Page 1 of 18

Form Approved

OMB No.: 0920-0621

Expiration Date: 01/31/2018

National Youth

Tobacco Survey (NYTS)

2017 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.

DO NOT write your name on this survey. The answers you give will be kept private. 

NO one will know what you write. 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. Fill in the circles in 

the booklet completely. 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 30333, ATTN: PRA (0920-0621).

PRINT ONLY
Page 2 of 18

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

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
Page 3 of 18

The next six sections of questions ask about your use of particular kinds of tobacco products, such as 

cigarettes, cigars, smokeless tobacco, electronic cigarettes, hookahs, pipes, snus, dissolvable 

tobacco, and bidis.

The first 12 questions are about smoking conventional cigarettes (ones that have to be lit and burned).

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

A. Definitely yes 

B. Probably yes

C. Probably not

D. Definitely not

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

A. Yes 

B. No 

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

A. I have never smoked cigarettes, not even one or two puffs

B. 8 years old or younger 

C. 9 years old

D. 10 years old

E. 11 years old

F. 12 years old

G. 13 years old

H. 14 years old

I. 15 years old

J. 16 years old

K. 17 years old

L. 18 years old

M. 19 years old or older

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

A. I have never smoked cigarettes, not even one or two puffs

B. 1 or more puffs but never a whole cigarette

C. 1 cigarette

D. 2 to 5 cigarettes

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

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

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

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

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

answer that fits)

A. I have never smoked cigarettes, not even one or two puffs

B. Earlier today 

C. Not today but sometime during the past 7 days

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

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

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

G. 1 to 4 years ago

H. 5 or more years ago
Page 4 of 18

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

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

12. During the past 30 days, on the days you smoked, about how many cigarettes did you smoke per 

day? 

A. I did not smoke cigarettes during the past 30 days

B. Less than 1 cigarette per day

C. 1 cigarette per day

D. 2 to 5 cigarettes per day

E. 6 to 10 cigarettes per day

F. 11 to 20 cigarettes per day

G. More than 20 cigarettes per day

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

A. I did not smoke cigarettes during the past 30 days

B. I did not smoke a usual brand

C. American Spirit

D. Camel

E. GPC, Basic, or Doral

F. Kool

G. Lucky Strike

H. Marlboro

I. Newport

J. Parliament

K. Virginia Slims

L. Some other brand not listed here

M. Not sure

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

you usually smoked menthol?

A. I did not smoke cigarettes during the past 30 days

B. Yes

C. No

D. Not sure

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not
Page 5 of 18

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

The next five questions are about the use of cigars, cigarillos, or little cigars such as Black and Mild, 

Swisher Sweets, Dutch Masters, White Owl, or Phillies Blunts.

18. 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

19. Have you ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher 

Sweets, Dutch Masters, White Owl, or Phillies Blunts, even one or two puffs? 

A. Yes 

B. No 

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

A. I have never smoked cigars, cigarillos, or little cigars, not even one or two puffs

B. 8 years old or younger 

C. 9 years old 

D. 10 years old

E. 11 years old

F. 12 years old

G. 13 years old

H. 14 years old

I. 15 years old

J. 16 years old

K. 17 years old

L. 18 years old

M. 19 years old or older

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

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 
Page 6 of 18

22. 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. I did not smoke cigars, cigarillos, or little cigars during the past 30 days

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

C. 1 per day

D. 2 to 5 per day

E. 6 to 10 per day

F. 11 to 20 per day

G. More than 20 per day

The next four questions are about the use of chewing tobacco, snuff, or dip. Do not think about snus 

or dissolvable tobacco products when you answer these questions. 

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

A. Definitely yes

B. Probably yes

C. Probably not

D. Definitely not

24. Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, 

Skoal Bandits, or Copenhagen, even just a small amount? 

A. Yes 

B. No 

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

A. I have never used chewing tobacco, snuff, or dip

B. 8 years old or younger 

C. 9 years old 

D. 10 years old

E. 11 years old

F. 12 years old

G. 13 years old

H. 14 years old

I. 15 years old

J. 16 years old

K. 17 years old

L. 18 years old

M. 19 years old or older

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

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 
Page 7 of 18

The next 11 questions are about electronic cigarettes or e-cigarettes. E-cigarettes are battery powered 

devices that usually contain a nicotine-based liquid that is vaporized and inhaled. You may also know 

them as e-cigs, vape-pens, hookah-pens, e-hookahs, e-cigars, e-pipes, personal vaporizers, or mods. 

Some brand examples include NJOY, Blu, Vuse, MarkTen, Logic, Vapin Plus, eGo, and Halo.

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

A. Definitely yes 

B. Probably yes

C. Probably not

D. Definitely not

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

A. Yes 

B. No 

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

A. I have never used e-cigarettes

B. 8 years old or younger 

C. 9 years old 

D. 10 years old

E. 11 years old

F. 12 years old

G. 13 years old

H. 14 years old

I. 15 years old

J. 16 years old

K. 17 years old

L. 18 years old

M. 19 years old or older

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

A. 0 days

B. 1 day

C. 2 to 10 days

D. 11 to 20 days

E. 21 to 50 days

F. 51 to 100 days

G. Over 100 days

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

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
Page 8 of 18

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

or more)

A. I have never tried an e-cigarette in the past 30 days

B. A gas station or convenience store

C. A grocery store

D. A drugstore

E. A mall or shopping center kiosk/stand

F. On the Internet

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

H. Some other place not listed here

I. From a family member

J. From a friend

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

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

A. I have never tried an e-cigarette

B. Friend or family member used them

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

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

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

F. Famous people on TV or in movies use them

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

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

I. They can be used in areas where other tobacco products, such as cigarettes, are not allowed

J. I used them for some other reason

34. Have you ever used marijuana, marijuana concentrates, marijuana waxes, THC, or hash oils in an ecigarette? 

A. I have never used an electronic product

B. Yes

C. No

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

A. Definitely yes 

B. Probably yes 

C. Probably not 

D. Definitely not

36. 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 

37. 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
Page 9 of 18

The next eight questions are about smoking tobacco in a hookah, which is a type of waterpipe. Shisha 

(or hookah tobacco) is smoked in a hookah. 

38. 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

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

A. Yes 

B. No 

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

puffs?

A. I have never smoked tobacco from a hookah or waterpipe

B. 8 years old or younger 

C. 9 years old 

D. 10 years old

E. 11 years old

F. 12 years old

G. 13 years old

H. 14 years old

I. 15 years old

J. 16 years old

K. 17 years old

L. 18 years old

M. 19 years old or older

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

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 

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

more) 

A. I did not smoke tobacco in a hookah or waterpipe during the past 30 days

B. At my house

C. At a friend’s house

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

E. At a hookah bar

F. At a café or restaurant

G. Some other place not listed here
Page 10 of 18

43. 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 

44. 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

45. 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

The next two questions are about the use of other tobacco products, not described in the previous 

sections.

46. 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 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

47. 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 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
Page 11 of 18

Now thinking about your responses to questions from the last six sections about past 30 day use of 

cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipes, snus, dissolvable tobacco, and 

bidis.

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

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

The next two questions ask about flavors in tobacco products.

49. 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 (small brown cigarettes wrapped in a leaf)

I. I did not use any of the flavored tobacco products listed above in the past 30 days 

50. 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

H. I did not use flavored tobacco products in the past 30 days

The next two questions are about issues related to urges or needs to use tobacco products.

51. 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

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

A. I do not want to use tobacco

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
Page 12 of 18

The next four questions are about quitting tobacco products.

53. Are you seriously thinking about quitting the use of all tobacco products? (Please choose the first

answer that fits)

A. I do not use tobacco products

B. Yes, during the next 30 days

C. Yes, during the next 6 months

D. Yes, during the next 12 months

E. Yes, but not during the next 12 months

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

54. 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 use tobacco products during the past 12 months

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

C. 1 time

D. 2 times

E. 3 to 5 times

F. 6 to 9 times

G. 10 or more times

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

A. I do not smoke cigarettes 

B. Yes, during the next 30 days

C. Yes, during the next 6 months

D. Yes, during the next 12 months

E. Yes, but not during the next 12 months

F. No, I am not thinking about quitting cigarettes

56. 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 smoke cigarettes during the past 12 months

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

C. 1 time

D. 2 times

E. 3 to 5 times

F. 6 to 9 times

G. 10 or more times

The next four questions are about getting tobacco products.

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

A. I did not get any tobacco products during the past 30 days

B. I bought them myself

C. I had someone else buy them for me

D. I asked someone to give me some

E. Someone offered them to me

F. I bought them from another person

G. I took them from a store or another person

H. I got them some other way 
Page 13 of 18

58. 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

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. Some other place not listed here 

59. 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

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

A. Easy

B. Somewhat easy

C. Not easy at all

The next four questions are about different issues related to tobacco. 

A warning label tells you if a product is harmful to you and can be either a picture or words.

61. 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

62. 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

63. 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
Page 14 of 18

64. 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

The next nine questions ask about your thoughts on tobacco products.

65. 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

66. How much do you think people harm themselves when they use chewing tobacco, snuff, dip, or 

snus, some days but not every day? 

A. No harm

B. Little harm

C. Some harm

D. A lot of harm 

67. Do you believe that chewing tobacco, snuff, dip, or snus 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 chewing tobacco, snuff, dip, or snus

E. I don’t know enough about these products

68. 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

69. 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
Page 15 of 18

70. 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

71. 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

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

A. Strongly agree

B. Agree

C. Disagree

D. Strongly disagree

73. 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

The next four questions ask about issues related to tobacco advertisement. Do not think of electronic 

cigarettes.

74. 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 

75. 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 
Page 16 of 18

76. 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 

77. When you watch TV 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 go to the movies

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always 

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

cigarettes or other tobacco products.

78. 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 

79. 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 

80. 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 
Page 17 of 18

81. When you watch TV, how often do you see ads or promotions for e-cigarettes?

A. I do not watch TV

B. Never

C. Rarely

D. Sometimes

E. Most of the time

F. Always

The next three questions ask about you being around other people’s tobacco smoke. Do not include 

exposure to vapor from e-cigarettes.

82. 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

83. 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 

84. During the past 30 days, on how many days did you breathe the smoke from someone who was 

smoking tobacco products in an indoor or outdoor public place? Examples of indoor public places are 

school buildings, stores, restaurants, and sports arenas. Examples of outdoor public places are school 

grounds, parking lots, stadiums, and parks.

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
Page 18 of 18

The next question asks about being around other people’s e-cigarette vapor. Do not include exposure 

to smoke from other tobacco products.

85. During the past 30 days, on how many days did you breathe the vapor from someone who was using

an e-cigarette in an indoor or outdoor public place? Examples of indoor public places are school

buildings, stores, restaurants, and sports arenas. Examples of outdoor public places are school

grounds, parking lots, stadiums, and parks.

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

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

86. 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 waterpipes)

G. Use snus

H. Use dissolvable tobacco products

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

J. No one who lives with me now uses any form of tobacco

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

A. Yes

B. No

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

remembering, or making decisions?

A. Yes

B. No

PRINT ONLY