe. Shisha (or hookah tobacco) is smoked in a hookah.



  1. Have you ever tried smoking tobacco in a hookah or waterpipe, even one or two puffs?

  1. Yes

  2. No [SKIP TO QN51]



  1. How old were you when you first tried smoking tobacco in a hookah or waterpipe, even one or two puffs?

  1. 8 years old or younger

  2. 9 years old

  3. 10 years old

  4. 11 years old

  5. 12 years old

  6. 13 years old

  7. 14 years old

  8. 15 years old

  9. 16 years old

  10. 17 years old

  11. 18 years old

  12. 19 years old or older




  1. During the past 30 days, on how many days did you smoke tobacco in a hookah or waterpipe?


Specify: |__|__| (Range 0 – 30)


[PROGRAMMING: RANGE (0 – 30) ALLOWED]


IF RESPONSE EQ (0) SKIP TO INSTRUCT_7.

ELSE IF RESPONSE EQ (1-30) CONTINUE TO QN 50.


  1. During the past 30 days, where did you smoke tobacco in a hookah or waterpipe? (Select one or more)

  1. At my house

  2. At a friend’s house

  3. At a family member’s house, other than my house

  4. At a hookah bar

  5. At a café or restaurant

  6. Some other place not listed here


  • ALL RESPONSES SKIP TO INSTRUCT_7



  1. Have you ever been curious about smoking tobacco in a hookah or waterpipe?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think that you will try smoking tobacco in a hookah or waterpipe soon?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. Do you think you will smoke tobacco in a hookah or waterpipe in the next year?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



  1. If one of your best friends were to offer you a hookah or waterpipe with tobacco, would you try it?

  1. Definitely yes

  2. Probably yes

  3. Probably not

  4. Definitely not



INSTRUCT_7: The next section is about the use of other tobacco products, not described in the previous sections.



  1. Which of the following tobacco products have you ever tried, even just one time? (Select one or more)

  1. Roll-your-own cigarettes

  2. Pipes filled with tobacco (not hookah or waterpipe)

  3. Snus, such as Camel, Marlboro, or General Snus

  4. Dissolvable tobacco products such as Ariva, Stonewall, Camel orbs, Camel sticks, Marlboro sticks, or Camel strips

  5. Bidis (small brown cigarettes wrapped in a leaf)

  6. I have never tried any of the products listed above [EXCLUSIVE] [SKIP TO INSTRUCT_8]



  1. In the past 30 days, which of the following products have you used on at least one day? (Select one or more)

  1. Roll-your-own cigarettes

  2. Pipes filled with tobacco (not hookah or waterpipe)

  3. Snus, such as Camel, Marlboro, or General Snus

  4. Dissolvable tobacco products such as Ariva, Stonewall, Camel orbs, Camel sticks, Marlboro sticks, or Camel strips

  5. Bidis (small brown cigarettes wrapped in a leaf)

  6. I have not used any of the products listed above in the past 30 days [EXCLUSIVE]



INSTRUCT_8: The next section is about “heated tobacco products”. Some people refer to these products as “heat-not-burn” tobacco products. “Heated tobacco products” heat tobacco sticks or capsules to produce a vapor. They are different from e-cigarettes, which heat a liquid to produce a vapor. Some brands of “heated tobacco products” include iQOS, glo, and Eclipse.



  1. Before today, have you heard of “heated tobacco products”?

  1. Yes

  2. No

  3. Don’t know/Not Sure


IF QN57 EQ (1 [A]) [CONTINUE TO QN58]

IF QN57 EQ (2-3 [B-C]) [SKIP TO INSTRUCT_9a]



  1. Have you ever tried a “heated tobacco product”, even just one time?

  1. Yes

  2. No

  3. Don’t Know/Not Sure


IF QN58 EQ (1 [A]) [CONTINUE TO QN59]

IF QN58 EQ (2-3 [B-C]) [SKIP TO INSTRUCT_9a]



  1. During the past 30 days, on how many days did you use a heated tobacco product?


Specify: |__|__| (Range 0 – 30)


[PROGRAMMING: RANGE (0 – 30) ALLOWED]


ALL RESPONSES CONTINUE TO INSTRUCT_9a


INSTRUCT_9a: (programming, only)


IF “never tobacco product user” SKIP TO INSTRUCT_13a. (all tobacco products)

IF [(QN6 EQ (2) AND QN18 EQ (2) AND QN27 EQ (2) AND QN34 EQ (2) AND QN47 EQ (2) AND QN55F EQ (1) AND [((QN57 EQ (2-3)) OR (QN57 EQ (1) AND QN58 EQ (2-3))]] SKIP TO INSTRUCT_13a]


IF “current tobacco product user” CONTINUTE TO INSTRUCT_9. (of at least one product)

IF [(QN6 EQ (1) AND QN9 EQ (1-3)) OR (QN18 EQ (1) AND QN20 EQ (1-30)) OR (QN27 EQ (1) AND QN29 EQ (1-30)) OR (QN34 EQ (1) AND QN37 EQ (1-3)) OR (QN47 EQ (1) AND QN49 EQ (1-30)) OR (QN55A EQ (1) AND QN56A EQ (1)) OR (QN55B EQ (1) AND QN56B EQ (1)) OR (QN55C EQ (1) AND QN56C EQ (1)) OR (QN55D EQ (1) AND QN56D EQ (1)) OR (QN55E EQ (1) AND QN56E EQ (1)) OR (QN58 EQ (1) AND QN59 EQ (1-30))] CONTINUE TO INSTRUCT_9


IF “former tobacco product user” SKIP TO INSTRUCT_11. (of at least one product)

IF [(QN6 EQ (1) AND QN9 EQ (4-7)) OR (QN18 EQ (1) AND QN20 EQ (0)) OR (QN27 EQ (1) AND QN29 EQ (0)) OR (QN34 EQ (1) AND QN37 EQ (4-7)) OR (QN47 EQ (1) AND QN49 EQ (0)) OR (QN55A EQ (1) AND QN56F EQ (1)) OR (QN55B EQ (1) AND QN56F EQ (1)) OR (QN55C EQ (1) AND QN56F EQ (1)) OR (QN55D EQ (1) AND QN56F EQ (1)) OR (QN55E EQ (1) AND QN56F EQ (1)) OR (QN58 EQ (1) AND QN59 EQ (0))] SKIP TO INSTRUCT_11



INSTRUCT_9: Now think about your responses to the questions about past 30 day use of cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, roll-your-own cigarettes, pipes, snus, dissolvable tobacco, bidis, and heated tobacco products.



  1. During the past 30 days, on how many days did you use any tobacco product(s)?

Specify: |__|__| (Range 0 – 30)


[PROGRAMMING: RANGE (0 – 30) ALLOWED]


  • ALL RESPONSES CONTINUE TO INSTRUCT_10


INSTRUCT_10: The next few questions ask about flavors in tobacco products.



  1. 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)

  1. Cigars, cigarillos, or little cigars

  2. Chewing tobacco, snuff, or dip

  3. E-cigarettes

  4. Tobacco in a hookah or waterpipe

  5. Pipe filled with tobacco (not waterpipe)

  6. Snus

  7. Dissolvable tobacco products

  8. Bidis

  9. Roll-your-own cigarettes

  10. Heated tobacco products

  11. I did not use any flavored tobacco products in the past 30 days [EXCLUSIVE]


IF QN61 EQ (11 [K]) THEN SKIP TO INSTRUCT_11

IF ((QN61 EQ (1 [A]) OR (QN61 EQ (2 [B])) OR (QN61 EQ (3 [C])) OR QN61 EQ (4 [D])) OR QN61 EQ (5 [E])) OR QN61 EQ (6 [F])) OR QN61 EQ (7[G])) OR QN61 EQ (8 [H])) OR QN61 EQ (9 [I])) OR QN61 EQ (10 [J]))) THEN CONTINUE TO QN62.



  1. What flavors of tobacco products have you used in the past 30 days? (Select one or more)

  1. Menthol or mint

  2. Clove or spice

  3. Fruit

  4. Chocolate

  5. Alcoholic drink (such as wine, cognac, margarita, or other cocktails)

  6. Candy, desserts or other sweets

  7. Some other flavor not listed here (Specify: _____________________________)


ALL RESPONSES CONTINUE TO INSTRUCT_11



INSTRUCT_11: The next two questions are about issues related to urges to use tobacco products.



  1. 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?

  1. Yes

  2. No



  1. How soon after you wake up do you want to use a tobacco product?

  1. I do not want to use tobacco products

  2. Within 5 minutes

  3. From 6 to 30 minutes

  4. From more than 30 minutes to 1 hour

  5. After more than 1 hour but less than 24 hours

  6. I rarely want to use tobacco products


IF current tobacco product user (any product), CONTINUE TO INSTRUCT_12.

IF [((QN6 EQ (1)) and (QN9 EQ (4-5))] SKIP TO INSTRUCT_12a.

ELSE SKIP TO INSTRUCT_13a.




INSTRUCT_12: The next few questions are about quitting tobacco products.



  1. Are you seriously thinking about quitting the use of all tobacco products? (Please choose the first answer that fits)

  1. Yes, during the next 30 days

  2. Yes, during the next 6 months

  3. Yes, during the next 12 months

  4. Yes, but not during the next 12 months

  5. No, I am not thinking about quitting the use of all tobacco products



  1. 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?

  1. I did not try to quit all tobacco products during the past 12 months

  2. 1 time

  3. 2 times

  4. 3 to 5 times

  5. 6 to 9 times

  6. 10 or more times


[IF [((QN6 EQ (1)) AND (QN9 EQ (1-3))] CONTINUE TO QN68.]

[ELSE SKIP TO INSTRUCT_13]



  1. Are you seriously thinking about quitting cigarettes? (Please choose the first answer that fits)

  1. Yes, during the next 30 days

  2. Yes, during the next 6 months

  3. Yes, during the next 12 months

  4. Yes, but not during the next 12 months

  5. No, I am not thinking about quitting cigarettes


[ALL RESPONSES SKIP TO QN68]



INSTRUCT_12a: The next question is about quitting cigarettes.



  1. 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?

  1. I did not try to quit during the past 12 months

  2. 1 time

  3. 2 times

  4. 3 to 5 times

  5. 6 to 9 times

  6. 10 or more times


[IF [((QN6 EQ (1)) AND (QN9 EQ (1-3))] CONTINUE TO INSTRUCT_13]

[IF [((QN6 EQ (1)) and (QN9 EQ (4-5))] SKIP TO INSTRUCT_13a]



INSTRUCT_13: The next few questions are about getting tobacco products.



  1. During the past 30 days, how did you get your own tobacco products? (Select one or more)

  1. I bought them myself

  2. I had someone else buy them for me

  3. I asked someone to give me some

  4. Someone offered them to me

  5. I bought them from another person

  6. I took them from a store or another person

  7. I got them in some other way (specify: ______________________________________)



  1. During the past 30 days, where did you buy your own tobacco products? (Select one or more)

  1. I did not buy tobacco products during the past 30 days

  2. A gas station or convenience store

  3. A grocery store

  4. A drugstore

  5. A vending machine

  6. On the Internet

  7. Through the mail

  8. A vape shop or tobacco shop

  9. Some other place not listed here (specify): ___________________________________



  1. During the past 30 days, did anyone refuse to sell you any tobacco products because of your age?

  1. I did not try to buy any tobacco products during the past 30 days

  2. Yes

  3. No


[ALL RESPONSES SKIP TO QN72]



INSTRUCT_13a: The next two questions ask your thoughts about getting tobacco products.



  1. How easy do you think it is for people your age to buy tobacco products in a store?

  1. Easy

  2. Somewhat easy

  3. Not easy at all



  1. How easy do you think it is for people your age to buy tobacco products online?

  1. Easy

  2. Somewhat easy

  3. Not easy at all



INSTRUCT_14: 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.



  1. During the past 30 days, how often did you see a warning label on a cigar, cigarillo, or little cigar package?

  1. I did not see a cigar, cigarillo, or little cigar package during the past 30 days

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. During the past 30 days, how often did you see a warning label on an e-cigarette package?

  1. I did not see an e-cigarette package during the past 30 days

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. During the past 30 days, how often did you see a warning label on a package of hookah tobacco?

  1. I did not see a package of hookah tobacco during the past 30 days

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. 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?

  1. Yes

  2. No

  3. Not sure



INSTRUCT_15: The next 11 questions ask about your thoughts on tobacco products.



  1. How much do you think people harm themselves when they smoke cigarettes some days but not every day?

  1. No harm

  2. Little harm

  3. Some harm

  4. A lot of harm



  1. How much do you think people harm themselves when they use chewing tobacco, snuff, dip, snus, or dissolvable tobacco products, some days but not every day?

    1. No harm

    2. Little harm

    3. Some harm

    4. A lot of harm



  1. Do you believe that chewing tobacco, snuff, dip, snus, or dissolvable tobacco products are (LESS ADDICTIVE, EQUALLY ADDICTIVE, or MORE ADDICTIVE) than cigarettes?

  1. Less addictive

  2. Equally addictive

  3. More addictive

  4. I have never heard of chewing tobacco, snuff, dip, snus, or dissolvable tobacco products

  5. I don’t know enough about these products



  1. How much do you think people harm themselves when they use e-cigarettes some days but not every day?

  1. No harm

  2. Little harm

  3. Some harm

  4. A lot of harm



  1. Do you believe that e-cigarettes are (LESS ADDICTIVE, EQUALLY ADDICTIVE, or MORE ADDICTIVE) than cigarettes?

  1. Less addictive

  2. Equally addictive

  3. More addictive

  4. I have never heard of e-cigarettes

  5. I don’t know enough about these products



  1. How much do you think people harm themselves when they smoke tobacco in a hookah or waterpipe some days but not every day?

  1. No harm

  2. Little harm

  3. Some harm

  4. A lot of harm



  1. Do you believe that smoking tobacco in a hookah or waterpipe is (LESS ADDICTIVE, EQUALLY ADDICTIVE, or MORE ADDICTIVE) than cigarettes?

  1. Less addictive

  2. Equally addictive

  3. More addictive

  4. I have never heard of smoking tobacco in a hookah or waterpipe

  5. I don’t know enough about these products



  1. Compared to a typical cigarette, would you think that a cigarette advertised as low nicotine would be…

  1. Much less harmful

  2. Slightly less harmful

  3. Equally harmful

  4. Slightly more harmful

  5. Much more harmful



  1. How strongly do you agree with the statement ‘All tobacco products are dangerous’?

  1. Strongly agree

  2. Agree

  3. Disagree

  4. Strongly disagree



  1. Not including the vapor from e-cigarettes, do you think that breathing smoke from other people’s cigarettes or other tobacco products causes…

  1. No harm

  2. Little harm

  3. Some harm

  4. A lot of harm



  1. Do you think that breathing the vapor from other people’s e-cigarettes causes…

  1. No harm

  2. Little harm

  3. Some harm

  4. A lot of harm



INSTRUCT_16: The next four questions ask about issues related to advertisements for tobacco products such as cigarettes, cigars, smokeless tobacco, hookahs, roll-your-own cigarettes, pipes, snus, dissolvable tobacco, and bidis. Do not think of electronic cigarettes.



  1. When you are using the Internet, how often do you see ads or promotions for cigarettes or other tobacco products?

  1. I do not use the Internet

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. When you read newspapers or magazines, how often do you see ads or promotions for cigarettes or other tobacco products?

  1. I do not read newspapers or magazines

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. 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?

  1. I never go to a convenience store, supermarket, or gas station

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. When you watch TV or streaming services (such as Netflix, Hulu, or Amazon Prime), or go to the movies, how often do you see ads or promotions for cigarettes or other tobacco products?

  1. I do not watch TV or streaming services, or go to the movies

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



INSTRUCT_17: The next four questions ask about issues related to e-cigarette advertisement. Do not think about cigarettes or other tobacco products.



  1. When you are using the Internet, how often do you see ads or promotions for e-cigarettes?

  1. I do not use the Internet

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. When you read newspapers or magazines, how often do you see ads or promotions for e-cigarettes?

  1. I do not read newspapers or magazines

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. When you go to a convenience store, supermarket, or gas station, how often do you see ads or promotions for e-cigarettes?

  1. I never go to a convenience store, supermarket, or gas station

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



  1. When you watch TV or streaming services (such as Netflix, Hulu, or Amazon Prime), or go to the movies, how often do you see ads or promotions for e-cigarettes?

  1. I do not watch TV or streaming services, or go to the movies

  2. Never

  3. Rarely

  4. Sometimes

  5. Most of the time

  6. Always



INSTRUCT_18: The next three questions ask about you being around other people’s tobacco smoke. Do not include exposure to vapor from e-cigarettes.



  1. During the past 7 days, on how many days did someone smoke tobacco products in your home while you were there?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days

  7. 6 days

  8. 7 days



  1. During the past 7 days, on how many days did you ride in a vehicle when someone was smoking a tobacco product?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days

  7. 6 days

  8. 7 days



  1. During the past 30 days, on how many days did you smell 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, stadiuns, and parks.

  1. 0 days

  2. 1 or 2 days

  3. 3 to 5 days

  4. 6 to 9 days

  5. 10 to 19 days

  6. 20 to 29 days

  7. All 30 days



INSTRUCT_19: The next two questions asks about being around other people’s e-cigarette vapor. Do not include exposure to smoke from other tobacco products.



  1. During the past 30 days, on how many days did you smell 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.


  1. 0 days

  2. 1 or 2 days

  3. 3 to 5 days

  4. 6 to 9 days

  5. 10 to 19 days

  6. 20 to 29 days

  7. All 30 days




  1. Have you ever seen anyone using an e-cigarette, such as JUUL, Vuse, MarkTen, or blu in any locations in or around your school? (Select one or more)

  1. No [EXCLUSIVE]

  2. Yes, inside a school bathroom or locker room

  3. Yes, inside a classroom

  4. Yes, inside some other area of the school (hallway, cafeteria)

  5. Yes, outside of the school, such as in the parking lot, sidewalk, or other school grounds

  6. Yes, somewhere else not listed here



INSTRUCT_20: The last three questions ask about your experiences at home and at school.



  1. Does anyone who lives with you now…? (Select one or more)

  1. Smoke cigarettes

  2. Smoke cigars, cigarillos, or little cigars

  3. Use chewing tobacco, snuff, or dip

  4. Use e-cigarettes

  5. Smoke tobacco in a hookah or waterpipe

  6. Smoke pipes filled with tobacco (not hookah or waterpipes)

  7. Use snus

  8. Use dissolvable tobacco products

  9. Smoke bidis (small brown cigarettes wrapped in a leaf)

  10. Use heated tobacco products

  11. No one who lives with me now uses any form of tobacco [EXCLUSIVE]



  1. Do you speak a language other than English at home?

  1. Yes

  2. No



  1. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

  1. Yes

  2. No



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AuthorGentzke, Andrea (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2021-01-20

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