Form 1 Tobacco Use Form

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 3e - English
PATH Study Data Collection Instruments:
Tobacco Use Form
June 18, 2013

PATH
Tobacco Use Form
Version 7.5
OMB Control Number: 0925-0664

Expiration Date: 11/30/2015

Public reporting burden for this collection of information is estimated to average 4 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 (XXXX-XXXX). Do
not return the completed form to this address.

PATH – Wave 1
Tobacco Use Form

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Tobacco Use Form
Version 7.5

TOBACCO USE FORM
PROGRAM:
The Tobacco Use Form captures recent exposure to nicotine prior to biospecimen collection. This form will
be used by Hooper Holmes phlebotomists for blood collection and Westat field interviewers when collection
occurs on a different day than when the Adult Extended questionnaire was administered. When collected by
Hooper Holmes, assign PATH IDs starting with the letter “H”. When collected by Westat field interviewers,
assign PATH IDs starting with the letter “W”.
BOX 1
Display question H/WY0001 on one screen. Show the question stem first, then show each item with the
yes/no responses.
PATH ID:

H/WY0001

Screen ID:

Have you used any of the following products today, yesterday or the day before yesterday?
1
2
3
4
5
6
7
8
9
10
11
12
-8
-7

Cigarettes
E-cigarettes
Traditional cigars
Cigarillos
Filtered cigars
Pipe filled with tobacco
Hookah
Snus pouches
Smokeless tobacco (such as loose snus, moist snuff, dip, spit or chew)
Dissolvable tobacco
A nicotine patch, gum, inhaler, nasal spray, lozenge or pill
Chantix, varenicline, Wellbutrin, Zyban, or bupropion
DON’T KNOW
REFUSED

GO TO H/WC0100
GO TO H/WE0100
GO TO BOX 2
GO TO BOX 2
GO TO BOX 2
GO TO H/WP0100
GO TO H/WH0100
GO TO BOX 3
GO TO BOX 3
GO TO H/WD0100
GO TO H/WN0307
GO TO H/WN0327
GO TO BOX 4
GO TO BOX 4

ASK: Respondents who have agreed to biospecimen collection
PATH ID:

H/WC0100

Screen ID:

When did you last smoke a cigarette?
1
2
3
4
5
-8
-7

GO TO H/WC0103
GO TO H/WC0102
GO TO H/WC0102
GO TO H/WC0102
GO TO H/WE0100
GO TO H/WE0100
GO TO H/WE0100

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

ASK: Respondents who have smoked a cigarette today, yesterday or the day before yesterday
(H/WY0001[1]=1)

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Tobacco Use Form

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Tobacco Use Form
Version 7.5
PATH ID:

H/WC0102

Screen ID:

When you last smoked a cigarette [FILL BASED ON H/WC0100], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have smoked a cigarette today, yesterday or the day before yesterday
(H/WC0100=2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WC0100]
If H/WC0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WC0100, making first letter lowercase.
PATH ID:

H/WC0103

Screen ID:

How many cigarettes [have/did] you [smoked/smoke] [FILL BASED ON H/WC0100]? A pack usually has 20
cigarettes in it.
I__I__I
1
Number
-8
DON’T KNOW
-7
REFUSED
ASK Respondents who have smoked a cigarette in past hour, today, yesterday or the day before yesterday
(H/WC0100=1 or 2 or 3 or 4)
PROGRAM: If respondent smoked in past hour or sometime today (H/WC0100=1 or 2), display “have” and
“smoked”. If respondent smoked yesterday or the day before yesterday (H/WC0100=3 or 4), display “did”
and “smoke”.
PROGRAM: [FILL BASED ON H/WC0100]
If H/WC0100=1 OR 2, display “today”
If H/WC0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WC0100
PATH ID:

H/WE0100

Screen ID:

When did you last use an e-cigarette?
1
2
3
4
5
-8
-7

GO TO H/WE0103
GO TO H/WE0102
GO TO H/WE0102
GO TO H/WE0102
GO TO BOX 2
GO TO BOX 2
GO TO BOX 2

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

ASK: Respondents who have used an e-cigarette today, yesterday or the day before yesterday
(H/WY0001[2]=1)

PATH – Wave 1
Tobacco Use Form

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Tobacco Use Form
Version 7.5
PATH ID:

H/WE0102

Screen ID:

When you last used an e-cigarette [FILL BASED ON H/WE0100], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have used an e-cigarette today, yesterday or the day before yesterday
(H/WE0100=2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WE0100]
If H/WE0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WE0100, making first letter lowercase.
PATH ID:

H/WE0103

Screen ID:

How many puffs from an e-cigarette [have/did] you [taken/take] [FILL BASED ON H/WE0100]?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK Respondents who have used an e-cigarette in past hour, today, yesterday or the day before yesterday
(H/WE0100=1 or 2 or 3 or 4)
PROGRAM: If respondent used in past hour or sometime today (H/WE0100=1 or 2), display “have” and
“taken”. If respondent used yesterday or the day before yesterday (H/WE0100=3 or 4), display “did” and
“take”.
PROGRAM: [FILL BASED ON H/WE0100]
If H/WE0100=1 OR 2, display “today”
If H/WE0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WE0100, making first letter lowercase.
BOX 2
If H/WY0001[3]=1, fill CIGARFILL with “traditional cigar”.
If H/WY0001[4]=1, fill CIGARFILL with “cigarillo”
If H/WY0001[5]=1, fill CIGARFILL with “filtered cigar”
Repeat H/WG0100-H/WG0103 for each type of cigar the respondent reports smoking in H/WY0001[3,4,5].

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Tobacco Use Form
Version 7.5
PATH ID:

H/WG0100

Screen ID:

When did you last smoke a [CIGARFILL]?
1
2
3
4
5
-8
-7

GO TO H/WG0103
GO TO H/WG0102
GO TO H/WG0102
GO TO H/WG0102
GO TO H/WP0100
GO TO H/WP0100
GO TO H/WP0100

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

ASK: Respondents who have smoked a [CIGARFILL] today, yesterday or the day before yesterday
(H/WY0001[3,4,5]=1)
PATH ID:

H/WG0102

Screen ID:

When you last smoked a [CIGARFILL] [FILL BASED ON H/WG0100], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have smoked a [CIGARFILL] today, yesterday or the day before yesterday
(H/WG0100=2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WG0100]
If H/WG0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WG0100, making first letter lowercase.
PATH ID:

H/WG0103

Screen ID:

How many [CIGARFILL]s [have/did] you [smoked/smoke] [FILL BASED ON H/WG0100]?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK Respondents who have smoked a [CIGARFILL] in past hour, today, yesterday or the day before
yesterday (H/WG0100=1 or 2 or 3 or 4)
PROGRAM: If respondent smoked in past hour or sometime today (H/WG0100=1 or 2), display “have” and
“smoked”. If respondent smoked yesterday or the day before yesterday (H/WG0100=3 or 4), display “did”
and “smoke”.
PROGRAM: [FILL BASED ON H/WG0100]
If H/WG0100=1 OR 2, display “today”
If H/WG0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WG0100, making first letter lowercase.

PATH – Wave 1
Tobacco Use Form

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Tobacco Use Form
Version 7.5
PATH ID:

H/WP0100

Screen ID:

When did you last smoke a a pipe filled with tobacco?
1
2
3
4
5
-8
-7

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

GO TO H/WP0103
GO TO H/WP0102
GO TO H/WP0102
GO TO H/WP0102
GO TO H/WH0100
GO TO H/WH0100
GO TO H/WH0100

ASK: Respondents who have smoked a pipe today, yesterday or the day before yesterday (H/WY0001[6]=1)
PATH ID:

H/WP0102

Screen ID:

When you last smoked a pipe filled with tobacco [FILL BASED ON H/WP0100], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have smoked a pipe today, yesterday or the day before yesterday (H/WP0100=2 or
3 or 4)
PROGRAM: [FILL BASED ON H/WP0100]
If H/WP0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WP0100, making first letter lowercase.
PATH ID:

H/WP0103

Screen ID:

How many bowls filled with pipe tobacco [have/did] you [smoked/smoke] [FILL BASED ON H/WP0100]?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK Respondents who have smoked a pipe in past hour, today, yesterday or the day before yesterday
(H/WP0100=1 or 2 or 3 or 4)
PROGRAM: If respondent smoked in past hour or sometime today (H/WP0100=1 or 2), display “have” and
“smoked”. If respondent smoked yesterday or the day before yesterday (H/WP0100=3 or 4), display “did”
and “smoke”.
PROGRAM: [FILL BASED ON H/WP0100]
If H/WP0100=1 OR 2, display “today”
If H/WP0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WP0100, making first letter lowercase.

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Tobacco Use Form

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Tobacco Use Form
Version 7.5
PATH ID:

H/WH0100

Screen ID:

When did you last smoke hookah?
1
2
3
4
5
-8
-7

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

GO TO H/WH0103
GO TO H/WH0102
GO TO H/WH0102
GO TO H/WH0102
GO TO BOX 3
GO TO BOX 3
GO TO BOX 3

ASK: Respondents who have smoked hookah today, yesterday or the day before yesterday
(H/WY0001[7]=1)
PATH ID:

H/WH0102

Screen ID:

When you last smoked hookah [FILL BASED ON H/WH0100], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have smoked hookah today, yesterday or the day before yesterday (H/WH0100=2
or 3 or 4)
PROGRAM: [FILL BASED ON H/WH0100]
If H/WH0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WH0100, making first letter lowercase.
PATH ID:

H/WH0103

Screen ID:

How many puffs from a hookah [have/did] you [taken/take] [FILL BASED ON H/WH0100]?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK Respondents who have smoked hookah in past hour, today, yesterday or the day before yesterday
(H/WH0100=1 or 2 or 3 or 4)
PROGRAM: If respondent smoked in past hour or sometime today (H/WH0100=1 or 2), display “have” and
“taken”. If respondent smoked yesterday or the day before yesterday (H/WH0100=3 or 4), display “did” and
“take”.
PROGRAM: [FILL BASED ON H/WH0100]
If H/WH0100=1 OR 2, display “today”
If H/WH0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WH0100, making first letter lowercase.

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Tobacco Use Form
Version 7.5
BOX 3
If H/WY0001[8]=1, fill SMKLSSFILL with “snus pouches”
If H/WY0001[9]=1, fill SMKLSSFILL with “smokeless tobacco”
Repeat H/WS0100-H/WS0103 for each type of smokeless tobacco the respondent reports using in
H/WY0001[8,9].
PATH ID:

H/WS0100

Screen ID:

When did you last use [SMKLSSFILL]?
1
2
3
4
5
-8
-7

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

GO TO H/WS0103
GO TO H/WS0102
GO TO H/WS0102
GO TO H/WS0102
GO TO H/WD0100
GO TO H/WD0100
GO TO H/WD0100

ASK: Respondents who have used [SMKLSSFILL], yesterday or the day before yesterday
(H/WY0001[8,9]=1)
PATH ID:

H/WS0102

Screen ID:

When you last used [SMKLSSFILL] [FILL BASED ON H/WS0100], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have used [SMKLSSFILL] today, yesterday or the day before yesterday
(H/WS0100=2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WS0100]
If H/WS0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WS0100, making first letter lowercase.

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Tobacco Use Form
Version 7.5
PATH ID:

H/WS0103

Screen ID:

How many [times/snus pouches] [have/did] you [used/use] [smokeless tobacco] [FILL BASED ON
H/WS0100]?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK Respondents who have used [SMKLSSFILL] in past hour, today, yesterday or the day before yesterday
(H/WS0100=1 or 2 or 3 or 4)
PROGRAM: If SMKLSSTYPE[1]=1, display “times” and “smokeless tobacco”; if SMKLSSTYPE[2]=2, display
“snus pouches”. If respondent used in past hour or sometime today (H/WS0100=1 or 2), display “have” and
“used”. If respondent used yesterday or the day before yesterday (H/WS0100=3 or 4), display “did” and
“use”.
PROGRAM: [FILL BASED ON H/WS0100]
If H/WS0100=1 OR 2, display “today”
If H/WS0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WS0100, making first letter lowercase.
PATH ID:

H/WD0100

Screen ID:

When did you last use dissolvable tobacco?
1
2
3
4
5
-8
-7

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

GO TO H/WD0103
GO TO H/WD0102
GO TO H/WD0102
GO TO H/WD0102
GO TO H/WN0307
GO TO H/WN0307
GO TO H/WN0307

ASK: Respondents who have used dissolvable tobacco today, yesterday or the day before yesterday
(H/WY0001[10]=1)
PATH ID:

H/WD0102

Screen ID:

When you last used dissolvable tobacco [FILL BASED ON H/WD0100], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have used dissolvable tobacco today, yesterday or the day before yesterday
(H/WD0100=2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WD0100]
If H/WD0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WD0100, making first letter lowercase.

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Tobacco Use Form
Version 7.5
PATH ID:

H/WD0103

Screen ID:

How many pieces of dissolvable tobacco [have/did] you [used/use] [FILL BASED ON H/WD0100]?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK Respondents who have used dissolvable tobacco in past hour, today, yesterday or the day before
yesterday (H/WD0100=1 or 2 or 3 or 4)
PROGRAM: If respondent used in past hour or sometime today (H/WD0100=1 or 2), display “have” and
“used”. If respondent used yesterday or the day before yesterday (H/WD0100=3 or 4), display “did” and
“use”.
PROGRAM: [FILL BASED ON H/WD0100]
If H/WD0100=1 OR 2, display “today”
If H/WD0100=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WD0100, making first letter lowercase.
PATH ID:

H/WN0307

Screen ID:

When did you last use a nicotine patch, gum, inhaler, nasal spray, lozenge or pill?
1
2
3
4
5
-8
-7

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

GO TO H/WN0309
GO TO H/WN0308
GO TO H/WN0308
GO TO H/WN0308
GO TO H/WN0327
GO TO H/WN0327
GO TO H/WN0327

ASK: Respondents who have used NRT today, yesterday or the day before yesterday (H/WY0001[11]=1)
PATH ID:

H/WN0308

Screen ID:

When you last used a nicotine patch, gum, inhaler, nasal spray, lozenge or pill [FILL BASED ON
H/WN0307], was it in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have used NRT today, yesterday or the day before yesterday (H/WN0307=2 or 3 or
4)
PROGRAM: [FILL BASED ON H/WN0307]
If H/WN0307=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WN0307, making first letter lowercase.

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Tobacco Use Form
Version 7.5
PATH ID:

H/WN0309

Screen ID:

When you used a nicotine patch, gum, inhaler, nasal spray, lozenge or pill [FILL BASED ON H/WN0307],
how many did you use?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK Respondents who have used NRT in past hour, today, yesterday or the day before yesterday
(H/WN0307=1 or 2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WN0307]
If H/WN0307=1 OR 2, display “today”
If H/WN0307=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WN0307, making first letter lowercase.
PATH ID:

H/WN0327

Screen ID:

When did you last use Chantix, varenicline, Wellbutrin, Zyban, or bupropion?
1
2
3
4
5
-8
-7

In the past hour
Sometime today
Yesterday
Day before yesterday
Three or more days ago
DON’T KNOW
REFUSED

GO TO H/WN0329
GO TO H/WN0328
GO TO H/WN0328
GO TO H/WN0328
GO TO BOX 4
GO TO BOX 4
GO TO BOX 4

ASK: Respondents who have used prescription drug to stop smoking today, yesterday or the day before
yesterday (H/WY0001[12]=1)
PATH ID:

H/WN0328

Screen ID:

When you last used Chantix, varenicline, Wellbutrin, Zyban, or bupropion [FILL BASED ON WN0327], was it
in the…
1
2
3
-8
-7

Morning
Afternoon
Evening
DON’T KNOW
REFUSED

ASK: Respondents who have taken a prescription drug to stop smoking today, yesterday or the day before
yesterday (H/WN0327=2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WN0327]
If H/WN0327=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WN0327, making first letter lowercase.

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Tobacco Use Form
Version 7.5
PATH ID:

H/WN0329

Screen ID:

When you used Chantix, varenicline, Wellbutrin, Zyban, or bupropion [FILL BASED ON WN0327], how
many did you take?
1
-8
-7

I__I__I
Number
DON’T KNOW
REFUSED

ASK: Respondents who have used a prescription drug to stop smoking in past hour, today, yesterday or the
day before yesterday (H/WN0327=1 or 2 or 3 or 4)
PROGRAM: [FILL BASED ON H/WN0327]
If H/WN0327=1 OR 2, display “today”
If H/WN0327=4, display “the day before yesterday”
Else, display text as shown in options selected in H/WN0327, making first letter lowercase.
BOX 4
Thank you. You have finished this part of the questionnaire. Please hand the computer to the interviewer.
Monitor Password: _____

The interviewer must now enter the Monitor Password into the computer.
ASK: Respondents who have agreed to biospecimen collection

PATH – Wave 1
Tobacco Use Form

13