Smoking Questionnaire
Smoking Questionnaire
Smoking Questionnaire
Participant ID
Date survey was completed MM/DD/YYYY
1. About how many cigarettes have you smoked in your entire life?
a. 10 cigarettes or less
b. 11 - 100 cigarettes (up to 5 packs)
c. 8 or 9 years old
d. 10 or 11 years old
e. 12 or 13 years old
f. 14 or 15 years old
g. 16 or 17 years old
h. 18 - 21 years old
i. 22 years old or older
14. About how long did your experimental smoking phase last? If you are a
current non-smoker, please indicate the length of time you experimented with
smoking before you stopped completely. If you are a current smoker, please
indicate the amount of time you experimented with smoking before becoming a
regular (daily or almost daily) smoker.
a. Less than 1 month
b. At least 1 month, but less than 6 months
c. At least 6 months, but less than 12 months (1 year)
d. At least 1 year, but less than 2 years
e. At least 2 years, but less than 4 years
f. 4 years or more
g. Don't know/not sure
15. During your experimental smoking phase, you may have smoked more
frequently at some times and less frequently at others. When you were smoking
most frequently during this phase, about how often did you smoke?
a. Daily or almost daily
b. At least weekly, but less than daily
c. At least monthly, but less than weekly
d. Less than monthly
e. Don't know/not sure
16. During your experimental smoking phase, you may have smoked more
cigarettes at some times than others. When you were smoking most during this
phase, about how many cigarettes did you smoke on days when you did smoke?
a. less than 1 cigarette per day
b. 1 cigarette per day
c. 2-5 cigarettes per day
d. 6-10 cigarettes per day
e. 11-20
f. 21 or more cigarettes per day
g. Other
17. During your experimental smoking phase, where did you usually smoke? (Select
only one response.)
a. At home
b. At school
c. At work
d. At friends' homes
e. At social events
f. In public places (e.g. parks, shopping centers, street corners)
18. During your experimental smoking phase, did you experience any of the
following regularly?
18.1. A pleasurable feeling
a. Yes
b. No
c. Don't know/not sure
18.2. A "buzz"
a. Yes
b. No
c. Don't know/not sure
b. No
c. Don't know/not sure
19. During your experimental smoking phase, did you believe that smoking
cigarettes could be harmful to your health?
a. Yes
b. No
c. Don't know/not sure
20. During your experimental smoking phase, did you believe that you could
become addicted to cigarettes?
a. Yes
b. No
c. Don't know/not sure
21. During your experimental smoking phase, did you think that smoking was
"cool"?
a. Yes
b. No
c. Don't know/not sure
22. During your experimental smoking phase, did you use any of the following
tobacco or nicotine products? Chewing tobacco or snuff, cigars, tobacco pipes, clove
cigarettes or bidis, nicotine replacement products such as gum or patch, or any
other tobacco products besides cigarettes.
a. Yes
b. No
23. When did you become a regular smoker?
a. I have never been a regular smoker
b. Before age 10
c. 10-13 years old
d. 14-17 years old
e. 18 - 21 years old
29. While you were growing up, did any of your parents/guardians smoke inside
your home?
a. Yes
b. No
c. Don't know/not sure
30. While you were growing up, did your parents/guardians allow visitors and guests
to smoke inside your home?
a. Yes
b. No
c. Don't know/not sure
31. While you were growing up, did your parents/guardians allo w you to smoke
inside your home?
a. Yes
b. No
c. Don't know/not sure
32. While you were growing up, did your parents/guardians ever talk to you about
the dangers of smoking?
a. Yes
b. No
c. Don't know/not sure
33. While you were growing up, did your parents/guardians tell you that you were
not allowed to smoke?
a. Yes
b. No
c. Don't know/not sure
34. While you were growing up, did you have a close relationship with your
parents/guardians?
a. Yes
b. No
39. During your experimental smoking phase, did people your age think that
smoking was "cool"?
a. None
b. Some
c. Most or all
d. Don't know/not sure
40. During your experimental smoking phase, did your friends think that smoking
was "cool"?
a. None
b. Some
c. Most or all
d. Don't know/not sure
41. When you were in school, were you taught about the dangers of smoking (for
example, lung cancer, heart disease, fire hazards)?
a. Yes
b. No
c. I did not attend school
d. Don't know/not sure
42. When you were in school, did you discuss the reasons why people smoke in any
of your classes?
a. Yes
b. No
c. I did not attend school
d. Don't know/not sure
43. When you were in school, were you taught about the side effects of smoking,
such as making teeth yellow, causing wrinkles, or making smokers smell bad?
a. Yes
b. No
b. No
c. Don't know/not sure
49. During your experimental smoking phase, was smoking allowed in any of the
following areas in your workplace? (Check all that apply.)
a. In my work area
b. In common areas (lobbies, rest rooms, lunch rooms)
c. In designated smoking areas
d. Don't know/not sure
e. Smoking was not allowed anywhere in my workplace
f. I was not working during my experimental smoking phase
50. During your experimental smoking phase, how many of your coworkers smoked?
a. I was not working during my experimental smoking phase
b. Most or all
c. Some
d. None
e. Don't know/not sure
51. When you were growing up, did the religious community you belonged to have a
general attitude toward smoking tobacco?
a. I did not belong to a religious community
b. My religious community did not approve of smoking
c. My religious community did not have a dominant attitude toward smoking
d. Smoking was accepted by my religious community
e. My religious community used tobacco in its ceremonies
f. Don't know/not sure
52. When you were growing up, did the ethnic community you belonged to have a
general attitude toward smoking tobacco?
a. I did not belong to an ethnic community
60. During your experimental smoking phase, did anyone refuse to sell you
cigarettes because of your age?
a. No
b. Sometimes
c. Often
d. I did not try to buy cigarettes
e. Don't know/not sure
61. During your experimental smoking phase, could you usually afford cigarettes?
a. Yes
b. No
c. I did not try to buy cigarettes
d. Don't know/not sure
62. As a teen, do you think you had a healthy lifestyle?
a. Yes
b. Somewhat
c. No
d. Don't know/not sure
63. As a teen, how often did you eat fruits and vegetables?
a. Less than 1 serving a day
b. Usually 1 serving a day
c. Usually 2-3 servings a day
d. Usually 4-5 servings or more a day
e. Don't know/not sure
64. As a teen, did you have a healthy diet? A healthy diet contains a wide variety of
foods and is high in fruits and vegetables, lean protein, low-fat dairy products, and
whole grain. It is low in sugar, fat, and salt.
a. Not at all
a. Yes
b. No
c. Dont Know/Not Sure
77. What is your race or ethnic group? (Check all that apply.)
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Other
g. Don't know/not sure
78. Which of these groups would you say best represents you race? (Check only
one.)
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Other
g. Don't know/not sure
79. When you were growing up, what language did you speak most often at home?
a. Chinese
b. English
c. Indonesian
d. Korean
e. Russian
f. Spanish
g. Tagalog
h. Telugu
i. No Response
j. Other
80. What is the highest grade or year of school you have completed?
a. Did not graduate from high school
b. High school graduate or equivalent (GED)
c. Some college or technical/vocational school, but no degree or certificate
d. Junior college or technical/vocational school degree or certificate
e. Bachelors degree or higher
81. What is the highest grade or year of school your parents/guardians completed?
(Answer on a separate line for each parent/guardian.)
81.1. Parent/guardian 1
a. Did not graduate from high school
b. High school graduate or equivalent (GED)
c. Some college or technical/vocational school, but no degree or certificate
d. Junior college or technical/vocational school degree or certificate
e. Bachelors degree or higher
81.2. Parent/guardian 2
a. Did not graduate from high school
b. High school graduate or equivalent (GED)
c. Some college or technical/vocational school, but no degree or certificate
d. Junior college or technical/vocational school degree or certificate
e. Bachelors degree or higher
81.3. Parent/guardian 3
a. Did not graduate from high school
b. High school graduate or equivalent (GED)
g. Other
85. When you were a teen, in what one state did you mostly live? (write in state)
86. How would you describe the area where you live?
a. Urban
b. Suburban
c. Rural
101. Is the subject a case, a control, or neither?
a. Case
b. Control
c. Neither
102. What is the FTND for this subject?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
10
c. C/T
d. not known
104. Subjects genotype for DRD2 -141 Ins/Del is:
a. I/I
b. D/D
c. I/D
d. not known
105. Subjects genotype for DDC is:
a. G/G
b. A/A
c. G/A
d. not known
106. Subjects combined genotype is: