During the past ten years have you received a tetanus shot?

Have you received a tetanus shot in the past 10 years?

Was your most recent tetanus shot given in 2005 or later?

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?

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?

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.

Do you work outside the home?

How many smoke inside the home?

Including yourself, how many persons in your household are current cigarette smokers?

Which of the following best describes the policy about smoking at your work place?

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?

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?

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?

Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?

Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?

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

During your last pregnancy, did any doctor, nurse, or other health professional advise you not to smoke?

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?

About how long has it been since you last smoked cigarettes?

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

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

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?

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."

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?

In restaurants, do you feel that smoking should be:

• Totally banned
• Allowed in designated areas
• Allowed anywhere

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?

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?

Would you support or oppose increasing the tax on smokeless tobacco? Smokeless tobacco products include chewing tobacco, snuf and snus.

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.

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?

Do you smoke cigarettes now?

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?

Have you ever smoked a cigar, even just a few puffs?

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?

In the past month, did you smoke cigars:

• Everyday
• Several times per week
• Once per week
• Less than once per week

Including yourself, how many persons in your household are current cigarette smokers?

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?

Would you like to stop smoking?

Do you work outside the home?

Which of the following best describes the policy about smoking at your work place?

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?

Do you still experience problems as a result of a head injury?

Have you ever had a head injury which caused you to lose consciousness or completely black out?

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?