Form Approved

 OMB No. 0920-0621 

 Exp. Date: 04/30/2021

National Youth

 Tobacco Survey (NYTS)

2019 Questionnaire

Thank You Very Much For Your Help.

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).

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

1. How old are you? 

A. 9 years old 

B. 10 years old 

C. 11 years old 

D. 12 years old 

E. 13 years old 

F. 14 years old 

G. 15 years old 

H. 16 years old 

I. 17 years old 

J. 18 years old 

K. 19 years old or older 

2. What is your sex? 

A. Male

B. Female

3. What grade are you in? 

A. 6th

B. 7th

C. 8th

D. 9th

E. 10th

F. 11th

G. 12th

H. Ungraded or other grade 

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

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

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

C. Yes, Puerto Rican

D. Yes, Cuban

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

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

A. American Indian or Alaska Native

B. Asian

C. Black or African American

D. Native Hawaiian or Other Pacific Islander

E. 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 owncigarettes, 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).

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

A. Yes 

B. No  [SKIP TO Q14]

IF Q6 EQ (NA) [Not Answered] –SOFT VALIDATION
7. How old were you when you first tried cigarette smoking, even one or two puffs?

A. 8 years old or younger 

B. 9 years old

C. 10 years old

D. 11 years old

E. 12 years old

F. 13 years old

G. 14 years old

H. 15 years old

I. 16 years old

J. 17 years old

K. 18 years old

L. 19 years old or older

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

A. 1 or more puffs but never a whole cigarette

B. 1 cigarette

C. 2 to 5 cigarettes

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

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

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

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

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

Specify: |__|__| (Range: 0 – 30)

[PROGRAMMING: RANGE (0 – 30) ALLOWED]

IF Q9 EQ (NA) –SOFT VALIDATION

[IF Q6 EQ (NA) AND Q9 EQ (NA)  SKIP TO INSTRUCT_3]

[IF Q6 EQ (NA) AND Q9 EQ (0)  SKIP TO INSTRUCT_3]

[IF Q6 EQ (NA) AND Q9 EQ (1-30)  CONTINUE TO Q10]

[ELSE, IF Q6 EQ (1) AND Q9 EQ (0-30)  CONTINUE TO Q10]

10. When was the last time you smoked a cigarette, even one or two puffs? (Please choose the first 

answer that fits)

A. Earlier today 

B. Not today but sometime during the past 7 days

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

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

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

F. 1 to 4 years ago 

G. 5 or more years ago 

[IF Q9 EQ (NA)  GO TO INSTRUCT_3]

[IF Q9 EQ (0)  GO TO INSTRUCT_3]

[ELSE IF Q9 EQ (1-30)  CONTINUE TO Q11]

11. 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. 

A. Less than 1 cigarette per day

B. 1 cigarette per day

C. 2 to 5 cigarettes per day

D. 6 to 10 cigarettes per day

E. 11 to 20 cigarettes per day

F. More than 20 cigarettes per day
12. During the past 30 days, what brand of cigarettes did you usually smoke? (Choose only one answer)

A. I did not smoke a usual brand

B. American Spirit

C. Camel

D. GPC, Basic, or Doral

E. Kool

F. Marlboro

G. Newport

H. L&M

I. Pall Mall

J. Winston

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

L. Not sure

13. Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that 

you usually smoked menthol?

A. Yes

B. No

C. Not sure

 [ALL RESPONSES SKIP TO INSTRUCT_3]

[IF Q13 EQ (NA) SKIP TO INSTRUCT_3]

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

A. Definitely yes 

B. Probably yes

C. Probably not

D. Definitely not

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not 

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not

INSTRUCT_3: The next several questions are about the use of cigars, cigarillos, or little cigars such as

Swisher Sweets, Black and Mild, Garcia y Vega, Cheyenne, White Owl, or Dutch Masters.

18. 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? 

A. Yes 

B. No  [SKIP TO Q23]

IF Q18 EQ (NA) – SOFT VALIDATION
19. How old were you when you first tried smoking a cigar, cigarillo, or little cigar, even one or two puffs? 

A. 8 years old or younger 

B. 9 years old 

C. 10 years old

D. 11 years old

E. 12 years old

F. 13 years old

G. 14 years old

H. 15 years old

I. 16 years old

J. 17 years old

K. 18 years old

L. 19 years old or older

20. 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 Q20 EQ (NA) – SOFT VALIDATION

[IF Q18 EQ (1) AND Q20 EQ (0)  SKIP TO INSTRUCT_4]

[IF Q18 EQ (NA) AND Q20 EQ (NA)  SKIP TO INSTRUCT_4]

[IF Q18 EQ (NA) AND Q20 EQ (0)  SKIP TO INSTRUCT_4]

[IF Q18 EQ (NA) AND Q20 EQ (1-30)  CONTINUE TO Q21]

[IF Q18 EQ (1) AND Q20 EQ (1-30)  CONTINUE TO Q21]

21. During the past 30 days, on the days that you smoked, about how many cigars, cigarillos, or little cigars 

did you smoke per day? 

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

B. 1 per day

C. 2 to 5 per day

D. 6 to 10 per day

E. 11 to 20 per day

F. More than 20 per day

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

A. Regular cigars

B. Cigarillos

C. Little Cigars

D. Don’t Know  [EXCLUSIVE]

 [ALL RESPONSES SKIP TO INSTRUCT_4]

 [IF Q22 EQ (NA) SKIP TO INSTRUCT_4]

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

A. Definitely yes

B. Probably yes

C. Probably not

D. Definitely not

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

A. Definitely yes

B. Probably yes

C. Probably not

D. Definitely not
25. Do you think you will smoke a cigar, cigarillo, or little cigar in the next year?

A. Definitely yes

B. Probably yes

C. Probably not

D. Definitely not

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

A. Definitely yes

B. Probably yes

C. Probably not

D. 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. 

27. Have you ever used chewing tobacco, snuff, or dip, such as Copenhagen, Grizzly, Skoal, or Longhorn, 

even just a small amount? 

A. Yes 

B. No  [SKIP TO Q30]

[IF Q27 EQ (NA) – SOFT VALIDATION]

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

A. 8 years old or younger 

B. 9 years old 

C. 10 years old

D. 11 years old

E. 12 years old

F. 13 years old

G. 14 years old

H. 15 years old

I. 16 years old

J. 17 years old

K. 18 years old

L. 19 years old or older

29. 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] 

IF Q29 EQ (NA) – SOFT VALIDATION

[IF Q27 EQ (NA) AND Q29 EQ (NA)  SKIP TO INSTRUCT_5]

[IF Q27 EQ (NA) AND Q29 EQ (0)  SKIP TO INSTRUCT_5]

[IF Q27 EQ (NA) AND Q29 EQ (1-30)  SKIP TO INSTRUCT_5]

[IF Q27 EQ (1) AND Q29 EQ (0-30)  SKIP TO INSTRUCT_5]

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

A. Definitely yes

B. Probably yes

C. Probably not

D. Definitely not

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

A. Definitely yes

B. Probably yes

C. Probably not

D. Definitely not
32. Do you think you will use chewing tobacco, snuff, or dip in the next year?

A. Definitely yes

B. Probably yes

C. Probably not

D. Definitely not

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

A. Definitely yes

B. Probably yes

C. Probably not

D. 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. 

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

A. Yes 

B. No  [SKIP TO Q43]

[IF Q34 EQ (NA) – SOFT VALIDATION]

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

A. 8 years old or younger 

B. 9 years old 

C. 10 years old

D. 11 years old

E. 12 years old

F. 13 years old

G. 14 years old

H. 15 years old

I. 16 years old

J. 17 years old

K. 18 years old

L. 19 years old or older

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

A. 1 day

B. 2 to 10 days

C. 11 to 20 days

D. 21 to 50 days

E. 51 to 100 days

F. Over 100 days

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

Specify: |__|__| (Range 0 – 30)

[PROGRAMMING: RANGE (0 – 30) ALLOWED] 

IF Q37 EQ (NA) – SOFT VALIDATION

[IF Q34 EQ (NA) AND Q37 EQ (NA)  SKIP TO INSTRUCT_6]

[IF Q34 EQ (NA) AND Q37 EQ (0)  SKIP TO INSTRUCT_6]

[IF Q34 EQ (NA) AND Q37 EQ (1-30)  CONTINUE TO Q38]

[IF Q34 EQ (1) AND Q37 EQ (0-30)  CONTINUE TO Q38]
38. When was the last time you used an e-cigarette, even one or two times? (Please choose the first 

answer that fits)

A. Earlier today

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

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

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

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

F. 1 to 4 years ago 

G. 5 or more years ago 

[IF Q37 EQ (NA)  SKIP TO INSTRUCT_6]

[IF Q37 EQ (0)  SKIP TO Q42]

[ELSE IF Q37 EQ (1-30)  CONTINUE TO Q39] 

39. 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. 

A. A disposable e-cigarette

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

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

D. A mod system (a mod system is customized by the user with their own combination of batteries, 

atomizers, etc.)

E. I don’t know the type

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

A. I did not use a usual brand 

B. Blu

C. JUUL

D. Logic

E. MarkTen

F. NJOY

G. Vuse

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

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

more)

A. A gas station or convenience store

B. A grocery store

C. A drugstore

D. A mall or shopping center kiosk/stand

E. On the Internet

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

G. Some other place not listed here

H. From a family member

I. From a friend

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

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

A. Friend or family member used them

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

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

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

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

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

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

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

I. I was peer pressured into using them

J. I can use them to do tricks

K. I was curious about them

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

ALL RESPONSES SKIP TO INSTRUCT_6. 

[IF Q42 EQ (NA) SKIP TO INSTRUCT_6]
43. Have you ever been curious about using an e-cigarette? 

A. Definitely yes 

B. Probably yes

C. Probably not

D. Definitely not

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not 

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. 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. 

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

A. Yes 

B. No  [SKIP TO Q51]

[IF Q47 EQ (NA) – SOFT VALIDATION] 

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

puffs?

A. 8 years old or younger 

B. 9 years old 

C. 10 years old

D. 11 years old

E. 12 years old

F. 13 years old

G. 14 years old

H. 15 years old

I. 16 years old

J. 17 years old

K. 18 years old

L. 19 years old or older

49. 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 Q49 EQ (NA) – SOFT VALIDATION

[IF Q47 EQ (1) AND Q49 EQ (0)  SKIP TO INSTRUCT_7]

[IF Q47 EQ (NA) AND Q49 EQ (NA)  SKIP TO INSTRUCT_7]

[IF Q47 EQ (NA) AND Q49 EQ (0)  SKIP TO INSTRUCT_7]

[IF Q47 EQ (NA) AND Q49 EQ (1-30)  CONTINUE TO Q50]

[IF Q47 EQ (1) AND Q49 EQ (1-30)  CONTINUE TO Q50]
50. During the past 30 days, where did you smoke tobacco in a hookah or waterpipe? (Select one or more) 

A. At my house

B. At a friend’s house

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

D. At a hookah bar

E. At a café or restaurant

F. Some other place not listed here

 ALL RESPONSES SKIP TO INSTRUCT_7

[IF Q50 EQ (NA) SKIP TO INSTRUCT_7]

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

A. Definitely yes 

B. Probably yes

C. Probably not

D. Definitely not

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not 

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not

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

sections.

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

A. Roll-your-own cigarettes

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

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

D. Dissolvable tobacco products such as Ariva, Stonewall, Camel orbs, Camel sticks, Marlboro sticks, 

or Camel strips

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

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

IF Q55A EQ (NA) AND Q55B EQ (NA) AND Q55C EQ (NA) AND Q55D EQ (NA) AND Q55E EQ (NA) AND 

Q55F EQ (NA) – SOFT VALIDATION

[IF Q55A EQ (1) OR Q55B EQ (1) OR Q55C EQ (1) OR Q55D EQ (1) OR Q55E EQ (1)  CONTINUE TO Q56] 
56. In the past 30 days, which of the following products have you used on at least one day? (Select one or 

more) 

A. Roll-your-own cigarettes 

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

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

D. Dissolvable tobacco products such as Ariva, Stonewall, Camel orbs, Camel sticks, Marlboro sticks, 

or Camel strips

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

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

IF Q56A EQ (NA) AND Q56B EQ (NA) AND Q56C EQ (NA) AND Q56D EQ (NA) AND Q56E EQ (NA) AND 

Q56F EQ (NA) –SOFT VALIDATION

[ALL RESPONSES CONTINUE TO INSTRUCT_8]

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. 

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

A. Yes

B. No

C. Don’t know/Not Sure

[ALL RESPONSES CONTINUE TO Q58]

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

A. Yes  [CONTINUE TO Q59]

B. No  [SKIP TO INSTRUCT_9a]

C. Don’t Know/Not Sure  [CONTINUE TO Q59]

IF Q58 EQ (NA) –SOFT VALIDATION

[IF Q58 EQ (NA)  CONTINUE TO Q59.

59. 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] 

IF Q59 EQ (NA) – SOFT VALIDATION

ALL RESPONSES CONTINUE TO INSTRUCT_9a
INSTRUCT_9a: (programming, only)

CONDITION #1: “current tobacco product user”

IF { [Q9=1-30] OR 

[Q20=1-30] OR

[Q29=1-30] OR

[Q37=1-30] OR 

[Q49=1-30] OR 

[(Q56A=1 OR Q56B=1 OR Q56C=1 OR Q56D=1 OR Q56E=1)] OR 

[Q59=1-30] }

 CONTINUE TO INSTRUCT_9

ELSE, continue to “never tobacco product user” screener [condition #2] 

CONDITION #2: “never tobacco product user” 

IF [(Q6=2 OR Q6=NA) AND 

(Q18=2 OR Q18=NA) AND 

(Q27=2 OR Q27=NA) AND 

(Q34=2 OR Q34=NA) AND 

(Q47=2 OR Q47=NA) AND 

[Q55F=1 OR (Q55A=NA AND Q55B=NA AND Q55C=NA AND Q55D=NA AND Q55E=NA AND 

Q55F=NA)] AND 

(Q58=2 OR Q58=3 OR Q58=NA)]

 SKIP TO INSTRUCT_13a

ELSE, continue to “former tobacco product user” screener [condition #3]

CONDITION #3: “former tobacco product user” 

IF [(Q6=1 OR Q18=1 OR Q27=1 OR Q34=1 OR Q47=1 OR Q55A=1 OR Q55B=1 OR

Q55C=1 OR Q55D=1 OR Q55E=1 OR Q58=1) AND 

[((Q9=0 OR Q9=NA-SKIP) AND (Q20=0 OR Q20=NA-SKIP) AND (Q29=0 OR 

Q29=NA-SKIP) AND (Q37=0 OR Q37=NA-SKIP) AND (Q49=0 OR Q49=NA-SKIP)

AND Q56F=1 AND (Q59=0 ORQ59=NA-SKIP))]

 SKIP TO INSTRUCT_11

ELSE, IF [(Q6=1 OR Q18=1 OR Q27=1 OR Q34=1 OR Q47=1 OR Q55F=1 OR 

Q58=1) AND

[((Q9=0 OR Q9=NA-SKIP] AND (Q20=0 OR Q20=NA-SKIP) AND (Q29=0 OR 

Q29=NA-SKIP) AND (Q37=0 OR Q37=NA-SKIP) AND (Q49=0 OR Q49=NA-SKIP) 

AND Q56F=NA-SKIP AND (Q59=0 ORQ59=NA-SKIP))]

 SKIP TO INSTRUCT_11

ELSE, continue to condition #4 screener

CONDITION #4: Respondent does not satisfy condition 1, 2, or 3. 

ELSE, Continue to INSTRUCT_13a. 

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.

60. 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.
61. 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)

A. Cigars, cigarillos, or little cigars 

B. Chewing tobacco, snuff, or dip

C. E-cigarettes

D. Tobacco in a hookah or waterpipe

E. Pipe filled with tobacco (not waterpipe)

F. Snus

G. Dissolvable tobacco products

H. Bidis

I. Roll-your-own cigarettes

J. Heated tobacco products

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

IF [Q61A EQ (NA) AND Q61B EQ (NA) AND Q61C EQ (NA) AND Q61D EQ (NA) AND Q61E EQ (NA) 

AND Q61F EQ (NA) AND Q61G EQ (NA) AND Q61H EQ (NA) AND Q61I EQ (NA) AND Q61J EQ (NA) 

AND Q61K EQ (NA)]  SKIP TO INSTRUCT_11

IF Q61K EQ (1)  SKIP TO INSTRUCT_11 

IF [(Q61A EQ (1) OR Q61B EQ (1) OR Q61C EQ (1) OR Q61D EQ (1) OR Q61E EQ (1) OR Q61F EQ 

(1) OR Q61G EQ (1) OR Q61H EQ (1) OR Q61I EQ (1) OR Q61J EQ (1)]  CONTINUE TO Q62.

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

A. Menthol or mint

B. Clove or spice

C. Fruit

D. Chocolate

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

F. Candy, desserts or other sweets

G. 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.

63. 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?

A. Yes

B. No

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

A. I do not want to use tobacco products

B. Within 5 minutes

C. From 6 to 30 minutes

D. From more than 30 minutes to 1 hour

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

F. I rarely want to use tobacco products 

IF current tobacco product user (Condition #1 from INSTRUCT_9a), CONTINUE TO INSTRUCT_12. 

ELSE SKIP TO INSTRUCT_13a.

[IF Q64 EQ (NA)  SKIP TO INSTRUCT_13a]

INSTRUCT_12: The next few questions are about quitting tobacco products.
65. Are you seriously thinking about quitting the use of all tobacco products? (Please choose the first

answer that fits)

A. Yes, during the next 30 days

B. Yes, during the next 6 months

C. Yes, during the next 12 months

D. Yes, but not during the next 12 months

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

66. 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?

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

B. 1 time

C. 2 times

D. 3 to 5 times

E. 6 to 9 times

F. 10 or more times

[IF Q6 EQ (1) AND Q9 EQ (1-30)  CONTINUE TO Q67]

[IF Q6 EQ (NA) AND Q9 EQ (1-30)  CONTINUE TO Q67]

[ELSE SKIP TO INSTRUCT_13] 

[ELSE IF Q66 EQ (NA) SKIP TO INSTRUCT_13a]

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

A. Yes, during the next 30 days

B. Yes, during the next 6 months

C. Yes, during the next 12 months

D. Yes, but not during the next 12 months

E. No, I am not thinking about quitting cigarettes

68. 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?

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

B. 1 time

C. 2 times

D. 3 to 5 times

E. 6 to 9 times

F. 10 or more times

ALL RESPONSES  CONTINUE TO INSTRUCT_13

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

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

A. I bought them myself

B. I had someone else buy them for me

C. I asked someone to give me some

D. Someone offered them to me

E. I bought them from another person

F. I took them from a store or another person

G. I got them in some other way (specify: ______________________________________)
70. During the past 30 days, where did you buy your own tobacco products? (Select one or more) 

A. I did not buy tobacco products during the past 30 days  EXCLUSIVE RESPONSE

B. A gas station or convenience store

C. A grocery store

D. A drugstore

E. A vending machine

F. On the Internet

G. Through the mail

H. A vape shop or tobacco shop

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

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

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

B. Yes

C. No

[ALL RESPONSES  SKIP TO Q72]

IF Q71 EQ (NA)  SKIP TO Q72]

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

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

A. Easy

B. Somewhat easy

C. Not easy at all

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

A. Easy

B. Somewhat easy

C. 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.

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

package?

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

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always

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

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

B. Never

C. Rarely

D. Sometimes

E. Most of the time

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

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

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always

77. 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?

A. Yes

B. No

C. Not sure

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

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

day?

A. No harm

B. Little harm

C. Some harm

D. A lot of harm

79. 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? 

A. No harm

B. Little harm

C. Some harm

D. A lot of harm 

80. Do you believe that chewing tobacco, snuff, dip, snus, or dissolvable tobacco products are (LESS 

ADDICTIVE, EQUALLY ADDICTIVE, or MORE ADDICTIVE) than cigarettes?

A. Less addictive

B. Equally addictive

C. More addictive

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

E. I don’t know enough about these products

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

day?

A. No harm

B. Little harm

C. Some harm

D. A lot of harm

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

than cigarettes?

A. Less addictive

B. Equally addictive

C. More addictive

D. I have never heard of e-cigarettes

E. I don’t know enough about these products
83. How much do you think people harm themselves when they smoke tobacco in a hookah or waterpipe

some days but not every day?

A. No harm

B. Little harm

C. Some harm

D. A lot of harm

84. Do you believe that smoking tobacco in a hookah or waterpipe is (LESS ADDICTIVE, EQUALLY 

ADDICTIVE, or MORE ADDICTIVE) than cigarettes?

A. Less addictive

B. Equally addictive

C. More addictive

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

E. I don’t know enough about these products

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

A. Much less harmful

B. Slightly less harmful

C. Equally harmful

D. Slightly more harmful

E. Much more harmful

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

A. Strongly agree

B. Agree

C. Disagree

D. Strongly disagree

87. Not including the vapor from e-cigarettes, do you think that breathing smoke from other people’s 

cigarettes or other tobacco products causes...

A. No harm

B. Little harm

C. Some harm

D. A lot of harm

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

A. No harm

B. Little harm

C. Some harm

D. 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.

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

products?

A. I do not use the Internet

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 
90. When you read newspapers or magazines, how often do you see ads or promotions for cigarettes or 

other tobacco products?

A. I do not read newspapers or magazines

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 

91. 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?

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

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 

92. 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?

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

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 

INSTRUCT_17: The next four questions ask about issues related to e-cigarette advertisement. Do not 

think about cigarettes or other tobacco products.

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

A. I do not use the Internet

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 

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

A. I do not read newspapers or magazines

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 

95. When you go to a convenience store, supermarket, or gas station, how often do you see ads or 

promotions for e-cigarettes?

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

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 
96. 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?

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

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. 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.

97. During the past 7 days, on how many days did someone smoke tobacco products in your home while 

you were there?

A. 0 days

B. 1 day

C. 2 days

D. 3 days

E. 4 days

F. 5 days

G. 6 days

H. 7 days

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

tobacco product?

A. 0 days

B. 1 day

C. 2 days

D. 3 days

E. 4 days

F. 5 days

G. 6 days

H. 7 days 

99. 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. 

A. 0 days

B. 1 or 2 days

C. 3 to 5 days

D. 6 to 9 days

E. 10 to 19 days

F. 20 to 29 days

G. 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.
100. During the past 30 days, on how many days did you smell the vapor from someone who was using an ecigarette 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.

A. 0 days

B. 1 or 2 days

C. 3 to 5 days

D. 6 to 9 days

E. 10 to 19 days

F. 20 to 29 days

G. All 30 days

101. 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)

A. No  [EXCLUSIVE]

B. Yes, inside a school bathroom or locker room

C. Yes, inside a classroom

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

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

F. Yes, somewhere else not listed here

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

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

A. Smoke cigarettes

B. Smoke cigars, cigarillos, or little cigars

C. Use chewing tobacco, snuff, or dip

D. Use e-cigarettes

E. Smoke tobacco in a hookah or waterpipe

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

G. Use snus

H. Use dissolvable tobacco products

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

J. Use heated tobacco products

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

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

A. Yes

B. No

104. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating,

remembering, or making decisions?

A. Yes

B. No

PRINT ONLY