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OMB No.: 0920-0621 

Expiration Date: 12/31/2004

National Youth 

Tobacco Survey (NYTS) 

2004 Questionnaire

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.

Thank You Very Much For Your Help. 
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TODAY’S DATE 

Month Day

F March F 0 F 1 

F April F 1 F 2 

F May F 2 F 3 

F June F 3 F 4 

F 5 

F 6 

F 7 

F 8 

F 9 

The first questions ask for 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 

l. 20 years old 

m. 21 years old 

2. What is your sex?

a. Female 

b. Male 

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 of Spanish or Hispanic origin? 

a. Yes 

 b. No

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

(Please select 1 or more than one category.) Would 

you say: 

a. American Indian or Alaska Native 

b. Asian 

c. Black or African American 

d. Native Hawaiian or Other Pacific Islander 

e. White 

6. During an average week, how much money do you get 

from a job and other sources (allowance, etc.)?

a. None

b. Less than $1 

c. $1 to $5 

d. $6 to $10 

e. $11 to $20 

f. $21 to $50 

g. $51 to $100 

h. $101 to $150 

i. $151 or more 

7. During the past 30 days, how many days did you miss 

school for any reason, with or without permission? 

a. 0 days 

b. 1 day 

c. 2 to 5 days 

d. 6 to 10 days 

e. 11 or more days 

The next questions ask about your use of tobacco. 

The first group of questions is about cigarette 

smoking. 

8. Have you ever tried cigarette smoking, even one or 

two puffs?

a. Yes 

b. No 

9. How old were you when you smoked a whole cigarette 

for the first time? 

a. I have never smoked a whole cigarette 

b. 8 years old or younger 

c. 9 

d. 10 

e. 11 

f. 12 

g. 13 

h. 14 

i. 15 

j. 16 

k. 17 years old or older 

10. About how many cigarettes have you smoked in your 

entire life? 

a. None

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) 
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11. Now think back 12 months ago. At this time last year, 

about how much were you smoking?

a. I have never smoked cigarettes 

b. I have smoked in my life, but I wasn’t smoking at this 

time last year 

c. I smoked on some days at this time last year 

d. I smoked on most days at this time last year 

e. I smoked every day at this time last year 

12. Have you ever smoked cigarettes daily, that is, at least 

one cigarette every day for 30 days? 

a. Yes 

b. No 

13. 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 

14. During the past 30 days, on the days you smoked, 

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 

15. 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 30days 

b. I do not have 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 

16. What type of cigarette did you usually smoke in the 

past 30 days?

a. I have never smoked 

b. I have smoked but not in the past 30 days 

c. I do not have a usual type 

d. Regular/Full flavor/ 

e. Light 

f. Ultra Light 

17. Are the cigarettes you usually smoke menthol 

cigarettes? 

a. I do not smoke cigarettes 

b. Yes 

c. No 

18. When was the last time you smoked a cigarette, even 

one or two puffs? 

a. I have never smoked 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 

19. Where do you smoke cigarettes? 

(CHOOSE ONE OR MORE ANSWERS)

a. I do not smoke now

b. At home

c. At school

d. At work

e. In the car

f. At friends’ houses

g. At sports events, parties, dances, raves, or other 

social events

h. In public buildings (restaurants, fast food places, 

shopping malls, or other hangouts)

i. Outdoors (sidewalks, parking lots, parks, or other 

places)

20. Have you ever tried any of these tobacco products? 

(CHOOSE ONE OR MORE ANSWERS) 

a. Eclipse cigarettes 

b. Omni 

c. Advance Lights 

d. Accord 

e. Ariva 

f. I have not tried any of these products 

21. During the past 30 days, how did you usually get 

your own cigarettes? (CHOOSE ONLY ONE 

ANSWER)

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

b. I bought them in a store such as a convenience 

store, supermarket, or gas station 

c. I bought them from a vending machine 

d. I gave someone else money to buy them for me 

e. I borrowed them from someone else 

f. I stole them 

g. A person 18 years old or older gave them to me 

h. I got them some other way 

22. During the past 30 days, where did you buy the last 

pack of cigarettes you bought? (CHOOSE ONLY 

ONE ANSWER) 

a. I did not buy a pack of cigarettes during the past 30 

days 

b. A gas station 

c. A convenience store 

d. A grocery store 

e. A drugstore 

f. A vending machine 

g. I bought them over the Internet 

h. Other 
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23. When you bought or tried to buy cigarettes in a 

store during the past 30 days, were you ever asked 

to show proof of age? 

a. I did not try to buy cigarettes in a store during the 

past 30 days 

b. Yes, I was asked to show proof of age 

c. No, I was not asked to show proof of age 

24. During the past 30 days, did anyone ever refuse to 

sell you cigarettes because of your age? 

a. I did not try to buy cigarettes in a store during the 

past 30 days 

b. Yes, someone refused to sell me cigarettes 

because of my age 

c. No, no one refused to sell me cigarettes because of 

my age 

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

smoke cigarettes on school property? 

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 

26. Do you want to stop smoking cigarettes? 

a. I do not smoke now 

b. Yes 

c. No 

27. Are you seriously thinking about quitting smoking? 

a. I have never smoked 

b. I do not smoke now 

c. Yes, within the next 30 days 

d. Yes, within the next 6 months 

e. Yes, but not within the next 6 months 

f. No, I am not thinking of quitting smoking 

g. Not sure 

28. How many times during the past 12 months have 

you stopped smoking for one day or longer because 

you were trying to quit smoking? 

 

a. I have not smoked in the past 12 months 

b. I have not tried to quit 

c. 1 time 

d. 2 times 

e. 3 to 5 times 

f. 6 to 9 times 

g. 10 or more times 

29. When you last tried to quit, how long did you stay 

off cigarettes? 

a. I have never smoked cigarettes 

b. I have never tried to quit 

c. Less than a day 

d. 1 to 2 days 

e. 3 to 7 days 

f. More than 7 days but less than 30 days 

g. 30 days or more but less than 6 months 

h. 6 months or more but less than a year 

i. 1 year or more 

30. During the past 12 months, did a medical doctor,

dentist, or nurse ask you whether you smoke

cigarettes?

a. Yes 

b. No 

c. I don’t know/I can’t remember 

 

31. During the past 12 months, did a medical doctor, 

dentist, or nurse tell you to stop smoking? 

a. I have never smoked 

b. Yes 

c. No 

d. I don’t know/I can’t remember 

32. In the past 12 months, did you do any of the 

following to help you stop smoking? (CHOOSE 

ONE OR MORE ANSWERS)

a. I have never smoked 

b. I have not smoked in the past 12 months 

c. I did not try to quit in the past 12 months 

d. Attended a program in my school 

e. Attended a program in the community 

f. Called a help line or quit line 

g. Used nicotine gum 

h. Used nicotine patch 

i. Used any medicine to help quit 

j. Visited an internet quit site 

k. Got help from family or friends 

l. I tried to quit but did something else 

m. I tried to quit but did not do any of these things 

33. In the past 12 months, did you have to go to a stop 

smoking class because you were caught smoking? 

a. I have never smoked 

b. I have not smoked in the past 12 months 

c. Yes, I had to go to a stop smoking class 

d. No, I did not have to go to a stop smoking class 

34. Do you think you would be able to quit smoking 

cigarettes now if you wanted to? 

a. I do not smoke now 

b. Yes 

c. No 

35. How long can you go without smoking before you 

feel like you need a cigarette? 

a. I have never smoked cigarettes 

b. I do not smoke now 

c. Less than 1 hour 

d 1 to 3 hours 

e. More than 3 hours but less than a day 

f. A whole day 

g. Several days 

h. A week or more 

36. How true is this statement for you? After not 

smoking for a while, I feel restless and irritable. 

a. I have never smoked cigarettes 

b. I don’t smoke now 

c. Not at all true 

d. Not very true 

e. Fairly true 

f. Very true 
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37. How true is this statement for you? When I go 

without a smoke for a few hours, I experience 

craving. 

a. I have never smoked cigarettes 

b. I don’t smoke now

c. Not at all true 

d. Not very true 

e. Fairly true 

f. Very true 

The next questions are about smokeless tobacco—

chewing tobacco, snuff, or dip. 

38. Have you ever used chewing tobacco, snuff, or dip,

such as Redman, Levi Garrett, Beechnut, Skoal, 

Skoal Bandits, or Copenhagen? 

a. Yes 

b. No

39. 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 

d. 10 

e. 11 

f. 12 

g. 13 

h. 14 

i. 15 

j. 16 

k. 17 years old or older 

40. 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 

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

use chewing tobacco, snuff, or dip on school

property?

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 

f. All 30 days 

The next questions are about cigars and pipes. 

42. Have you ever tried smoking cigars, cigarillos, 

or little cigars, even one or two puffs? 

a. Yes 

b. No 

43. How old were you when you smoked a cigar, 

cigarillo, or little cigar for the first time? 

a. I have never smoked a cigar, cigarillo or little cigar 

b. 8 years old or younger 

c. 9 

d. 10 

e. 11 

f. 12 

g. 13 

h. 14 

i. 15 

j. 16 

k. 17 years old or older 

44. 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 

45. Have you ever tried smoking tobacco in a pipe, even

one or two puffs? 

a. Yes 

b. No 

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

smoke tobacco in a pipe?

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 questions are about bidies and kreteks. 

Bidis (or “beedies”) are small brown cigarettes from

India made of tobacco wrapped in a leaf tied with a

thread. They can taste like vanilla, chocolate, cherry 

or other flavors. Kreteks (or “clove cigarettes”) are 

cigarettes containing tobacco and clove extract. 

47. Have you ever tried smoking any of the 

following: 

a. Bidis 

b. Kreteks 

c. I have tried both bidis and kreteks 

d. I have never smoked bidis or kreteks 

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

smoke bidis?

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

smoke kreteks?

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 questions ask about other people smoking 

and using tobacco around you. 

50. During the past 7 days, on how many days were you

in the same room with someone who was smoking

cigarettes? 

a. 0 days 

b. 1 or 2 days 

c. 3 or 4 days 

d. 5 or 6 days 

e. 7 days 

51. During the past 7 days, on how many days did you

ride in a car with someone who was smoking

cigarettes?

a. 0 days 

b. 1 or 2 days 

c. 3 or 4 days 

d. 5 or 6 days 

e. 7 days 

52. Do you think the smoke from other people’s 

cigarettes is harmful to you? 

a. Definitely yes 

b. Probably yes 

c. Probably not 

d. Definitely not 

53. Does anyone who lives with you now smoke 

cigarettes?

a. Yes 

b. No 

54. Does anyone who lives with you now use chewing

tobacco, snuff, or dip?

a. Yes 

b. No 

55. How many of your four closest friends smoke 

cigarettes? 

a. None

b. One 

c. Two 

d. Three 

e. Four 

f. Not sure 

56. How many of your four closest friends use chewing

tobacco, snuff, or dip?

a. None

b. One 

c. Two 

d. Three 

e. Four 

f. Not sure 

57. Which statement best describes the rules about 

smoking inside your home?

a. Smoking is not allowed anywhere inside my home 

b. Smoking is allowed in some places or at some

times 

c. Smoking is allowed anywhere in my home 

d. There are no rules about smoking in my home

The next questions ask about your thoughts about 

tobacco. 

58. Do you think you will smoke a cigarette at 

anytime during the next year? 

a. Definitely yes 

b. Probably yes 

c. Probably not 

d. Definitely not 

59. Do you think you will be smoking cigarettes 5 years 

from now?

a. I definitely will 

b. I probably will

c. I probably will not 

d. I definitely will not 

60. If one of your best friends offered you a cigarette, 

would you smoke it? 

a. Definitely yes 

b. Probably yes 

c. Probably not 

d. Definitely not 

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

a. I have already tried smoking cigarettes 

b. Yes 

c. No 

62. During the past 12 months, has either of your

parents (or guardians) told you not to smoke

cigarettes?

a. Mother (female guardian) only 

b. Father (male guardian) only

c. Both 

d. Neither 

63. In the past 12 months, how often have your parents

or guardians discussed the dangers of tobacco use 

with you? 

a. Never 

b. Rarely

c. Sometimes 

d. Often 

e. Very often 
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64. Do you think it is safe to smoke for only a year or

two, as long as you quit after that? 

a. Definitely yes 

b. Probably yes 

c. Probably not 

d. Definitely not 

65. Do you think smoking cigarettes makes young

people look cool or fit in? 

a. Definitely yes 

b. Probably yes 

c. Probably not 

d. Definitely not 

Some tobacco companies make items like sports 

gear, t-shirts, lighters, hats, jackets, and sunglasses 

that people can buy or receive free. 

66. During the past 12 months, did you buy or 

receive anything that has a tobacco company name 

or picture on it? 

a. Yes 

b. No 

67. Would you ever use or wear something that has a 

tobacco company name or picture on it such as a 

lighter, t-shirt, hat, or sunglasses?

a. Definitely yes 

b. Probably yes 

c. Probably not 

d. Definitely not 

The next questions ask about events you may have 

attended or what you have seen or heard on the TV, 

radio, movies, billboards, signs, newspapers, 

magazines, stores, or the Internet. 

68. During the past 12 months, have you

participated in any community activities to

discourage people your age from using cigarettes,

chewing tobacco, snuff, dip, or cigars? 

a. Yes 

b. No 

c. I did not know about any activities 

69. During the past 30 days, how many times did you 

see anti-smoking messages on TV?

a. I did not watch TV in the past 30 days 

b. None

c. 1 to 3 times in the past 30 days 

d. 1 to 3 times per week 

e. Daily or almost daily

f. More than once a day 

70. During the past 30 days, how many times did you 

hear anti-smoking messages on the radio?

a. I did not listen to the radio in the past 30 days 

b. None

c. 1 to 3 times in the past 30 days 

d. 1 to 3 times per week 

e. Daily or almost daily

f. More than once a day 

71. During the past 30 days, how many times did you 

see anti-smoking messages on the Internet?

a. I did not use the Internet in the past 30 days

b. None

c. 1 to 3 times in the past 30 days 

d. 1 to 3 times per week 

e. Daily or almost daily

f. More than once a day 

72. During the past 30 days, how many times have you 

seen anti-smoking messages on billboards or

outdoor signs?

a. None in the past 30 days 

b. 1 to 3 times in the past 30 days 

c. 1 to 3 times per week 

d. Daily or almost daily

e. More than once a day 

73. During the past 30 days, how many times did you 

see anti-smoking messages in magazines or

newspapers? 

a. I did not read magazines or newspapers 

b. None in the past 30 days 

c. 1 to 3 times in the past 30 days 

d. 1 to 3 times per week 

e. Daily or almost daily

f. More than once a day 

74. When you watch TV or go to movies, how often do

you see actors using tobacco? 

a. I don’t watch TV or go to movies 

b. Most of the time 

c. Some of the time 

d. Hardly ever 

e. Never 

75. When you are using the Internet, how often do you 

see ads for tobacco products? 

a. I do not use the Internet 

b. Most of the time 

c. Some of the time 

d. Hardly ever 

e. Never 

76. When you read newspapers or magazines, how

often do you see ads or promotions for cigarettes 

and other tobacco products? 

a. I do not read newspapers or magazines 

b. All of the time 

c. Most of the time 

d. Some of the time 

e. Hardly ever 

f. Never 

77. When you go to a convenience store, supermarket, 

or gas station, how often do you see ads for 

cigarettes and other tobacco products or items that 

have tobacco company names or pictures on them?

a. I never go to a convenience store, supermarket, or 

gas station 

b. All of the time 

c. Most of the time 

d. Some of the time 

e. Hardly ever 

f. Never 
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The last questions ask if you were taught about 

tobacco in your classes. 

78. During this school year, did you practice ways

to say “No” to tobacco in any of your classes (for 

example, by role playing)? 

a. Yes 

b. No 

c. Not sure 

79. During this school year, were you taught in any of 

your classes the reasons why people your age 

smoke?

a. Yes 

b. No 

c. Not sure 

80. During this school year, were you taught in any of 

your classes that most people your age do not 

smoke cigarettes?

a. Yes 

b. No 

c. Not sure 

81. During this school year, were you taught in any of 

your classes about the dangers of tobacco use?

a. Yes 

b. No 

c. Not sure 

Thank you for participating in this survey. 

DO NOT WRITE BELOW THIS LINE 

OFFICE USE ONLY 

1. Who administered this survey? 

a. Teacher or other school staff person 

b. Data collector 

2. When was this survey administered? 

a. As part of the original survey administration 

b. As part of a make-up session 

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