19 Tobacco Use

ID NUMBER:

FORM CODE: TBE VERSION: A 6/18/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 03 minutes per response, including the 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Tobacco Use Questionnaire

ID NUMBER:

FORM CODE: TBE VERSION: A 6/18/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark a check in the appropriate box for the response. Unless instructed, mark ONLY one response.

A. Cigarette Smoking

1. Have you ever smoked at least 100 cigarettes in your entire life?

No 0  GO TO QUESTION 10

Yes 1

2. How old were you when you first started to smoke cigarettes fairly regularly?

Years old

Never smoked cigarettes regularly

3. Do you NOW smoke daily, some days or not at all?

Daily 1  GO TO QUESTION 4

Some days 2  GO TO QUESTION 5

Not at all 3  GO TO QUESTION 6

B. Smoke Daily

4. How many cigarettes do you smoke per day now?

Cigarettes per day (1 = 1 or fewer per day)

4a. Did you ever quit smoking for 6 months or longer?

No 0  GO TO QUESTION 9

Yes 1

4b. For how many years in total did you quit smoking?

Years  GO TO QUESTION 7

C. Smoke Some Days

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

Number of days

5a. During the past 30 days, on days that you smoked, how many cigarettes did you smoke per

day?

Cigarettes per day (1 = 1 or fewer per day)

5b. Did you ever quit smoking for 6 months or longer?

No 0  GO TO QUESTION 9

Yes 1

5c. For how many years in total did you quit smoking?

Years  GO TO QUESTION 7

D. Currently Smoke Not at All

6. How old were you when you completely stopped smoking?

Years old

6a. When you were a smoker, did you ever quit smoking for 6 months or longer before you

completely stopped smoking?

No 0  GO TO QUESTION 7

Yes 1

6b. During the time that you were a smoker, for how many years in total did you quit smoking?

Years

E. Smoking Cessation

7. What is the main reason you quit smoking cigarettes?

Advice of physician 1

Health reasons, self-initiated, including disease precaution 2

Pressure from others, excluding physician 3

Other 4

If other, please specify: ________________________

8. Of the items listed below, which have you used in the attempt to quit smoking? (Mark all that apply)

a. Nicotine gum

b. Nicotine patch

c. Nicotine spray

d. Xyban (bupropion)

e. Chantix (varenicline)

f. None of the above

9. Of the entire time you have or had smoked, on average how many cigarettes do you or did you smoke per day?

Cigarettes per day (1 = 1 or fewer per day)

F. Pipe Smoking

10. Have you ever smoked a pipe regularly? (Regularly means more than 12 oz. of tobacco in a lifetime.)

No 0

Yes 1

G. Cigar Smoking

11. Have you ever smoked cigars regularly? (Regularly means more than 1 cigar/week for one year at any time in your life.)

No 0

Yes 1

H. Second-hand Smoke Exposure

12. Before age 13, did you live with a regular cigarette smoker who smoked in your home?

No 0  GO TO QUESTION 14

Yes 1

Don’t know 9  GO TO QUESTION 14

13. Did your mother smoke in your home?

No 0

Yes 1

Don’t know 9

14. Not counting yourself, how many people currently living in your household smoke regularly in the home?

None 0

1 person 1  GO TO QUESTION 16

2 people 2  GO TO QUESTION 16

3 people 3  GO TO QUESTION 16

4 or more people 4  GO TO QUESTION 16

15. Since age 13 have you ever lived with a regular cigarette smoker (not including yourself) who smoked in your home?

No 0

Yes 1

16. During the past year, how many hours per week, on average, were you in close contact with people who were smoking? This includes time at home, at work, in a car, or other close quarters.

Hours per week

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