Tetanus Diphtheria
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
During the past ten years have you received a tetanus shot?
 
Have you received a tetanus shot in the past 10 years?
 
There are currently two types of tetanus shots available for adults. One contains the tetanus diphtheria vaccine. The other type contains tetanus diphtheria and pertussis or whooping cough vaccine. Did your doctor say your recent tetanus shot included the pertussis or whooping cough vaccine?
 
Since 2005, have you had a tetanus shot?

If yes,ask:
“Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?”

 
Was your most recent tetanus shot given in 2005 or later?
 
Tetanus Diphtheria, Adolescents`
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
I would like to ask you about the tetanus diphtheria vaccine for your child.
Has he/she received a tetanus shot in the past 10 years?
 
There are currently two types of tetanus shots available today for older children and teenagers. One contains the tetanus diphtheria vaccine. The other type contains tetanus diphtheria and pertussis or whooping cough vaccine. Did the doctor say his/her most recent tetanus shot included the pertussis or whooping cough vaccine?
 
Was his/her most recent tetanus shot given in 2005 or later?
 
TOBACCO ISSUES:
 
Other Tobacco Products
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
A bidi is a flavored cigarette from India. Have you ever smoked a bidi, even one or two puffs?
 
Do you currently use cigars, pipes, bidis, kreteks, or any other tobacco product?
Do not include cigarettes, snus, snuff, or chewing tobacco.

NOTE: Bidis are small, brown, hand-rolled cigarettes from India and other southeast Asian countries. Kreteks are clove cigarettes made in Indonesia that contain clove extract and tobacco.
 
Do you currently use any tobacco products other than cigarettes, such as cigars, pipes, bidis, kreteks, or any other tobacco product?

NOTE: Bidis are small, brown, hand-rolled cigarettes from India and other southeast Asian countries. Kreteks are clove cigarettes made in Indonesia that contain clove extract and tobacco.
 
Do you now smoke a pipe every day, some days, or not at all?
 
Do you currently use chewing tobacco or snuff every day, some days, or not at all?
 
Do you currently use chewing tobacco, snuff or snus every day, some days, or not at all?
 
Do you now smoke bidis every day, some days, or not at all?
 
Do you now smoke cigars every day, some days, or not at all?
 
Have you ever smoked a cigar, even one or two puffs?
 
Have you ever smoked tobacco in a pipe, even one or two puffs?
 
Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?
 
Have you ever used or tried any smokeless tobacco products such as chewing tobacco, snuff, or snus? (Snus rhymes with goose).

NOTE: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches, that is placed under the lip against the gum.
 
Passive Smoke Exposure
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Do you work outside the home?
1998s
 
How many smoke inside the home?
1998s
 
Including yourself, how many persons in your household are current cigarette smokers?
1998s
 
Which of the following best describes the policy about smoking at your work place?
1998s
 
Secondhand Smoke I
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
On how many of the past 7 days, did someone smoke in your indoor workplace while you were there?
 
On how many of the past 7 days, did anyone smoke in your home while you were there?
 
Which statement best describes the rules about smoking inside your home? Do not include decks, garages, or porches.
 
In bars, do you THINK smoking should be allowed in all areas, some areas or not allowed at all?
 
In restaurants, do you THINK smoking should be allowed in all areas, some areas or not allowed at all?
 
Inside indoor workplaces, do you THINK smoking should be allowed in all areas, some areas or not allowed at all?
 
Secondhand Smoke Policy
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Which statement best describes the rules about smoking inside your home?
 
Which statement best describes the rules about smoking inside your home?
Do not include decks, garages, or porches.
 
While working at your job, are you indoors most of the time?
 
Which of the following best describes your place of work's official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?

Note: For workers who visit clients or work at home, "place of work" means their base location. For self-employed persons who work at home, the official smoking policy means the home smoking policy.
 
Which of the following best describes your place of work’s official smoking policy for work areas?
 
Secondhand Smoke Work Policy
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
While working at your job, are you indoors most of the time?
 
Which of the following best describes your place of work’s official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?

Note: For workers who visit clients or work at home, “place of work” means their base location. For self-employed persons who work at home, the official smoking policy means the home smoking policy.
 
Which of the following best describes your place of work’s official smoking policy for work areas?
 
Smokeless Tobacco Use
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?
1993o, 1994o, 1995o, 1996o, 1997o
 
Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?
 
Smoking and Pregnancy
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Have you been pregnant in the last 5 years?
 
[FORMER SMOKER:] Previously you reported you have smoked at least 100 cigarettes in your life but currently do not smoke cigarettes. During your last pregnancy, did you smoke cigarettes:

[CURRENT SMOKER:] Previously you reported you have smoked at least 100 cigarettes in your life and currently smoke every day or some days. During your last pregnancy, did you smoke cigarettes:

Please read:
  • Every day
  • Some days
  • Not at all
2006s
 
During your last pregnancy, did any doctor, nurse, or other health professional advise you not to smoke?
2006s
 
Smoking Cessation
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
About how long has it been since you last smoked cigarettes?
 
In the last 12 months, how many times have you seen a doctor, nurse or other health professional to get any kind of care for yourself?
 
In the last 12 months, on how many visits were you advised to quit smoking by a doctor or other health provider?
 
On how many visits did your doctor, nurse or other health professional recommend or discuss medication to assist you with quitting smoking, such as nicotine gum, patch, nasal spray, inhaler, lozenge, or prescription medication such as Wellbutrin/Zyban/Bupropion?

(Pronunciation: Well BYOU trin/ZEYE ban/byou PRO pee on)
 
On how many visits did your doctor or health provider recommend or discuss methods and strategies other than medication to assist you with quitting smoking?
 
Smoking Cessation, Doctor Advised
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
About how long has it been since you last smoked cigarettes?
 
Tobacco Cessation
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Are you planning to quit in the next 30 days?
 
Are you seriously considering quitting cigarettes in the next 6 months?
 
(Has a doctor or other health professional) ever advised you to quit smoking?
 
Have you ever used any of the following methods even for one day to help you quit smoking:
a. Nicotine gum
 
Have you ever used any of the following methods even for one day to help you quit smoking:
b. Nicotine patch
 
Have you ever used any of the following methods even for one day to help you quit smoking:
c. Nicotine nasal spray
 
Have you ever used any of the following methods even for one day to help you quit smoking:
d. Nicotine inhaler
 
Have you ever used any of the following methods even for one day to help you quit smoking:
e. Zyban, also called burproprion or wellbutrin - a pill
 
Have you ever used any of the following methods even for one day to help you quit smoking:
f. A quit smoking class or group
 
Have you ever used any of the following methods even for one day to help you quit smoking:
g. 'Cold turkey' or quitting on your own
 
Tobacco Indicators
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
A telephone quitline is a free telephone-based service that connects people who use tobacco with someone who can help them quit. Are you aware of any telephone quitline services that are available to help “you” [or “people”] quit using tobacco?
 
During the past 30 days, that is, since [fill in with appropriate DATE], on how many days did you smoke cigars, cigarillos, or very small cigars that look like cigarettes?

IF RESPONDENT IS UNSURE WHAT CIGARILLOS ARE, SAY: “Cigarillos are small, regular cigars. They are usually sold individually or in packs of 5 or 8. Some common brands are Black and Mild’s, Swisher Sweets Cigarillos, and Phillies Blunts, but there are others.”

IF RESPONDENT IS UNSURE WHAT VERY SMALL CIGARS THAT LOOK LIKE CIGARETTES ARE, SAY:“Very small cigars that look like cigarettes are usually brown in color and have a spongy filter like a cigarette. They are about the same size as cigarettes and are often sold in packs of 20. Some common brands are Prime Time little filter cigars and Winchester little filter cigars, but there are others.”
 
Have you ever tried smoking cigars, cigarillos, or very small cigars that look like cigarettes in your entire life, even one or two puffs?

IF RESPONDENT IS UNSURE WHAT CIGARILLOS ARE, SAY: “Cigarillos are small, regular cigars. They are usually sold individually or in packs of 5 or 8. Some common brands are Black and Mild’s, Swisher Sweets Cigarillos, and Phillies Blunts, but there are others.”

IF RESPONDENT IS UNSURE WHAT VERY SMALL CIGARS THAT LOOK LIKE CIGARETTES ARE, SAY:“Very small cigars that look like cigarettes are usually brown in color and have a spongy filter like a cigarette. They are about the same size as cigarettes and are often sold in packs of 20. Some common brands are Prime Time little filter cigars and Winchester little filter cigars, but there are others.”
 
Have you ever used or tried any dissolvable tobacco products such as Ariva, Stonewall, orbs, sticks, or strips?

INTERVIEWER NOTE: Dissolvable tobacco is finely milled tobacco which dissolves in the mouth.
 
Have you ever used or tried Electronic Cigarettes or E-cigarettes, such as Ruyan or NJOY?
 
How much additional tax on a pack of cigarettes would you be willing to support if some or all of the money raised was used to support programs designed to reduce tobacco use?
  • More than two dollars a pack
  • Two dollars a pack
  • One dollar a pack
  • Fifty to ninety-nine cents a pack
  • Less than fifty cents a pack
  • No tax increase
 
The Kansas State Legislature passed a statewide smoking ban in 2010 that prohibits smoking in indoor public places. Do you support or oppose this law?

INTERVIEWER NOTE: The Kansas Indoor Clean Air Act bans smoking in restaurants, bars, work places and other indoor public places, but does not ban smoking in casinos, 20% of hotel rooms and some private clubs.
 
Would you support or oppose increasing the tax on smokeless tobacco? Smokeless tobacco products include chewing tobacco, snuff and snus (snus rhymes with goose).
Interviewer Note: Snus (Swedish for snuff) is moist smokeless tobacco, usually sold in small pouches, that is placed under the lip against the gum.
 
When you quit smoking or the last time you tried to quit smoking, did you use nicotine replacement therapy - gum, patches, lozenges, nasal spray, inhaler, or the medications Zyban/Wellbutrin/buproprion (ZEYE ban/Well BYOU trin/byou PRO pee on) or Chantix/varenicline (SHAN tix/VAR en i cline) to assist you?
2009s
 
When you quit smoking or the last time you tried to quit smoking, did you use a telephone quitline to assist you?
Read if necessary: "A telephone quit line is a free telephone-based service that connects smokers with trained counselors who can help them quit smoking."
2009s
 
When you quit smoking or the last time you tried to quit smoking, did you use one-on-one counseling from a healthcare provider to assist you?
2009s
 
Tobacco Questions, Supplemental
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
In restaurants, do you feel that smoking should be:
  • Totally banned
  • Allowed in designated areas
  • Allowed anywhere
 
Which statement best describes the rules about smoking inside your home?
Do not include decks, garages, or porches.
  • Smoking is not allowed anywhere inside my home.
  • Smoking is allowed in some places or at some times.
  • Smoking is allowed anywhere inside my home.
  • There are no rules about smoking inside my home.
 
Which statement best describes the rules about smoking inside your home?
  • Smoking is not allowed anywhere inside your home.
  • Smoking is allowed in some places or at some times.
  • Smoking is allowed anywhere inside the home.
  • There are no rules about smoking inside the home.
 
Tobacco Related Issues
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Did this statewide smoking ban passed by the Kansas state legislature in 2010 prompt you to quit smoking or try to quit smoking?
 
During the past 30 days, have you heard or seen any advertisement for the Kansas Tobacco Quitline 1-800-QUIT-NOW?
 
Have you ever used or tried any dissolvable tobacco products such as Ariva, Stonewall, orbs, sticks, or strips?
 
Have you ever used or tried Electronic Cigarettes or E-cigarettes, such as Ruyan or NJOY?
 
How much additional tax on a pack of cigarettes would you be willing to support?
 
In general, do you support statewide laws that ban smoking in indoor public places such as stores, restaurants, bars, casinos, clubs, and sport arenas?
 
Kansas state legislature passed a statewide smoking ban in 2010 that prohibits smoking in indoor public places. Has this new law prompted you to eat out more often, less often or was there no difference?
 
The Kansas State Legislature passed a statewide smoking ban in 2010 that prohibits smoking in indoor public places. Do you support or oppose this law?

INTERVIEWER NOTE: The Kansas Indoor Clean Air Act bans smoking in restaurants, bars, work places and other indoor public places, but does not ban smoking in casinos, 20% of hotel rooms and some private clubs.
 
Would you support or oppose increasing the tax on smokeless tobacco? Smokeless tobacco products include chewing tobacco, snuf and snus.
 
Tobacco Tax
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
How much additional tax on a pack of cigarettes would you be willing to support?
 
How much additional tax on a pack of cigarettes would you be willing to support if some or all of the money raised was used to support programs designed to reduce tobacco use?
 
Would you support or oppose increasing the tax on smokeless tobacco? Smokeless tobacco products include chewing tobacco, snuf and snus.
 
Tobacco Use
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
About how long has it been since you last smoked cigarettes regularly, that is, daily?
 
Do you currently use chewing tobacco, snuff or snus every day, some days or not at all?

INTERVIEWER INSTRUCTION: Snus (Swedish for snuff) is a moist smokeless tobacco, ususally sold in small pouches that are placed under the lip against the gum.
 
Do you now smoke cigarettes everyday, some days, or not at all?
1996c, 1997c, 1998c, 1999cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2000cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2001cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2002cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2003cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2004cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2005cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2006cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2007cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2008cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2009cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2010cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2011cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2012cfor Do you now smoke cigarettes everyday, some days, or not at all?, 2013cfor Do you now smoke cigarettes everyday, some days, or not at all?
 
Do you smoke cigarettes now?
1993c, 1994c, 1995c
 
During the past 12 months, have you quit smoking for 1 day or longer?
 
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
2001cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2002cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2003cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2004cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2005cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2006cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2007cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2008cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2009cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2010cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2011cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2012cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?, 2013cfor During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
 
Have you ever smoked a cigar, even just a few puffs?
1998c
 
Have you smoked at least 100 cigarettes in your entire life?
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999cfor Have you smoked at least 100 cigarettes in your entire life?, 2000cfor Have you smoked at least 100 cigarettes in your entire life?, 2001cfor Have you smoked at least 100 cigarettes in your entire life?, 2002cfor Have you smoked at least 100 cigarettes in your entire life?, 2003cfor Have you smoked at least 100 cigarettes in your entire life?, 2004cfor Have you smoked at least 100 cigarettes in your entire life?, 2005cfor Have you smoked at least 100 cigarettes in your entire life?, 2006cfor Have you smoked at least 100 cigarettes in your entire life?, 2007cfor Have you smoked at least 100 cigarettes in your entire life?, 2008cfor Have you smoked at least 100 cigarettes in your entire life?, 2009cfor Have you smoked at least 100 cigarettes in your entire life?, 2010cfor Have you smoked at least 100 cigarettes in your entire life?, 2011cfor Have you smoked at least 100 cigarettes in your entire life?, 2012cfor Have you smoked at least 100 cigarettes in your entire life?, 2013cfor Have you smoked at least 100 cigarettes in your entire life?
 
How long has it been since you last smoked cigarettes regularly?
 
How long has it been since you last smoked a cigarette, even one or two puffs?
 
How many smoke inside the home?
1995s
 
In the past month, did you smoke cigars:
  • Everyday
  • Several times per week
  • Once per week
  • Less than once per week
1998c
 
Including yourself, how many persons in your household are current cigarette smokers?
1995s
 
On the average, about how many cigarettes a day do you now smoke?
 
On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
 
When was the last time you smoked a cigar?
1998c
 
Would you like to stop smoking?
1993c
 
Workplace Smoking
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Do you work outside the home?
1993s, 1994s, 1995s
 
Which of the following best describes the policy about smoking at your work place?
 
Transportation Physical Activity
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
The next two questions are about physical activity that you may do as part of your daily transportation to your job, the store, or other places that you go. Please include physical activity that you may have included in your previous answers.
During the past month, did you ride a bicycle for transportation, like to go to or from work, to run errands, or to go somewhere else that you wanted or needed to go?
 
The next two questions are about physical activity that you may do as part of your daily transportation to your job, the store, or other places that you go. Please include physical activity that you may have included in your previous answers.
During the past month, did you walk for transportation, like to go to or from work, to run errands, or to go somewhere else that you wanted or needed to go?
 
Traumatic Brain Injury
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional ever told you that you have suffered a traumatic brain injury (TBI)?
 
Do you still experience problems as a result of a head injury?
1997s
 
Have you ever had a head injury which caused you to lose consciousness or completely black out?
1997s
 
Including yourself, how many people in your household have received medical care or are limited in any way in any activities as a result of an injury to their head or brain?