Form 1 Tobacco

Public reporting burden for this collection of information is estimated to average 04
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 (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL- Visit 2- Tobacco Use Questionnaire
FORM CODE:TBE
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION
0a.

/

Completion Date:

/

0b.

Staff ID:

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to code
'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

The following questions are about tobacco and tobacco use.
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  GO TO QUESTION 8a
C. Smoke Some Days
5.
During the past 30 days, how many days did you smoke cigarettes?
Number of days
5.a.

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 GO TO QUESTION 8a

TBE-Tobacco Use_12-10-2013.docx

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FORM CODE: TBE
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

D. Currently Smoke Not at All
6.

How old were you when you completely stopped smoking?
Years old

7.

What is the main reason you quit smoking cigarettes?
Advice of physician
Health reasons, self-initiated, including disease prevention
Pressure from others, excluding physician
Other
If other, please specify: ________________________

1
2
3
4

E. Smoking Cessation Aids
8.

Has a doctor ever prescribed any aids to help you quit smoking, such as nicotine replacement gum, the
patch, or any type of medication?
No
0
Yes, currently using 1
Yes, past use 2

9.

Have you ever used any over-the-counter aids to help you quit smoking, such as nicotine replacement
gum, the patch, or any type of medication?
No
0
Yes, currently using 1
Yes, past use 2

10.

Have you ever used behavioral or group therapy to help you quit smoking?
No
0
Yes
1

11.

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. Products other than cigarettes
12.

During the past 30 days, did you do any of the following, and if yes, on how many days did you do each?
12.a.

Smoke tobacco using a hookah (waterpipe)?
No
0
Yes
1
12.a.1. How many days

12.b.

Use spit tobacco, chew, dip, or "snus" tobacco (Copenhagen, Skoal, Grizzly)?
No
0
Yes
1
12.b.1. How many days

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FORM CODE: TBE
VERSION: 1, 12/10/2013

ID NUMBER:
12.c.

Contact
Occasion

0

2

SEQ #

Smoke an e-cigarette or electronic cigarette (Blu, V2)?
No
0
Yes
1
12.c.1. How many days

12.d.

Smoke a cigar, cigarillo or flavored cigar (Black & Mild, Swisher Sweets)?
No
0
Yes
1
12.d.1. How many days

13.

Not counting yourself, how many people currently living in your household smoke regularly in the home?
None 0
1 person 1
2 people 2
3 people 3
4 or more people 4

14.

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

TBE-Tobacco Use_12-10-2013.docx

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