Tob

2

This survey i

things you do thprograms for you

DO NOT write 

kept private.

NO one will k

you really do and 

Completing th

questions will nquestions. If you are no wrong ans

The question

describe the typenot be used to fin

Please read e

circles in the binstructions of thPublic reporting burden including time for reviewneeded, and completing and a person is not requcontrol number. Send cinformation

including su

cc

SCHOOL ID

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

DO NOT WRITE IN THIS BOX

OFFICE USE ONLY

PRINT ONLY
DIRECTIONS

• Use a #2 pencil only.• Make dark marks.• Fill in a response like this:• If you change your answer, erase your old

answer completely.

AB D

 4. Are you Hispanic, Latino/a, or Spanish origin

(One or more categories may be selected)?

The first five questions ask for some backgroundinformation about you.

JanuaryFebruaryMarchAprilMayJune

Month Day

TODAY'S DATE

0123

0123456789

 1. How old are you?

ABCD

E

F

9 years old10 years old11 years old12 years old13 years old14 years old

G

H

I

J

K

15 years old16 years old17 years old18 years old19 years old or older

A

 2. What is your sex?

Male

B Female

 3. What grade are you in?

ABCD

E

No, not of Hispanic, Latino, Latina, or Spanish originYes, Mexican, Mexican American, Chicano or ChicanaYes, Puerto RicanYes, CubanYes, Another Hispanic, Latino/a or Spanish origin

 5. What race or races do you consider yourself to be?

(You can CHOOSE ONE ANSWER or MORETHAN ONE ANSWER)

ABCD

E

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite

This section ask about if you'll try tobacco thatis smoked or put in your mouth.

Definitely yesProbably yesProbably notDefinitely not

ABCD

 6. At any time during the next 12 months do you think you

will use any form of tobacco?

 7. Do you think that you will try any form of tobacco soon?

Definitely yesProbably yesProbably notDefinitely not

ABCD

 8. If one of your best friends were to offer you any form

of tobacco, would you use it?

Definitely yesProbably yesProbably notDefinitely not

ABCD

The next six sections ask about your use ofdifferent kinds of tobacco products.

78. During this school year, we

classes about why you shou

A YesB No

79. During the past 30 days, to 

including yourself, smoked a property when he or she wa

A YesB No
13. How old were you when you 

even one or two puffs?

ABCD

E

F

G

I have never smoked cigtwo puffs8 years old or younger9 years old10 years old11 years old12 years old13 years old

H

I

J

K

L

M

14 years old15 years old16 years old17 years old18 years old19 years old or older

14. About how many cigarettes 

entire life?

I have never smoked cigpuffs1 or more puffs but neve1 cigarette2 to 5 cigarettes6 to 15 cigarettes (about 

ABCD

E

12. If one of your best friends w

would you smoke it?

AB

Definitely yesProbably yesProbably notDefinitely not

CD

10. Do you think you will smoke 

Definitely yesProbably yesProbably notDefinitely not

11. Do you think that you will try 

Definitely yesProbably yesProbably notDefinitely not

ABCDABCD

68. Out of every 10 students in your grade at school, how

many do you think smoke cigarettes?

012345678910

ABCD

E

F

G

H

I

J

K

Always be allowedBe allowed only at some times or in some placesNever be allowed

ABC

70. In your opinion, in their vehicles, people should...

Always allow smokingSometimes allow smokingNever allow smoking

ABC

71. Do you think that breathing smoke from other people's

cigarettes or other tobacco products causes...

No harmLittle harmSome harmA lot of harm

ABCD

69. In your opinion, inside your home, smoking tobacco

products should...

72. Do you believe any of the following are less harmful than

smoking cigarettes? (You can CHOOSE ONE ANSWERor MORE THAN ONE ANSWER)

Smoking tobacco from a hookah or waterpipeSmoking tobacco from a pipe other than a waterpipeSmoking Bidis (small brown cigarettes wrapped in aleaf)Smoking Clove cigarettes (kreteks)Smoking flavored cigars

little cigars and cigarillos (such

ABCD

E

The next seven questions are about your thoughtsabout tobacco.

73. Do you believe any of the following are less harmful than

smoking cigarettes? (You can CHOOSE ONE ANSWERor MORE THAN ONE ANSWER)

Using chewing tobacco, snuff, or dipUsing snus, such as Camel or Marlboro SnusUsing dissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, Marlboro sticks,or Camel stripsUsing electronic cigarettes, such as Ruyan or NJOYDo not knowI do not believe that any of the above products are lessharmful than cigarettes

74. Do you think smoking cigarettes makes young people look

cool or fit in?

75. Do you think young people who smoke cigarettes have

more friends?

ABCD

E

F

Definitely yesProbably yes

AB

Probably notDefinitely not

CD

Definitely yesProbably yes

AB

Probably notDefinitely not

CD

The last six questions are about your experiencesat home, in your community, and at school.

76. Would your parents or guardians strongly disapprove if you

used tobacco products?

ABCD

E

F

I don't use tobacco products, and my parents wouldstrongly disapprove if I didI don't use tobacco products, and my parents wouldnot strongly disapprove if I didI use tobacco products, and my parents stronglydisapproved when they first found outI use tobacco products, and my parents did notstrongly disapprove when they first found outI use tobacco products, but my parents don't know,and they would strongly disapprove if they knewI use tobacco products, but my parents don't know,and they would not strongly disapprove if they knew
20. During the past 30 days, how did you get your own

cigarettes? (You can CHOOSE ONE ANSWER orMORE THAN ONE ANSWER)

I did not get cigarettes during the past 30 daysI bought a pack of cigarettes myselfI had someone else buy a pack of cigarettes for meI asked someone to give me a cigaretteSomeone offered me a cigaretteI bought cigarettes from another personI took cigarettes from a store or another personI got cigarettes some other way

ABCD

E

F

G

H

22. During the past 30 days, did anyone refuse to sell you

cigarettes because of your age?

I did not try to buy cigarettes during the past 30 daysYesNo

ABC

The next five questions are about smoking cigars.

23. 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

21. During the past 30 days, where did you buy your own

cigarettes? (You can CHOOSE ONE ANSWER orMORE THAN ONE ANSWER)

ABCD

E

F

G

H

I did not buy cigarettes during the past 30 daysA gas station or convenience storeA grocery storeA drugstoreA vending machineOver the InternetThrough the mailSome other place not listed here

19. Menthol cigarettes are cigarettes that taste like mint.

During the past 30 days, were the cigarettes that youusually smoked menthol?

I did not smoke cigarettes during the past 30 daysYesNoNot sure

ABCD

26. During the past 30 days, how did you get your own

cigars, cigarillos, or little cigars? (You can CHOOSEONE ANSWER or MORE THAN ONE ANSWER)

I did not get cigars, cigarillos, or little cigars during thepast 30 daysI bought them myselfI had someone else buy them for meI asked someone to give me oneSomeone offered it to meI bought them from another personI took them from a store or another personI got them some other way

ABCD

E

F

G

H

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

smoke cigars, cigarillos, or little cigars?

0 days1 or 2 days3 to 5 days6 to 9 days

ABCD

10 to 19 days20 to 29 daysAll 30 days

E

F

G

I have never smoked cigars, cigarillos, or little cigars,not even one or two puffs8 years old or younger9 years old10 years old11 years old12 years old13 years old

ABCD

E

F

G

24. How old were you when you first tried smoking a cigar,

cigarillo, or little cigar, even one or two puffs?

14 years old15 years old16 years old17 years old18 years old19 years old or older

H

I

J

K

L

M

27. During the past 30 days, where did you buy your own

cigars, cigarillos, or little cigars? (You can CHOOSEONE ANSWER or MORE THAN ONE ANSWER)

I did not buy cigars, cigarillos, or little cigars duringthe past 30 days

A

0 days

The next five questions ask around other people's toba

59. During the past 7 days, on h

smoke tobacco products in yo

AB

0 days1 day6 days7 days

G

H

4 days5 days

E

F

2 days3 days

CD

60. During the past 7 days, on h

a vehicle where someone wa

AB

0 days1 day6 days7 days

G

H

4 days5 days

E

F

2 days3 days

CD

62. During the past 7 days, on 

the smoke from someone wproducts in the place where 

61. During the past 7 days, on 

the smoke from someone wproduct at your school, inclugrounds, and school parking 

AB

0 days1 day6 days7 days

G

H

4 days5 days

E

F

2 days3 days

CD

I do not have a jobI did not work during the 

ABC
The next five questions asmokeless tobacco. Pleausing snus when you ans

31. During the past 30 days, ho

chewing tobacco, snuff, or dONE ANSWER or MORE T

I did not get chewing tobpast 30 daysI bought it myselfI had someone else buy I asked someone to give 

ABCD

29. How old were you when you 

snuff, or dip for the first time

I have never used chewi8 years old or younger9 years old10 years old11 years old12 years old13 years old

ABCD

E

F

G

14 years old15 years old16 years old17 years old18 years old19 years old or older

H

I

J

K

L

M

30. During the past 30 days, on 

use chewing tobacco, snuff, 

0 days1 or 2 days3 to 5 days6 to 9 days

ABCD

10 to 19 days20 to 29 daysAll 30 days

E

F

G

28. Have you ever used chewin

as Redman, Levi Garrett, Bor Copenhagen, even just a 

A YesB No

I did not smoke cigarettes during the past 12 monthsI did not try to quit during the past 12 months1 time2 times3 to 5 times6 to 9 times

ABCD

E

F

54. During the past 12 months, how many times have you

stopped smoking cigarettes for one day or longerbecause you were trying to quit smoking cigarettesfor good?

The next six questions are about quitting tobaccoproducts.

53. Are you seriously thinking about quitting cigarettes?

(PLEASE CHOOSE THE FIRST ANSWER THAT FITS)

I do not smoke cigarettesYes, within the next 30 daysYes, within the next 6 monthsYes, within the next 12 monthsYes, but not within the next 12 monthsNo, I am not thinking about quitting cigarettes

ABCD

E

F

The next two questions are about visits to adoctor, dentist, nurse, or other healthprofessional.

51. Think about each time that you visited a doctor, dentist, or

nurse in the past 12 months. During any of these visitswere you asked if you used tobacco that is smoked or putin your mouth?

I did not see a doctor, dentist, or nurse duringthe past 12 monthsYesNo

ABC

52. During the past 12 months, did any doctor, dentist, or

nurse give you advice not to use tobacco that is smokedor put in your mouth?

I did not see a doctor, dentist, or nurse duringthe past 12 monthsYesNo

ABC

55. When you last tried to quit for good, how long did you

stay off cigarettes? (PLEASE CHOOSE THE FIRSTANSWER THAT FITS)

I have never smoked cigarettesI have never tried to quitLess than a day1 to 7 daysMore than 7 days but less than 30 daysMore than 30 days but less than 6 monthsMore than 6 months but less than 1 year1 year or more

ABCD

E

F

G

H

58. In the past 12 months, did you do any of the following to

help you quit using tobacco of any kind for good? (Youcan CHOOSE ONE ANSWER or MORE THAN ONEANSWER)

I did not use tobacco of any kind during the past 12monthsI did not try to quit during the past 12 monthsAttended a program in my schoolAttended a program in the communityCalled a telephone help line or telephone quit lineUsed nicotine gum

ABCD

E

F

57. During the past 12 months, how many times have you

stopped using all tobacco products for one day orlonger because you were trying to quit all tobaccoproducts for good?

I did not use tobacco products duringthe past 12 monthsI did not try to quit all tobacco productsduring the past 12 months1 time2 times3 to 5 times6 to 9 times10 or more times

ABCD

E

F

G

56. Are you seriously thinking about quitting the use of all

tobacco products? (PLEASE CHOOSE THE FIRST

ANSWER THAT FITS)

I do not use tobacco productsYes, within the next 30 daysYes, within the next 6 monthsYes, within the yearYes, but not within the yearNo, I am not thinking about quitting the use of alltobacco products

ABCD

E

F
The next three questions are about other formsof tobacco.

35. Which of the following tobacco products have you ever

heard of? (You can CHOOSE ONE ANSWER or MORETHAN ONE ANSWER)

Roll-your-own cigarettesFlavored cigarettes, such as Camel CrushBidis (small brown cigarettes wrapped in a leaf)Clove cigars (kreteks)Flavored little cigars (such as mint, clove, spice,alcohol (wine, cognac), candy, fruit, chocolate, orother sweets)Smoking tobacco from a hookah or a waterpipeSnus, such as Camel or Marlboro SnusDissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, or Camel stripsElectronic Cigarettes or E-cigarettes, such as Ruyanor NJOYSome other new tobacco products not listed hereI have never heard of any of the products listed aboveor any new tobacco product

ABCD

E

F

G

H

I

J

K

36. Which of the following tobacco products have you ever

tried, even just one time? (You can CHOOSE ONE

ANSWER or MORE THAN ONE ANSWER)

43. When you go to a convenie

gas station, how often do yocigarettes or other tobacco 

ABCD

E

F

I never go to a conveniegas stationNeverRarelySometimesMost of the timeAlways

42. During the past 30 days, did 

a tobacco company throughANSWER or MORE THAN 

The mailE-mailThe Internet

ABC

Social Networks (such aA text messageOn a cigarette pack or otI did not receive coupons 

D

E

F

G

37. In the past 30 days, which of the following products have

you used on at least one day? (You can CHOOSE ONE

ANSWER or MORE THAN ONE ANSWER)

Roll-your-own cigarettesFlavored cigarettes, such as Camel CrushBidis (small brown cigarettes wrapped in a leaf)Clove cigars (kreteks)Flavored little cigars (such as mint, clove, spice,alcohol (wine, cognac), candy, fruit, chocolate, orother sweets)Smoking tobacco from a hookah or a waterpipeSnus, such as Camel or Marlboro SnusDissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, or Camel stripsElectronic Cigarettes or E-cigarettes, such as Ruyanor NJOYSome other new tobacco products not listed hereI have not used any of the products listed above orany new tobacco product in the past 30 days

ABCD

E

F

G

H

I

J

K

Roll-your-own cigarettesFlavored cigarettes, such as Camel CrushBidis (small brown cigarettes wrapped in a leaf)Clove cigars (kreteks)Flavored little cigars (such as mint, clove, spice,alcohol (wine, cognac), candy, fruit, chocolate, orother sweets)Smoking tobacco from a hookah or a waterpipeSnus, such as Camel or Marlboro SnusDissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, or Camel stripsElectronic Cigarettes or E-cigarettes, such as Ruyanor NJOYSome other new tobacco products not listed hereI have never tried any of the products listed above orany new tobacco product

ABCD

E

F

G

H

I

J

K

I do not use the InternetNeverRarely

ABC

40. When you are using the Internet, how often do you see

ads or promotions for cigarettes or other tobacco products?

D

E

F

SometimesMost of the timeAlways

The next eleven questions ask about differentissues related to tobacco.

38. How easy would it be for you to get tobacco products

if you wanted some?

ABC

Very easySomewhat easyNot easy at all

39. Do you believe that tobacco companies try to get young

people under 18 to use tobacco products?

A YesB No

44. During the past 30 days, ho

or promotions for cigarettes were outdoors on a billboard outside a store?

45. When you watch TV or go to 

you see actors and actressetobacco products?

46. What is the name of your fa

(You can CHOOSE ONE AONE ANSWER)

American Spirit

A

I did not see an ad for ciproducts during the past NeverRarelySometimesMost of the timeAlways

ABCD

E

F

I do not watch TV or go tNeverRarelySometimesMost of the timeAlways

ABCD

E

F
The next three questions are about other formsof tobacco.

35. Which of the following tobacco products have you ever

heard of? (You can CHOOSE ONE ANSWER or MORETHAN ONE ANSWER)

Roll-your-own cigarettesFlavored cigarettes, such as Camel CrushBidis (small brown cigarettes wrapped in a leaf)Clove cigars (kreteks)Flavored little cigars (such as mint, clove, spice,alcohol (wine, cognac), candy, fruit, chocolate, orother sweets)Smoking tobacco from a hookah or a waterpipeSnus, such as Camel or Marlboro SnusDissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, or Camel stripsElectronic Cigarettes or E-cigarettes, such as Ruyanor NJOYSome other new tobacco products not listed hereI have never heard of any of the products listed aboveor any new tobacco product

ABCD

E

F

G

H

I

J

K

36. Which of the following tobacco products have you ever

tried, even just one time? (You can CHOOSE ONE

ANSWER or MORE THAN ONE ANSWER)

43. When you go to a convenie

gas station, how often do yocigarettes or other tobacco 

ABCD

E

F

I never go to a conveniegas stationNeverRarelySometimesMost of the timeAlways

42. During the past 30 days, did 

a tobacco company throughANSWER or MORE THAN 

The mailE-mailThe Internet

ABC

Social Networks (such aA text messageOn a cigarette pack or otI did not receive coupons 

D

E

F

G

37. In the past 30 days, which of the following products have

you used on at least one day? (You can CHOOSE ONE

ANSWER or MORE THAN ONE ANSWER)

Roll-your-own cigarettesFlavored cigarettes, such as Camel CrushBidis (small brown cigarettes wrapped in a leaf)Clove cigars (kreteks)Flavored little cigars (such as mint, clove, spice,alcohol (wine, cognac), candy, fruit, chocolate, orother sweets)Smoking tobacco from a hookah or a waterpipeSnus, such as Camel or Marlboro SnusDissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, or Camel stripsElectronic Cigarettes or E-cigarettes, such as Ruyanor NJOYSome other new tobacco products not listed hereI have not used any of the products listed above orany new tobacco product in the past 30 days

ABCD

E

F

G

H

I

J

K

Roll-your-own cigarettesFlavored cigarettes, such as Camel CrushBidis (small brown cigarettes wrapped in a leaf)Clove cigars (kreteks)Flavored little cigars (such as mint, clove, spice,alcohol (wine, cognac), candy, fruit, chocolate, orother sweets)Smoking tobacco from a hookah or a waterpipeSnus, such as Camel or Marlboro SnusDissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, or Camel stripsElectronic Cigarettes or E-cigarettes, such as Ruyanor NJOYSome other new tobacco products not listed hereI have never tried any of the products listed above orany new tobacco product

ABCD

E

F

G

H

I

J

K

I do not use the InternetNeverRarely

ABC

40. When you are using the Internet, how often do you see

ads or promotions for cigarettes or other tobacco products?

D

E

F

SometimesMost of the timeAlways

The next eleven questions ask about differentissues related to tobacco.

38. How easy would it be for you to get tobacco products

if you wanted some?

ABC

Very easySomewhat easyNot easy at all

39. Do you believe that tobacco companies try to get young

people under 18 to use tobacco products?

A YesB No

44. During the past 30 days, ho

or promotions for cigarettes were outdoors on a billboard outside a store?

45. When you watch TV or go to 

you see actors and actressetobacco products?

46. What is the name of your fa

(You can CHOOSE ONE AONE ANSWER)

American Spirit

A

I did not see an ad for ciproducts during the past NeverRarelySometimesMost of the timeAlways

ABCD

E

F

I do not watch TV or go tNeverRarelySometimesMost of the timeAlways

ABCD

E

F
The next five questions asmokeless tobacco. Pleausing snus when you ans

31. During the past 30 days, ho

chewing tobacco, snuff, or dONE ANSWER or MORE T

I did not get chewing tobpast 30 daysI bought it myselfI had someone else buy I asked someone to give 

ABCD

29. How old were you when you 

snuff, or dip for the first time

I have never used chewi8 years old or younger9 years old10 years old11 years old12 years old13 years old

ABCD

E

F

G

14 years old15 years old16 years old17 years old18 years old19 years old or older

H

I

J

K

L

M

30. During the past 30 days, on 

use chewing tobacco, snuff, 

0 days1 or 2 days3 to 5 days6 to 9 days

ABCD

10 to 19 days20 to 29 daysAll 30 days

E

F

G

28. Have you ever used chewin

as Redman, Levi Garrett, Bor Copenhagen, even just a 

A YesB No

I did not smoke cigarettes during the past 12 monthsI did not try to quit during the past 12 months1 time2 times3 to 5 times6 to 9 times

ABCD

E

F

54. During the past 12 months, how many times have you

stopped smoking cigarettes for one day or longerbecause you were trying to quit smoking cigarettesfor good?

The next six questions are about quitting tobaccoproducts.

53. Are you seriously thinking about quitting cigarettes?

(PLEASE CHOOSE THE FIRST ANSWER THAT FITS)

I do not smoke cigarettesYes, within the next 30 daysYes, within the next 6 monthsYes, within the next 12 monthsYes, but not within the next 12 monthsNo, I am not thinking about quitting cigarettes

ABCD

E

F

The next two questions are about visits to adoctor, dentist, nurse, or other healthprofessional.

51. Think about each time that you visited a doctor, dentist, or

nurse in the past 12 months. During any of these visitswere you asked if you used tobacco that is smoked or putin your mouth?

I did not see a doctor, dentist, or nurse duringthe past 12 monthsYesNo

ABC

52. During the past 12 months, did any doctor, dentist, or

nurse give you advice not to use tobacco that is smokedor put in your mouth?

I did not see a doctor, dentist, or nurse duringthe past 12 monthsYesNo

ABC

55. When you last tried to quit for good, how long did you

stay off cigarettes? (PLEASE CHOOSE THE FIRSTANSWER THAT FITS)

I have never smoked cigarettesI have never tried to quitLess than a day1 to 7 daysMore than 7 days but less than 30 daysMore than 30 days but less than 6 monthsMore than 6 months but less than 1 year1 year or more

ABCD

E

F

G

H

58. In the past 12 months, did you do any of the following to

help you quit using tobacco of any kind for good? (Youcan CHOOSE ONE ANSWER or MORE THAN ONEANSWER)

I did not use tobacco of any kind during the past 12monthsI did not try to quit during the past 12 monthsAttended a program in my schoolAttended a program in the communityCalled a telephone help line or telephone quit lineUsed nicotine gum

ABCD

E

F

57. During the past 12 months, how many times have you

stopped using all tobacco products for one day orlonger because you were trying to quit all tobaccoproducts for good?

I did not use tobacco products duringthe past 12 monthsI did not try to quit all tobacco productsduring the past 12 months1 time2 times3 to 5 times6 to 9 times10 or more times

ABCD

E

F

G

56. Are you seriously thinking about quitting the use of all

tobacco products? (PLEASE CHOOSE THE FIRST

ANSWER THAT FITS)

I do not use tobacco productsYes, within the next 30 daysYes, within the next 6 monthsYes, within the yearYes, but not within the yearNo, I am not thinking about quitting the use of alltobacco products

ABCD

E

F
20. During the past 30 days, how did you get your own

cigarettes? (You can CHOOSE ONE ANSWER orMORE THAN ONE ANSWER)

I did not get cigarettes during the past 30 daysI bought a pack of cigarettes myselfI had someone else buy a pack of cigarettes for meI asked someone to give me a cigaretteSomeone offered me a cigaretteI bought cigarettes from another personI took cigarettes from a store or another personI got cigarettes some other way

ABCD

E

F

G

H

22. During the past 30 days, did anyone refuse to sell you

cigarettes because of your age?

I did not try to buy cigarettes during the past 30 daysYesNo

ABC

The next five questions are about smoking cigars.

23. 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

21. During the past 30 days, where did you buy your own

cigarettes? (You can CHOOSE ONE ANSWER orMORE THAN ONE ANSWER)

ABCD

E

F

G

H

I did not buy cigarettes during the past 30 daysA gas station or convenience storeA grocery storeA drugstoreA vending machineOver the InternetThrough the mailSome other place not listed here

19. Menthol cigarettes are cigarettes that taste like mint.

During the past 30 days, were the cigarettes that youusually smoked menthol?

I did not smoke cigarettes during the past 30 daysYesNoNot sure

ABCD

26. During the past 30 days, how did you get your own

cigars, cigarillos, or little cigars? (You can CHOOSEONE ANSWER or MORE THAN ONE ANSWER)

I did not get cigars, cigarillos, or little cigars during thepast 30 daysI bought them myselfI had someone else buy them for meI asked someone to give me oneSomeone offered it to meI bought them from another personI took them from a store or another personI got them some other way

ABCD

E

F

G

H

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

smoke cigars, cigarillos, or little cigars?

0 days1 or 2 days3 to 5 days6 to 9 days

ABCD

10 to 19 days20 to 29 daysAll 30 days

E

F

G

I have never smoked cigars, cigarillos, or little cigars,not even one or two puffs8 years old or younger9 years old10 years old11 years old12 years old13 years old

ABCD

E

F

G

24. How old were you when you first tried smoking a cigar,

cigarillo, or little cigar, even one or two puffs?

14 years old15 years old16 years old17 years old18 years old19 years old or older

H

I

J

K

L

M

27. During the past 30 days, where did you buy your own

cigars, cigarillos, or little cigars? (You can CHOOSEONE ANSWER or MORE THAN ONE ANSWER)

I did not buy cigars, cigarillos, or little cigars duringthe past 30 days

A

0 days

The next five questions ask around other people's toba

59. During the past 7 days, on h

smoke tobacco products in yo

AB

0 days1 day6 days7 days

G

H

4 days5 days

E

F

2 days3 days

CD

60. During the past 7 days, on h

a vehicle where someone wa

AB

0 days1 day6 days7 days

G

H

4 days5 days

E

F

2 days3 days

CD

62. During the past 7 days, on 

the smoke from someone wproducts in the place where 

61. During the past 7 days, on 

the smoke from someone wproduct at your school, inclugrounds, and school parking 

AB

0 days1 day6 days7 days

G

H

4 days5 days

E

F

2 days3 days

CD

I do not have a jobI did not work during the 

ABC
13. How old were you when you 

even one or two puffs?

ABCD

E

F

G

I have never smoked cigtwo puffs8 years old or younger9 years old10 years old11 years old12 years old13 years old

H

I

J

K

L

M

14 years old15 years old16 years old17 years old18 years old19 years old or older

14. About how many cigarettes 

entire life?

I have never smoked cigpuffs1 or more puffs but neve1 cigarette2 to 5 cigarettes6 to 15 cigarettes (about 

ABCD

E

12. If one of your best friends w

would you smoke it?

AB

Definitely yesProbably yesProbably notDefinitely not

CD

10. Do you think you will smoke 

Definitely yesProbably yesProbably notDefinitely not

11. Do you think that you will try 

Definitely yesProbably yesProbably notDefinitely not

ABCDABCD

68. Out of every 10 students in your grade at school, how

many do you think smoke cigarettes?

012345678910

ABCD

E

F

G

H

I

J

K

Always be allowedBe allowed only at some times or in some placesNever be allowed

ABC

70. In your opinion, in their vehicles, people should...

Always allow smokingSometimes allow smokingNever allow smoking

ABC

71. Do you think that breathing smoke from other people's

cigarettes or other tobacco products causes...

No harmLittle harmSome harmA lot of harm

ABCD

69. In your opinion, inside your home, smoking tobacco

products should...

72. Do you believe any of the following are less harmful than

smoking cigarettes? (You can CHOOSE ONE ANSWERor MORE THAN ONE ANSWER)

Smoking tobacco from a hookah or waterpipeSmoking tobacco from a pipe other than a waterpipeSmoking Bidis (small brown cigarettes wrapped in aleaf)Smoking Clove cigarettes (kreteks)Smoking flavored cigars

little cigars and cigarillos (such

ABCD

E

The next seven questions are about your thoughtsabout tobacco.

73. Do you believe any of the following are less harmful than

smoking cigarettes? (You can CHOOSE ONE ANSWERor MORE THAN ONE ANSWER)

Using chewing tobacco, snuff, or dipUsing snus, such as Camel or Marlboro SnusUsing dissolvable tobacco products, such as Ariva,Stonewall, Camel orbs, Camel sticks, Marlboro sticks,or Camel stripsUsing electronic cigarettes, such as Ruyan or NJOYDo not knowI do not believe that any of the above products are lessharmful than cigarettes

74. Do you think smoking cigarettes makes young people look

cool or fit in?

75. Do you think young people who smoke cigarettes have

more friends?

ABCD

E

F

Definitely yesProbably yes

AB

Probably notDefinitely not

CD

Definitely yesProbably yes

AB

Probably notDefinitely not

CD

The last six questions are about your experiencesat home, in your community, and at school.

76. Would your parents or guardians strongly disapprove if you

used tobacco products?

ABCD

E

F

I don't use tobacco products, and my parents wouldstrongly disapprove if I didI don't use tobacco products, and my parents wouldnot strongly disapprove if I didI use tobacco products, and my parents stronglydisapproved when they first found outI use tobacco products, and my parents did notstrongly disapprove when they first found outI use tobacco products, but my parents don't know,and they would strongly disapprove if they knewI use tobacco products, but my parents don't know,and they would not strongly disapprove if they knew
DIRECTIONS

• Use a #2 pencil only.• Make dark marks.• Fill in a response like this:• If you change your answer, erase your old

answer completely.

AB D

 4. Are you Hispanic, Latino/a, or Spanish origin

(One or more categories may be selected)?

The first five questions ask for some backgroundinformation about you.

JanuaryFebruaryMarchAprilMayJune

Month Day

TODAY'S DATE

0123

0123456789

 1. How old are you?

ABCD

E

F

9 years old10 years old11 years old12 years old13 years old14 years old

G

H

I

J

K

15 years old16 years old17 years old18 years old19 years old or older

A

 2. What is your sex?

Male

B Female

 3. What grade are you in?

ABCD

E

No, not of Hispanic, Latino, Latina, or Spanish originYes, Mexican, Mexican American, Chicano or ChicanaYes, Puerto RicanYes, CubanYes, Another Hispanic, Latino/a or Spanish origin

 5. What race or races do you consider yourself to be?

(You can CHOOSE ONE ANSWER or MORETHAN ONE ANSWER)

ABCD

E

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite

This section ask about if you'll try tobacco thatis smoked or put in your mouth.

Definitely yesProbably yesProbably notDefinitely not

ABCD

 6. At any time during the next 12 months do you think you

will use any form of tobacco?

 7. Do you think that you will try any form of tobacco soon?

Definitely yesProbably yesProbably notDefinitely not

ABCD

 8. If one of your best friends were to offer you any form

of tobacco, would you use it?

Definitely yesProbably yesProbably notDefinitely not

ABCD

The next six sections ask about your use ofdifferent kinds of tobacco products.

78. During this school year, we

classes about why you shou

A YesB No

79. During the past 30 days, to 

including yourself, smoked a property when he or she wa

A YesB No
Tob

2

This survey i

things you do thprograms for you

DO NOT write 

kept private.

NO one will k

you really do and 

Completing th

questions will nquestions. If you are no wrong ans

The question

describe the typenot be used to fin

Please read e

circles in the binstructions of thPublic reporting burden including time for reviewneeded, and completing and a person is not requcontrol number. Send cinformation

including su

cc

SCHOOL ID

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

DO NOT WRITE IN THIS BOX

OFFICE USE ONLY