Supplementary Appendix
This appendix has been provided by the authors to give readers additional information about their work.
Supplement to: D’Souza G, Kreimer AR, Viscidi R, et al. Case–control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007;356:1944-56.
0. Site number ____________________
1. Attendant I.D. number ___________
2. Subject status
Case………………………01
Control…………………...02
A0. Subject identification number______________________
A1. Date of administration.
_______/ ________/_________
Month
Day
Year
A2. Subjects date of birth?
_______/________/__________
Month
Day
Year
SURVEY FOR WOMEN
PLEASE READ THESE INSTRUCTIONS FIRST
To select an answer, touch the button on the screen next to the answer. A check mark
should appear in the box.
To change your answer, touch the button next to your new answer. A check mark
should appear in the box.
To go to the next question, touch the "NEXT" button on the bottom right hand corner of
the screen.
To return to a previous question, touch the "BACK" button at the bottom left hand
corner of the screen.
To review general instructions at any time, touch the "HELP" button at the bottom of
the screen.
To hear a question again, touch the "REPEAT" button at the bottom of the screen.
Please feel free to ask the attendant for help if you need it at anytime.
EXAMPLES HERE
PRACTICE QUESTION 1 TO 3
1
Please answer all of the following questions. Please choose only one answer for each
question unless otherwise instructed.
Some of these questions may be difficult for you to answer or may be hard to remember.
Some of these matters are also very personal. Please take your time, and do your best to
answer all of the questions as honestly as possible. Each question you answer will help
the doctors learn more about the causes of cancer.
All information you provide is strictly confidential. Only the main doctors involved in
the research will have access to this information. This information will not be released
to anyone else at any time for any purpose.
A. GENERAL INFORMATION
The following set of questions asks general information about your background.
A3. What is your gender?
Male……………………………………………………………
Female………………………………………………………….
A4. How old are you now?
01
02
____________________Years old
A5. Where were you born?
North America (United States, Canada, Mexico)………… 01
Central or South America………………………………… 02
Caribbean region or Bermuda……………………………….03
Europe and the British Isles……………………………… 04
Middle East………………………………………………. 05
Asia………………………………………………………. 06
Africa…………………………………………………….. 07
South Asia / Indian subcontinent…………………………. 08
Pacific Islands……………………………………………... 09
Australia / New Zealand………………………………….. 10
Other……………………………………………………… 11
Unsure……………………………………………………. 12
A7. What was the highest grade or level of school that you finished?
None………………………………………………... 01
8th grade or less…………………………………….. 02
Some high school…………………………………... 03
2
High school graduate………………………………. 04
Post-high school vocational or technical school…… 05
Some college……………………………………….. 06
College graduate…………………………………….07
Masters or Business degree…………………………08
Doctoral or Law degree………………………….. 09
A8. What is the income of your family this year?
$ 5,000 or less………………………………………01
$ 5,001-10,000…………………………………….. 02
$10,001-20,000…………………………………….. 03
$20,001-30,000…………………………………….. 04
$30,001-40,000…………………………………….. 05
$40,001-50,000……………………………………. 06
More than $50,000………………………………….07
A9. Where do you live now?
Homeless or homeless shelter……………………………………………… 01
In public assistance housing……………………………………………….. 02
Living with relatives or friends who pay all of the bills………..…………. 03
In a rented apartment or house where you pay some of the bills………….. 04
In a rented apartment or house where you pay all of the bills……………... 05
In a condominium or house that you own..…………………………….… 06
Other……………………………………………………………………….. 07
A10. Which of the following best describes your current work status?
Not working by choice (for example: homemaker, full-time student)………01
Not working, on public assistance (disability, welfare)……………………. 02
Not working, but looking for work………………………………….…… 03
Working part time……………………………………………………..…… 04
Working full time………………………………………………………… 05
Retired……………………………………………………………………… 06
A11. Which of the following best describes your race or ethnic background?
White/Caucasian…………………………………… 01
Black/African American…………………………… 02
Hispanic……………………………………………. 03
American Indian/Native American………………… 04
Asian/Pacific Islander……………………………….05
South Asian/Indian subcontinent……………………06
Middle Eastern………………………………………07
Other……………………………………………….. 08
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A12. Which of the following describes your current marital status?
Single………………………………………………. 01
Married or living as married……………………….. 02
Separated…………………………………………… 03
Divorced……………………………………………. 04
Widowed…………………………………………….05
Other……………………………………………….. 06
B. HEALTH QUESTIONS
The following questions ask about your health.
B1. Which of the following best describes your energy and activity level now?
I have normal energy
I do not feel sick in any way.
I can do heavy physical work. ……………………………………. 01
I can do my normal activities
I sometimes feel sick.
I can’t do heavy physical work..……………………………………02
I am unable to go to work
I can take care of myself.
I spend less than half the day in bed or in a chair.…………………. 03
I am unable to do house work
I need help to dress, bathe, or make meals.
I spend more than half the day in bed or in a chair. ……………… 04
I spend the entire day in bed or in a chair
I need others to take care of me all of the time.………………….. 05
B2. (a) How much do you weigh now? _______________ pounds
B2. (b) Have you lost weight (more than five pounds) in the last six months?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to B3a.If YES, answer B2c and B2d.
B2. (c) How much weight have you lost? __________ pounds
4
B3. (b) In the past 2 years, have you seen a dentist or dental hygienist for a routine
check-up?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B3. (c) In the past 12 months, have you brushed your teeth almost everyday or everyday?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B3. (d) In the past year, have you used mouthwash everyday or almost everyday?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to B4.If YES, answer B3e.
B3. (e) How many times a day do you use mouthwash?
Once……………………………………………………………….. 01
Twice………………………………………………………………. 02
Three times a day………………………………………………… 03
More that three times a day……………………………………….. 04
B4. Which of the following applies to you?
I have all or most of my natural teeth……………………………… 01
I have a partial……………………………………………………… 02
I have upper dentures (plates)……………………………………...03
I have lower dentures (plates)……………………………………... 04
I have both upper and lower dentures (plates)……………………...05
None of the above ……………..……………………………………06
B5. (a) Has a doctor ever told you that you have heart disease, for example, angina, heart
attack, or heart failure?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B5. (b) Has a doctor ever told you that you have lung disease, for example, emphysema,
chronic bronchitis, or asthma?
5
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B5. (c) Has a doctor ever told you that you have kidney disease?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B5. (d) Has a doctor ever told you that you have liver disease, for example, hepatitis or
cirrhosis?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B5. (e) Has a doctor ever told you that you have high blood pressure (hypertension)?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B5. (f) Has a doctor ever told you that you have diabetes?
NO………………………………………………………………… 01
YES……………………………………………………………….…02
UNSURE…………………………………………………………... 03
B5. (h) Has a doctor ever told you that you had a stroke?
NO………………………………………………………………… 01
YES……………………………………………………………….…02
UNSURE…………………………………………………………... 03
B5. (i) Has a doctor ever told you that you have heartburn, gastric reflux, GERD or a
hiatal hernia?
NO………………………………………………………………… 01
YES……………………………………………………………….…02
UNSURE…………………………………………………………... 03
B6. Have you ever had viral hepatitis (for example Hepatitis A, B, or C)?
NO………………………………………………………………… 01
YES……………………………………………………………….…02
UNSURE…………………………………………………………... 03
B7. Have you ever had warts (papillomas) in your mouth or throat?
NO………………………………………………………………… 01
YES……………………………………………………………….…02
UNSURE…………………………………………………………... 03
6
B9. Have you ever had a sexually transmitted disease (STD)?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B10. Have you ever had gonorrhea (the clap)?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B11. Have you ever had syphilis?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B12. Have you ever had chlamydia?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
B13. Have you ever had genital herpes?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
B14. Have you ever had genital warts or human papillomavirus (HPV) infection?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
B15. Have you ever had trichomonas (or trich infection)?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
B17. Have you ever been tested for HIV, the virus that causes AIDS?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B18. Have you ever tested positive for HIV, the virus that causes AIDS?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
B19. (a) CASE Have you ever had a previous cancer?
7
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
B19. (a) CONTROL OR CANCER-CONTROL Have you ever had cancer?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to B20. If yes, answer B19 b and c.
B19. (b) FEMALE What kind of cancer did you have?
Mouth, tongue, throat, or voice box (larynx)……………………….01
Lung. ……………………………………………………………….02
Breast……………………………………………………………….03
Colon………………………………………………………………..04
Cervical……………………………………………………………..05
Esophageal (swallowing tube) ……………………………………..06
Skin…………………………………………………………………07
Leukemia or Lymphoma (cancer of blood or bone marrow)………08
Ovarian (cancer of the ovaries)…………………………………….09
Vulvar (cancer of the entrance to the vagina)………………………10
Anal (cancer of the anus)……………………………………………11
Other………………………………………………………………..12
Don’t know…………………………………………………………13
B19. (b) MALE What kind of cancer did you have?
Mouth, tongue, throat, or voice box (larynx)………………………. 01
Lung. ………………………………………………………………. 02
Prostate…………………………………………………………… 03
Colon……………………………………………………………….. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Anal (cancer of the anus)………………………………………… 09
Other……………………………………………………………….. 10
Don’t know………………………………………………………… 11
B19. (b1) How old were you when you were diagnosed with this cancer?
_________________________ years old
B19. (c) Have you had another cancer?
NO………………………………………………………………… 01
8
YES…………………………………………………………….…. 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to B20. If yes, answer B19d.
B19. (d) FEMALE What other kind of cancer did you have?
Mouth, tongue, throat, or voice box (larynx)………………………01
Lung. ……………………………………………………………….02
Breast……………………………………………………………….03
Colon………………………………………………………………..04
Cervical……………………………………………………………..05
Esophageal (swallowing tube) ……………………………………..06
Skin…………………………………………………………………07
Leukemia or Lymphoma (cancer of blood or bone marrow)………08
Ovarian (cancer of the ovaries)…………………………………….09
Vulvar (cancer of the entrance to the vagina)………………………10
Anal (cancer of the anus)……………………………………………11
Other………………………………………………………………..12
Don’t know…………………………………………………………13
B19. (d) MALE What other kind of cancer did you have?
Mouth, tongue, throat, or voice box (larynx)………………………. 01
Lung. ………………………………………………………………. 02
Prostate…………………………………………………………… 03
Colon……………………………………………………………….. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Anal (cancer of the anus)………………………………………… 09
Other……………………………………………………………….. 10
Don’t know………………………………………………………… 11
B19. (e) How old were you when you were diagnosed with this cancer?
_________________________ years old
B20. Have you had your tonsils out (removed)?
NO………………………………………………………………… 01
YES……………………………………………………………….…01
UNSURE…………………………………………………………... 03
B21. WOMEN ONLY Have you ever had a Pap smear (a test for cervical cancer)?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
9
Extra text: A Pap smear is a test for cervical cancer. A Pap smear is made from cells
scraped from the cervix (opening of the uterus / womb). A Pap smear is done during
every routine pelvic exam.
If NO or UNSURE, skip to B25, if YES proceed to B22.
B22. WOMEN ONLY How often have you had a Pap smear done?
Once a year ………………………………………………………... 01
Once every 2 to 3 years……………………………………………..02
Once every 4 to 5 years……………………………………………..03
Once every 6 to 10 years……………………………………………04
Less often than every ten years……………………………………..05
B23. (a) WOMEN ONLY Have you ever had an abnormal Pap smear?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to B25. If YES, proceed to B24a.
B24. (a) WOMEN ONLY Did you ever get treatment for an abnormal Pap smear?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to B25a. If YES, proceed to B24b.
B24. (b) WOMEN ONLY How old were you when you first needed treatment for an
abnormal Pap smear?
11-15 years old.……………………………………………..01
16-20 years old.……………………………………………..02
21-25 years old.……………………………………………..03
26-30 years old.……………………………………………..04
31-40 years old.……………………………………………..05
41-50 years old.……………………………………………..06
51-60 years old.……………………………………………..07
Over 60 years old.………………………………………… 08
B24. (c) WOMEN ONLY Did you have a hysterectomy (your uterus or womb
removed)?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
The following questions apply only to your blood relatives;
10
Do not include adopted, foster or step-parents.
Do not include adopted, foster, half or step-siblings.
Do not include adopted, foster or step-children.
B25. (a) Do you have blood-related sisters?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip toB26a . If YES proceed to B25 b.
B25. (b) How many blood-related sisters do you have? _________ sisters
B26. (a) Do you have blood-related brothers?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip toB27a . If YES proceed to B26b.
B26. (b) How many blood-related brothers do you have? _________ brothers
B27. (a) Do you have blood-related daughters?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
If NO, skip to B28a . If YES proceed to B27a.
B27. (b) How many blood-related daughters do you have? _________ daughters
B28. (a) Do you have blood-related sons?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
If NO, skip toB29 . If YES, ask part B.
B28. (b) How many blood-related sons do you have? _________ sons
B29. (a) Has either your mother, father, brothers or sisters (who have the same parents as
you), grandmother, or grandfather, son or daughter ever been diagnosed with cancer?
NO………………………………………………………………… 01
11
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
UKNOWN because I was adopted………………………………… 04
If NO, UNSURE or ‘UNKNOWN because I was adopted, skip to question B40, if YES
proceed to B29b.
B29. (b) Which of your family members has had cancer? You may choose more than
one.
Mother…………………………………………………………..
01
Father……………………………………………………………. 02
One or more sisters……………………………………………… 03
One or more brothers……………………………………………. 04
One or more daughters…………………………………………… 05
One or more sons………………………………………………… 06
Mother’s mother (maternal grandmother)……………………….. 07
Mother’s father (maternal grandfather)………………………….. 08
Father’s mother (paternal grandmother)…………………………. 09
Father’s father (paternal grandfather)……………………………. 10
The following questions will be asked, depending on the answer to this question.
MOTHER (Answer to B29b includes 01)
B30. (a) What type of cancer did your mother have? Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know………………………………………………………… 11
B30. (b) Was your mother diagnosed with cancer before the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B30. (c) Did your mother have more than one type of cancer during her lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
12
If NO or UNSURE, skip to next appropriate section depending on answer to B29b
above . If YES, proceed to B30 d.
B30. (d) What other type of cancer did your mother have?
Mouth, tongue, throat, or voice box (larynx)…………………….. 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know………………………………………………………… 11
FATHER (Answer to B29b includes 02)
B31. (a) What type of cancer did your father have? Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
B31. (b) Was your father diagnosed with cancer before the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B31. (c) Did your father have more than one type of cancer during his lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b
above. If YES proceed to B31d.
B31. (d) What other type of cancer did your father have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
13
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
SISTER (Answer to B29b includes 03)
B32. (a) How many of your sisters had cancer? _________ sister(s)
Repeat questions for each sister. These questions will be repeated as many times as
necessary for the number of sisters with cancer.
B32. (b) What type of cancer did your sister have? Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know………………………………………………………… 11
B32. (c) Was your sister diagnosed with cancer before the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B32. (d) Did your sister have more than one type of cancer during her lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b and
B32a above. If YES, proceed to B32e.
B32. (e) What other type of cancer did your sister have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
14
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know…………………………………………………………11
BROTHER (Answer to B29b includes 04)
B33. (a) How many of your brothers had cancer? _________ brother(s)
Repeat questions for each brother. These questions will be repeated as many times as
necessary for the number of brothers with cancer.
B33. (b) What type of cancer did your brother have? Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
B33. (c) Was your brother diagnosed with cancer before the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B33. (d) Did your brother have more than one type of cancer during his lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b and
B33a above. If YES proceed to B33e.
B33. (e) What other type of cancer did your brother have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
Prostate.……………………………………………………………..04
15
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
DAUGHTER (Answer to B29b includes 05)
B34. (a) How many of your daughters had cancer? _________ daughter(s)
Repeat questions for each daughter. These questions will be repeated as many times as
necessary for the number of daughters with cancer.
B34.
(b) What type of cancer did your daughter have? Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know………………………………………………………… 11
B34. (c) Was your daughter diagnosed with cancer before the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B34. (d) Did your daughter have more than one type of cancer during her lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b and
B34a above. If YES, proceed to B34e.
B34.
(e) What other type of cancer did your daughter have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
16
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know…………………………………………………………11
SONS (Answer to B29b includes 06)
B35. (a) How many of your sons had cancer? _________ son(s)
Repeat questions for each son. These questions will be repeated as many times as
necessary for the number of sons with cancer.
B35. (b) What type of cancer did your son have? Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
B35. (c) Was your son diagnosed with cancer before the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B35. (d) Did your son have more than one type of cancer during his lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b and
B35a above. If YES, proceed to B35e.
B35. (e) What other type of cancer did your son have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
Prostate.……………………………………………………………..04
17
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
MATERNAL GRANDMOTHER (Answer to b29b includes 07)
B36. (a) What type of cancer did your mother’s mother (maternal grandmother) have?
Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know…………………………………………………………11
B36. (b) Was your mother’s mother (maternal grandmother) diagnosed with cancer
before the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B36. (c) Did your mother’s mother (maternal grandmother) have more than one type of
cancer during her lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b
above. If YES, proceed to B36d.
B36. (d) What other type of cancer did your mother’s mother (maternal grandmother)
have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
18
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know…………………………………………………………11
MATERNAL GRANDFATHER (Answer to B29b includes 08)
B37. (a) What type of cancer did your mother’s father (maternal grandfather) have?
Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
B37. (b) Was your mother’s father (maternal grandfather) diagnosed with cancer before
the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B37. (c) Did your mother’s father (maternal grandfather) have more than one type of
cancer during his lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b
above. If yes proceed to B37d.
B37. (d) What other type of cancer did your mother’s father (maternal grandfather)
have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon………………………………………………………………..03
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
19
Don’t know………………………………………………………… 09
PATERNAL GRANDMOTHER (Answer to B29b includes 09)
B38. (a) What type of cancer did your father’s mother (paternal grandmother) have?
Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other………………………………………………………………..10
Don’t know…………………………………………………………11
B38. (b) Was your father’s mother (paternal grandmother) diagnosed with cancer before
the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B38. (c) Did your father’s mother (paternal grandmother) have more than one type of
cancer during her lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to next appropriate section depending on answer to B29b
above. If yes proceed to B81d.
B38. (d) What other type of cancer did your father’s mother (paternal grandmother)
have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Breast………………………………………………………………. 03
Colon……………………………………………………………….. 04
Cervical…………………………………………………………….. 05
Esophageal (swallowing tube) …………………………………….. 06
Skin………………………………………………………………… 07
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 08
Ovarian (cancer of the ovaries)……………………………………. 09
Other……………………………………………………………….. 10
Don’t know………………………………………………………… 11
20
PATERNAL GRANDFATHER (Answer to B29b includes 10)
B39. (a) What type of cancer did your father’s father (paternal grandfather) have?
Where did the cancer start?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon………………………………………………………………..03
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other………………………………………………………………..08
Don’t know…………………………………………………………09
B39. (b) Was your father’s father (paternal grandfather) diagnosed with cancer before
the age of 50?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
B39. (c) Did your father’s father (paternal grandfather) have more than one type of
cancer during his lifetime?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to B40a. If YES, proceed to B39 d.
B39. (d) What other type of cancer did your father’s father (paternal grandfather) have?
Mouth, tongue, throat, or voice box (larynx)……………………… 01
Lung. ………………………………………………………………. 02
Colon……………………………………………………………….. 03
Prostate.……………………………………………………………. 04
Esophageal (swallowing tube) …………………………………….. 05
Skin………………………………………………………………… 06
Leukemia or Lymphoma (cancer of blood or bone marrow)……… 07
Other……………………………………………………………….. 08
Don’t know………………………………………………………… 09
Again, the following questions apply only to your blood relatives; do not include
relatives by marriage or friends of the family.
B40. (a) Have your aunts, uncles, or cousins ever been diagnosed with head or neck
cancer? Head or neck cancer is cancer of the mouth, tongue, throat, or voice box
(larynx).
NO………………………………………………………………… 01
21
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
UNKNOWN because I was adopted………………………………. 04
If NO, UNSURE or ‘UNKNOWN because I was adopted,’ skip to question C1. If YES,
proceed to B40b..
C. SMOKING HABITS
The following questions ask about tobacco.
C3. Over the past 10 years, would you say that you have breathed other people's cigarette
smoke, on average, for more than two hours a day AT HOME?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
C4. Over the past 10 years, would you say that you have breathed other people's cigarette
smoke, on average, for more than two hours a day AT WORK?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
I never worked outside the home………………………………… 03
C5. When you were a child (under the age of 18), did you live with any adults who
smoked tobacco in your home?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
The following questions ask about cigarette smoking.
C6. In your lifetime, have you ever smoked cigarettes EVERYDAY FOR MORE THAN
ONE YEAR?
NO…………………………………………………………………..01
YES………………………………………………………………….02
If NO, skip to question C14.
C7. During the time that you smoked cigarettes, what type of cigarette did you
USUALLY smoke?
Menthol or menthol lights…………………………………….…… 01
Ultra Lights or Lights ………………………………………………02
Mediums………... ………………………………………………… 03
Regulars or Reds ………………………………………………… 04
Unfiltered ..………………………………………………………… 05
Bidi………………………………………………………………… 06
Unsure….. ………………………………………………………… 07
22
Extra text: A bidi is a type of cigarette made in India. It is filter-less, flavored and handrolled.
C8. How old were you when you first tried smoking cigarettes? ____________ years old
C9. How old were you when you started smoking cigarettes regularly (EVERY DAY
FOR MORE THAN ONE YEAR)? _________________ years old
C10. (a) Have you completely quit smoking cigarettes?
NO ………………………………………………………………….01
YES, I quit in the last 12 months……………………………………02
YES, I quit more than a year ago…………………………………... 03
If NO, skip to question C11a.
C10. (b) How old were you when you completely quit smoking cigarettes?
________________________________________________________________ years old
C11. (a) During the time that you smoked cigarettes, was there ever a period when you
quit for more than a year?
NO…………………………………………………………..01
YES………………………………………………………… 02
If NO, skip to question C13a.
C11. (b) How many times have you successfully quit smoking cigarettes for more than
one year?
Once……..…………………………………………………. 01
Twice………………………………………………………. 02
Three times………………………………………………… 03
More than three times……………………………………… 04
Repeat the next questions as many times as the interviewee reports having quit
cigarette smoking.
C12. (c) How old were you when you quit the first time?_________________ years old
C12. (d) How old were you when you re-started? ______________________ years old
C12. (e) How old were you when you quit the second time? ______________ years old
C12. (f) How old were you when you re-started? ______________________ years old
C12. (g) How old were you when you quit the third time?________________ years old
C12. (h) How old were you when you re-started? ______________________years old
23
C13. (a) During the time that you smoked, how many packs of cigarettes did you
USUALLY smoke per day?
Less than half a pack……………………….. 01
Half a pack…………………………………. 02
One pack…………………………………… 03
One and a half packs………………………. 04
Two packs…………………………………. 05
Two and a half packs………………………. 06
Three packs………………………………… 07
Three and a half packs……………………... 08
Four packs………………………………… 09
Five or more packs………………………… 10
C13. (b) During the time that you smoked, did the amount of cigarettes you USUALLY
smoked each day ever increase or decrease by more than half a pack?
NO…………………...…………………………………………
01
YES…………………………………………………………….
02
If NO, skip to question C14. If YES, proceed to C13c.
Please think about the time in your life that you smoked cigarettes.
The next questions ask about the number of cigarettes you smoked at different times
in your life. The period of time will be shown at the top of the screen. For
example, “from age 18 to 21 years old.”
Intervals depend on answers to A4,C9, C10a and C10b above. Questions begin in
interval age @ start smoking per question C9. Questions terminate in interval age @ quit
smoking per question C10b. If C10a response is NO, questions terminate at current age
per A4.
From age at start to 17 years old
C13. (c) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
24
Five or more packs………………………… 11
From 18 to 21 years old
C13. (d) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
From 22 to 25 years old
C13. (e) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
From 26 to 30 years old
C13. (f) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
25
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
From 31 to 40 years old
C13. (g) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
From 41 to 50 years old
C13. (h) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
From 51 to 60 years old
C13. (i) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
26
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
From 61 to 70 years old
C13. (j) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
From 71 to current age or age at quit years old
C13. (k) During this time, how many packs of cigarettes did you USUALLY smoke per
day?
None……………………………………….. 01
Less than half a pack……………………….. 02
Half a pack…………………………………. 03
One pack…………………………………… 04
One and a half packs………………………. 05
Two packs…………………………………. 06
Two and a half packs………………………. 07
Three packs………………………………… 08
Three and a half packs……………………... 09
Four packs………………………………… 10
Five or more packs………………………… 11
The following questions ask about smoking marijuana.
C14. Have you ever smoked marijuana (pot, weed) or hashish at least ONCE A
MONTH FOR MORE THAN ONE YEAR?
27
NO…………………………………………………………………..01
YES……………………………………………....………………… 02
If NO, skip to question C19. If YES, proceed to question C15.
C15. How old were you when you first tried smoking marijuana (pot, weed) or hashish?
_________________ years old
C16. How old were you when you started smoking marijuana (pot, weed) or hashish
regularly (at least ONCE A MONTH FOR ONE YEAR)? ________________years old
C17. (a) Have you completely quit smoking marijuana (pot, weed) or hashish?
NO ………………………………………………………………….01
YES, I quit in the last 12 months……………………………………02
YES, I quit more than a year ago…………………………………... 03
If NO, skip to question C17c. If YES, proceed to C17b.
C17. (b) How old were you when you completely quit smoking marijuana (pot, weed) or
hashish? _________________________________________________________years old
C17. (c) During the time that you smoked marijuana (pot, weed) or hashish, was there
ever a period when you quit for more than a year?
NO…………………………………………………………..01
YES………………………………………………………… 02
If NO, skip to question C18a.. If YES, proceed to question C17d.
C17. (d) How many times have you successfully quit smoking marijuana (pot, weed) or
hashish for more than one year?
Once……..…………………………………………………. 01
Twice………………………………………………………...02
Three times…………………………………………………..03
More than three times……………………………………… .04
Repeat the next questions as many times as the interviewee reports having quit
marijuana (pot, weed) or hashish smoking.
C17. (e) How old were you when you quit the first time?________________ years old
C17. (f) How old were you when you re-started? ______________________years old
C17. (g) How old were you when you quit the second time? _____________ years old
C17. (h) How old were you when you re-started? _____________________years old
28
C17. (i) How old were you when you quit the third time?_______________ years old
C17. (j) How old were you when you re-started? ______________________years old
C18. (a) During the time that you smoked marijuana (pot, weed, hashish), how many
bowls, pipes, or joints would you USUALLY smoke per month?
Less than one per month…………………………………………… 01
1 per month………………………………………………………… 02
2 – 4 per month (or about 1 per week)…………………………….. 03
5 – 8 per month (or about 2 per week)…………………………….. 04
9 – 12 per month (or about 3 per week)…………………………… 05
13 – 16 per month (or about 4 per week)………………………….. 06
17 – 20 per month (or about 5 per week)………………………….. 07
21 – 24 per month (or about 6 per week)………………………….. 08
25 – 28 per month (or about 7 per week or one per day)………….. 09
More than one a day………………………………………………..10
If “more than one a day (10),” proceed to C18b. If 01-09, proceed to C19.
C18. (b) How many bowls, pipes, or joints would you smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day……………………………………….05
Please think of the time in your life when you smoked marijuana.
The next questions ask about the amount of marijuana you smoked at different
times in your life. The period of time will be shown at the top of the screen. For
example, “from age 18 to 21 years old.”
From age at start to 17
C18. (c) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
29
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18e. If “more than one a day(11),” proceed to C18d.
C18. (d) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From 18 to 21 years old
C18. (e) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18g. If “more than one a day(11),” proceed to C18f.
C18. (f) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 22 to 25 years old
C18. (g) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
30
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18i. If “more than one a day(11),” proceed to C18h.
C25. (h) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 26 to 30 years old
C18. (i) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18k. If “more than one a day(11),” proceed to C18j
C18. (j) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
31
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 31 to 40 years old
C18. (k) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18m. If “more than one a day(11),” proceed to C18l.
C18. (l) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From 41 to 50 years old
C18. (m) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
32
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18o. If “more than one a day(11),” proceed to C18n.
C18. (n) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 51 to 60 years
C18. (o) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18q. If “more than one a day(11),” proceed to C18p.
C18. (p) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 61 to 70 years old
33
C18. (q) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C18s. If “more than one a day(11),” proceed to C18r.
C18. (r) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 71 to current age or age at quit years old
C18. (s) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C19. If “more than one a day(11),” proceed to C18t.
34
C18. (t) During this time, how many bowls, pipes, or joints of marijuana did you
USUALLY smoke per month?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
The following questions ask about smoking cigars.
C19. Have you ever smoked cigars at least ONCE A MONTH FOR MORE THAN
ONE YEAR?
NO…………………………………………………………………..01
YES……………………………....………………………………… 02
If NO, skip to question C26. If YES, proceed to question C20.
C20. How old were you when you first tried smoking cigars? ______________ years old
C21. How old were you when you started smoking cigars regularly (at least ONCE A
MONTH FOR ONE YEAR)? _________________ years old
C22. (a) Have you completely quit smoking cigars?
NO ………………………………………………………………….01
YES, I quit within the last year…………………………………….. 02
YES, I quit more than a year ago…………………………………... 03
If NO, skip to question C23a. If YES, proceed to question C22b.
C22. (b) How old were you when completely quit smoking cigars?
___________________________ years old
C23. (a) During the time that you smoked cigars, was there ever a period when you quit
for more than a year?
NO…………………………………………………………..01
YES………………………………………………………… 02
If NO, skip to question C24. If YES, proceed to question C23b.
C23. (b) If yes, how many times have you successfully quit smoking cigars for more
than one year?
Once……..…………………………………………………..01
Twice………………………………………………………...02
Three times…………………………………………………..03
More than three times……………………………………… .04
35
Repeat the next questions as many times as they report having quit cigar smoking.
C23. (c)
How old were you when you quit the first time?_____________years old
C23. (d)
How old were you when you re-started? ___________________years old
C23. (e)
How old were you when you quit the second time? ___________years old
C23. (f)
How old were you when you re-started? ___________________years old
C23. (g)
How old were you when you quit the third time?_____________years old
C23. (h)
How old were you when you re-started? ___________________years old
C24. During the time that you smoked cigars, what kind did you USUALLY smoke?
Slim ring cigars (cigarillos)………………………………………... 01
Standard ring cigars………………………………………………... 02
Heavy ring cigars…………………………………………………... 03
Unsure or other……………………………………………………...04
C25. (a) During the time that you smoked cigars, how many cigars did you USUALLY
smoke per month?
Less than one per month…………………………………………… 01
1 per month………………………………………………………… 02
2 – 4 per month (or about 1 per week)……………………………...03
5 – 8 per month (or about 2 per week)……………………………...04
9 – 12 per month (or about 3 per week)…………………………….05
13 – 16 per month (or about 4 per week)…………………………...06
17 – 20 per month (or about 5 per week)………………………….. 07
21 – 24 per month (or about 6 per week)………………………….. 08
25 – 28 per month (or about 7 per week or one per day)…………...09
More than one a day………………………………………………...10
If 01-09, skip to C25c. If “more than one a day(10),” proceed to C25b.
C25. (b) How many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
Please think about the times in your life when you smoked cigars.
36
The next questions ask about the number of cigars you smoked at different times in
your life. The period of time will be shown at the top of the screen. For example,
“from age 18 to 21 years old.”
Intervals depend on answers to A4,C21, C22a and C22b above. Questions begin in
interval age @ start smoking per question C21. Questions terminate in interval age @
quit smoking per question C22b. If C22a response is NO, questions terminate at current
age per A4.
From age at start to 17 years old
C25. (c) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C25e. If “more than one a day(11),” proceed to C25d.
C25. (d) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From 18 to 21 years old
C25. (e) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
37
More than one a day………………………………………………...11
If 01-10, skip to C25g. If “more than one a day(11),” proceed to C25f.
C25. (f) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 22 to 25 years old
C25. (g) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C25i. If “more than one a day(11),” proceed to C25h.
C25. (h) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 26 to 30 years old
C25. (i) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
38
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C25k. If “more than one a day(11),” proceed to C25j
C25. (j) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 31 to 40 years old
C25. (k) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C25m. If “more than one a day(11),” proceed to C25l.
C25. (l) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 41 to 50 years old
C25. (m) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
39
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C25o. If “more than one a day(11),” proceed to C25n.
C25. (n) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 51 to 60 years old
C25. (o) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C25q. If “more than one a day(11),” proceed to C25p.
C25. (p) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 61 to 70 years old
C25. (q) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
40
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C25s. If “more than one a day(11),” proceed to C25r.
C25. (r) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
From age 71 to current age or age at quit years old
C25. (s) During this time, how many cigars did you USUALLY smoke per month?
None……………………………………………………………….. 01
Less than one per month…………………………………………… 02
1 per month………………………………………………………… 03
2 – 4 per month (or about 1 per week)……………………………...04
5 – 8 per month (or about 2 per week)……………………………...05
9 – 12 per month (or about 3 per week)…………………………….06
13 – 16 per month (or about 4 per week)…………………………...07
17 – 20 per month (or about 5 per week)………………………….. 08
21 – 24 per month (or about 6 per week)………………………….. 09
25 – 28 per month (or about 7 per week or one per day)…………...10
More than one a day………………………………………………...11
If 01-10, skip to C26. If “more than one a day(11),” proceed to C25t.
C25. (t) During this time, how many cigars did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
41
The following questions ask about pipe smoking.
C26. Have you ever smoked a pipe at least ONCE A MONTH FOR MORE THAN
ONE YEAR?
NO…………………………………………………………………..01
YES……………………………………………....………………… 02
If NO, skip to question C34. If YES, proceed to question C27.
C27. How old were you when you first tried smoking a pipe? ______________years old
C28. How old were you when you started smoking a pipe regularly (AT LEAST ONCE
A MONTH FOR ONE YEAR)? _________________
C29. (a) Have you completely quit smoking a pipe?
NO ………………………………………………………………….01
YES, I quit within the last year…………………………………….. 02
YES, I quit more than a year ago…………………………………... 03
If NO, skip to question C30a. If YES, proceed to C29b.
C29. (b) How old were you when you completely quit smoking a pipe?
_______________________________________________________ years old
C31 (a). During the time that you smoked a pipe, how many bowls (or pipes full) of
tobacco did you USUALLY smoke per month?
Less than one per month…………………………………………… 01
1 per month………………………………………………………… 02
2 – 4 per month (or about 1 per week)……………………………...03
5 – 8 per month (or about 2 per week)……………………………...04
9 – 12 per month (or about 3 per week)…………………………….05
13 – 16 per month (or about 4 per week)…………………………...06
17 – 20 per month (or about 5 per week)………………………….. 07
21 – 24 per month (or about 6 per week)………………………….. 08
25 – 28 per month (or about 7 per week or one per day)…………...09
More than one a day………………………………………………...10
If 01-09, skip to C32. If “more than one a day(10),”proceed to question C31b.
C31 (b). How many bowls (or pipes full) of tobacco did you USUALLY smoke per day?
2 – 4 per day………………………………………………...01
5 – 6 per day……………………………………………….. 02
7 – 8 per day………………………………………………...03
8 – 12 per day……………………………………………… 04
More than 12 per day………………………………………..05
42
C32. During the time that you smoked a pipe, how many pouches of pipe tobacco did you
USUALLY smoke per month (average pouch contains one and one half ounces)?
Less than one per month…………………………………………… 01
1 per month………………………………………………………… 02
2 – 4 per month (or about 1 per week)……………………………...03
5 – 8 per month (or about 2 per week)……………………………...04
9 – 12 per month (or about 3 per week)…………………………….05
13 – 16 per month (or about 4 per week)…………………………...06
17 – 20 per month (or about 5 per week)………………………….. 07
21 – 24 per month (or about 6 per week)………………………….. 08
25 – 28 per month (or about 7 per week or one per day)…………...09
More than one a day………………………………………………...10
Unsure……………………………………………………………….11
The following questions ask about chewing tobacco.
C34. Have you ever used chewing tobacco nearly EVERY DAY FOR MORE THAN
ONE YEAR?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
If NO, skip to question C29. If YES, proceed to question C35.
C35. How old were you when you first tried chewing tobacco? __________ years old
C36. (a) How old were you when you started chewing tobacco regularly (NEARLY
EVERY DAY FOR ONE YEAR)? _________________ years old
C36. (b) Have you completely quit chewing tobacco?
NO ………………………………………………………………….01
YES, I quit within the last year…………………………………….. 02
YES, I quit more than a year ago…………………………………... 03
If NO, skip to question C37a. If YES, proceed to C36c.
C36. (c) How old were you when you completely quit chewing tobacco?
_______________________________________________________ years old
C38. (a) Did you USUALLY buy your chewing tobacco in cans (1.2 ounces) or pouches
(3 ounces)?
Cans……………………………………………………………… 01
Pouches………………………………………………………….. 02
Cans and pouches……………………………………………….. 03
Other…………………………………………………………….. 04
43
If “cans (01),” proceed to C38b. If “pouches (02),” skip to C38c. If “cans and pouches
(03),” proceed to both C38b and c. If other, skip to C39.
C38. (b) During the time that you chewed tobacco, how many cans of chewing tobacco
did you USUALLY chew per month?
Less than one per month…………………………………………… 01
1 per month………………………………………………………… 02
2 – 4 per month (or about 1 per week)……………………………...03
5 – 8 per month (or about 2 per week)……………………………...04
9 – 12 per month (or about 3 per week)…………………………….05
13 – 16 per month (or about 4 per week)…………………………...06
17 – 20 per month (or about 5 per week)………………………….. 07
21 – 24 per month (or about 6 per week)………………………….. 08
25 – 28 per month (or about 7 per week or one per day)…………...09
More than one a day………………………………………………...10
C38. (c) During the time that you chewed tobacco, how many pouches of chewing
tobacco did you USUALLY chew per month?
Less than one per month…………………………………………… 01
1 per month………………………………………………………… 02
2 – 4 per month (or about 1 per week)……………………………...03
5 – 8 per month (or about 2 per week)……………………………...04
9 – 12 per month (or about 3 per week)…………………………….05
13 – 16 per month (or about 4 per week)…………………………...06
17 – 20 per month (or about 5 per week)………………………….. 07
21 – 24 per month (or about 6 per week)………………………….. 08
25 – 28 per month (or about 7 per week or one per day)…………...09
More than one a day………………………………………………...10
The following questions ask about snorting tobacco through the nose.
C39. Did you ever snuff tobacco (snort tobacco through the nose) DAILY FOR MORE
THAN A YEAR?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
If NO, skip to question C42. If YES, proceed with question C40.
C40. How old were you when you started using snuff?_________________years old
C41. (a) Have you stopped using snuff?
NO ………………………………………………………………….01
YES, I quit within the last year…………………………………….. 02
YES, I quit more than a year ago…………………………………... 03
If NO, skip to question C42. If YES, proceed to question C41b.
44
C41. (b) How old were you when you stopped? _____________________ years old
The following questions ask about chewing betel, betel-quid, areca nut or paan.
C42. Have you ever chewed betel, betel-quid, areca nut or paan DAILY FOR MORE
THAN A YEAR?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
UNSURE……………………………………………………………03
If NO, skip to question C45. If YES, proceed with question C43.
C43. How old were you when you started chewing betel, betel-quid, areca nut or paan?
_______________________ years old
C44. (a) Have you completely quit chewing betel, betel-quid, areca nut or paan?
NO ………………………………………………………………….01
YES, I quit within the last year…………………………………….. 02
YES, I quit more than a year ago…………………………………... 03
If you answered NO to this question (C41), please skip to question C42.
C44. (b) How old were you when you completely stopped chewing betel, betel-quid,
areca nut or paan? ___________________years old
A few more questions about your use of tobacco.
C45. During the time that you smoked tobacco, did you smoke cigarettes, cigars, or a
pipe when you were sick?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
C46. During the time that you smoked tobacco, did you find it difficult not to smoke in
'non-smoking' areas?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
C47. During the time that you smoked tobacco, did you USUALLY smoke soon after
you woke up in the morning?
NO………………………………………………………………… 01
YES………………………………………………………………… 02
45
D. ALCOHOL DRINKING HABITS
The following questions are about drinking alcohol.
D1. (a) Did you ever drink alcoholic beverages (beer, wine, liquor) at least ONCE A
MONTH FOR MORE THAN A YEAR?
NO…………………………………………………………………..01
YES………………………………………………………………… 02
If NO, skip to question E1. If YES, proceed to question D1b.
D1. (b) How old were you when you first tried drinking alcohol?
________________________________________________________years old
D1. (c) How old were you when you started to drink alcohol regularly (AT LEAST ONE
DRINK A MONTH)?
D1. (d) Have you completely quit drinking alcohol?
NO………………………………………………………………… 01
YES, I quit drinking alcohol in the last twelve months………
02
YES, I quit drinking alcohol more than a year ago…………….. 03
If NO, skip to D3a. If YES, proceed to D2.
D2. How old were you when you completely quit drinking alcohol?
______________________________________________________________years old
D3. (a) During the time that you drank alcohol, was there ever a period when you quit for
more than one year?
NO…………………………………………………………..01
YES………………………………………………………… 02
If NO, skip to questionD4. If YES, proceed to question D3b.
D3. (b) How many times have you quit drinking alcohol for more than one year?
Once……..…………………………………………………..01
Twice………………………………………………………...02
Three times…………………………………………………..03
More than three times……………………………………… .04
Repeat the next questions as many times as the interviewee reports having quit
drinking alcohol.
D3. (c) How old were you when you quit the first time?________________ years old
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D3. (d) How old were you when you re-started? ______________________years old
D3. (e) How old were you when you quit the second time? ______________years old
D3. (f) How old were you when you re-started? ______________________ years old
D3. (g) How old were you when you quit the third time?________________ years old
D3. (h) How old were you when you re-started? ______________________ years old
The following questions ask about your use of drinks containing alcohol IN THE
LAST 12 MONTHS.
D4 . In the last 12 months, how often have you had some kind of drink containing alcohol
(beer, wine, liquor or other)?
I have not had alcohol in the last 12 months………………………. 01
Less than once a month…………………………………………… 02
About once a month……………………………………………
03
2 to 3 times a month………………………………………………...04
1 to 2 days a week…………………………………………………. 05
3 to 4 days a week…………………………………………………. 06
5 to 6 days a week…………………………………………………. 07
Every day………………………………………………………….. 08
If the answer to D4 above is 01, skip to question D20 below.
Please think about the times when you drank alcohol in the last 12 months.
D5. Did you drink beer or malt liquor in the last 12 months?
NO…………………………………………………………………. 01
YES. …………...…………………………………………………... 02
If NO, skip to question D10. If YES, proceed to D6..
D6. Which do you drink more often: beer or malt liquor?
Beer………………………………………………………………………. 01
Malt liquor (like Mickeys, Colt 45, Magnum 22)………………………. 02
Both beer and malt liquor………………………………………………… 03
D7. How often have you had beer or malt liquor to drink in the last 12 months?
Less than once a month……………………………………………. 01
About once a month………………………………………………... 02
2 to 3 times a month………………………………………………...03
1 to 2 days a week…………………………………………………. 04
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3 to 4 days a week…………………………………………………. 05
5 to 6 days a week…………………………………………………. 06
Every day………………………………………………………….. 07
D8. (a) When you drank beer or malt liquor in the last 12 months, would you say you
USUALLY drank it by the
12 ounce can, bottle, or glass……………………………………… 01
Pint can, bottle, or glass (16 ounces)………………………………. 02
22 ounce bottle or can……………………………………….………03
Quart bottle (32 ounces)…………………………………………….04
40 ounce bottle………………………………………………………05
If the response to D8 is can or bottle (01), then for the potential responses to the next
question, D9, only responses in cans or bottles (01- 10) will appear; if the response to
D8 is pint (02), then for the potential responses to the next question, D9, responses in
pints (11-20) will appear. if the response to D8 is quart (03), then for the potential
responses to the next question, D9, responses in quarts (21-25) will appear.
D9. On the days that you drank beer or malt liquor in the last 12 months, how many 12ounce cans, bottles or glasses did you USUALLY drink?
1-2 a day………………………………………….. 01
3-4 a day………………………………………….. 02
5-6 a day………………………………………….. 03
7-8 a day………………………………………….. 04
9-10 a day……..………………………………….. 05
11-12 a day….…………………………………….. 06
13-18 a day……………………………………….. 07
19-24 a day………………………………………. 08
25-30 a day………………………………………. 09
More than 30 a day………………………………… 10
I drank more than I could count….…………………11
On the days that you drank beer or malt liquor in the last 12 months, how many pint sized
cans, bottles or glasses did you USUALLY drink?
1-2 a day…………………………………………..
3-4 a day…………………………………………..
5-6 a day…………………………………………..
6-8 a day…………………………………………..
9-10 a day……..…………………………………..
11-12 a day….……………………………………..
13-18 a day………………………………………..
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12
13
14
15
16
17
18
19-24 a day………………………………………. 19
More than 24 a day………………………………. 20
I drank more than I could count….………………….21
On the days that you drank beer or malt liquor in the last 12 months, how many 22-ounce
bottles or cans did you USUALLY drink?
1-2 a day………………………………………….. 22
3-4 a day………………………………………….. 23
5-6 a day………………………………………….. 24
7-8 a day………………………………………….. 25
9-10 a day……..………………………………….. 26
11-12 a day….…………………………………….. 27
13-18 a day……………………………………….. 28
More than 18 bottles or cans a day…………………29
I drank more than I could count….………………… 30
On the days that you drank beer or malt liquor in the last 12 months, how many quarts
(32 ounce bottles) did you USUALLY drink?
1-2 a day………………………………………….. 31
3-4 a day………………………………………….. 32
5-6 a day………………………………………….. 33
7-8 a day………………………………………….. 34
9-10 a day……..………………………………….. 35
11-12 a day….…………………………………….. 36
More than 12 quarts a day………………………… 37
I drank more than I could count….………………… 38
On the days that you drank beer or malt liquor in the last 12 months, how many 40-ounce
bottles or cans did you USUALLY drink?
1-2 a day………………………………………….. 39
3-4 a day………………………………………….. 40
5-6 a day………………………………………….. 41
7-8 a day………………………………………….. 42
9-10 a day……..………………………………….. 43
More than 6 bottles or cans a day………………… 44
I drank more than I could count….………………… 45
Please think about the times when you drank alcohol in the last 12 months.
D10. Did you drink any wine in the last 12 months?
NO…………………………………………………………………..01
YES………………………………………………………………….02
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If NO, skip to question D15. If YES, proceed to D11.
D11. When you drank wine in the last 12 months, what kind did you USUALLY drink?
Red , pink, white or champagne…………………………………….01
Fortified (like Wild Irish Rose, Thunderbird, sherry, port)……….. 02
D12. How often did you drink wine in the last 12 months?
Less than once a month……………………………………………. 01
About once a month………………………………………………... 02
2 to 3 times a month………………………………………………...03
1 to 2 days a week…………………………………………………. 04
3 to 4 days a week…………………………………………………. 05
5 to 6 days a week…………………………………………………. 06
Every day………………………………………………………….. 07
D13. On the days when you drank wine in the last 12 months, did you USUALLY drink
it by the
Glass (about 6 ounces)…………………………………………….. 01
Pint bottle or large flask (375 ml)………………………………… 02
Fifth or standard size bottle (750 ml)……………………………….03
Quart bottle (about 1 liter)………………………………………… 04
1.5 liter bottle (about half a gallon)…………………………………
05
If the response to D13 is ‘glass’ (01), then for the potential responses to the next
question, D14, only responses in ‘glasses’ (01- 08) will appear.
If the response to D13 is ‘pint bottle or large flask’ (02), then for the potential
responses to the next question, D14, only responses in ‘pint bottle or large flask’ (0914) will appear.
If the response to D13 is ‘Fifth or standard size bottle’ (03), then for the potential
responses to the next question, D14, only responses in ‘Fifth or standard size bottle’
(15-21) will appear.
If the response to D13 is ‘Quart bottle’ (04), then for the potential responses to the next
question, D14, only responses in ‘Quart bottle’ (22- 28) will appear.
If the response to D13 is ‘Half gallon bottle’ (05), then for the potential responses to
the next question, D14, only responses in ‘Half gallon’ bottle (29- 35) will appear.
D14. On the days when you drank wine in the last 12 months, how many glasses did you
USUALLY drink?
1-2 glasses a day…………………………………………………… 01
50
3-4 glasses a day…………………………………………………… 02
5-6 glasses a day…………………………………………………….03
7-8 glasses a day…………………………………………………… 04
9-10 glasses a day………………………………………………….. 05
11-12 glasses a day………………………………………………… 06
More than 12 glasses a day………………………………………… 07
I drank more than I could count….………………………………….08
On the days when you drank wine in the last 12 months, how many pints did you
USUALLY drink?
1 pint a day………………………………………………………….09
2 pints a day…………………………………………………………10
3 pints a day……………………………………………………….. 11
4 pints a day……………………………………………………….. 12
More than 4 pints a day…………………………………………….13
I drank more than I could count….………………………………….14
On the days when you drank wine in the last 12 months, how many fifths or standard size
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 15
Half a bottle to less than one bottle a day………………………… 16
One bottle to less than one and a half bottles a day……………… 17
One and a half to less than two bottles a day……………………… 18
Two bottles a day………………………………………………… 19
More than 2 bottles a day…………………………………………. 20
I drank more than I could count….………………………………….21
On the days when you drank wine in the last 12 months, how many quart bottles did you
USUALLY drink?
Less than half a bottle a day………………………………………. 22
Half a bottle to less than one bottle a day………………………… 23
One bottle to less than one and a half bottles a day……………… 24
One and a half to less than two bottles a day……………………… 25
Two bottles a day………………………………………………… 26
More than 2 bottles a day…………………………………………. 27
I drank more than I could count….………………………………….28
On the days when you drank wine in the last 12 months, how many 1.5 liter bottles
(about half a gallon) did you USUALLY drink?
Less than half a bottle a day………………………………………. 29
Half a bottle to less than one bottle a day………………………… 30
One bottle to less than one and a half bottles a day……………… 31
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One and a half to less than two bottles a day……………………… 32
Two bottles a day………………………………………………… 33
More than 2 bottles a day…………………………………………. 34
I drank more than I could count….………………………………….35
Please think about the times when you drank alcohol in the last 12 months.
D15. Did you drink any liquor in the last 12 months (for example, whiskey, scotch,
bourbon, rye, gin, vodka, rum, tequila, brandy, amaretto, crème de menthe, schnapps,
Bailey’s Irish Crème)?
NO…………………………………………………………………..01
YES………………………………………………………………….02
If NO, skip to question D20. If YES, proceed to question D16.
D16. What kind of liquor did you USUALLY drink in the last 12 months?
Hard liquor (for examples, whiskey, vodka, gin, rum, cognac,
tequila, brandy)……………………………………………………. 01
Aperitif (for example, Bailey’s Irish crème, Crème de cassis, schnapps,
Crème de menthe, Kahlua, Amaretto, Godiva)…………… 02
Both hard liquor and aperitif……………………………………….. 03
D17. In the past 12 months, how often did you USUALLY drink liquor?
Less than once a month……………………………………………. 01
About once a month………………………………………………... 02
2 to 3 times a month………………………………………………...03
1 to 2 days a week…………………………………………………. 04
3 to 4 days a week…………………………………………………. 05
5 to 6 days a week…………………………………………………. 06
Every day………………………………………………………….. 07
D18. When you drank liquor in the last 12 months, would you say you drank it by the
Drink, shot or mini (about one and a half ounces)………………… 01
Shorty (100 ml)……………………………………………………. 02
Mickey or small flask bottle (200 ml)………………………………03
Pint or large flask bottle (375 ml)………………………………… 04
Fifth or standard size bottle (750 ml)……………………………….05
Quart bottle (about 1 liter)……………………………………..……06
Half gallon bottle (1.75 liters)……………………………………… 07
If the response to D18 is ‘Drink, shot or mini’ (01), then for the potential responses to
the next question, D19, only responses in ‘Drink, shot or mini’ (01- 08) will appear.
If the response to D18 is ‘Shorty’ (02), then for the potential responses to the next
question, D19, only responses in ‘Shorty’ (09- 16) will appear.
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If the response to D18 is ‘Mickey or small flask bottle’ (03), then for the potential
responses to the next question, D19, only responses in ‘Mickey or small flask bottle’
(17- 22) will appear.
If the response to D18 is ‘Pint or large flask bottle’ (04), then for the potential
responses to the next question, D19, only responses in ‘Pint or large flask bottle’ (2328) will appear.
If the response to D18 is ‘Fifth or standard size bottle’ (05), then for the potential
responses to the next question, D19, only responses in ‘Fifth or standard size bottle’
(29- 35) will appear.
If the response to D18 is ‘Quart bottle’ (06), then for the potential responses to the next
question, D19, only responses in ‘Quart bottle’ bottle (36- 42) will appear.
If the response to D18 is ‘Half gallon bottle’ (07), then for the potential responses to
the next question, D19, only responses in ‘Half gallon’ bottle (43- 49) will appear.
D19. On the days that you drank liquor in the last 12 months, how many drinks, shots, or
minis did you USUALLY drink?
1-2 drinks, shots or minis a day……………………………………01
3-4 drinks, shots or minis a day ……………………………………02
5-6 drinks, shots or minis a day ……………………………………03
7-8 drinks, shots or minis a day ……………………………………04
9-10 drinks, shots or minis a day ………………………………… 05
11-12 drinks, shots or minis a day …………………………………06
More than 12 drinks, shots or minis a day …………………………07
I drank more than I could count….………………………………….08
On the days when you drank liquor in the last 12 months, how many shorties did you
USUALLY drink?
1-2 bottles a day……………………………………09
3-4 bottles a day ……………………………………10
5-6 bottles a day ……………………………………11
7-8 bottles a day ……………………………………12
9-10 bottles a day ………………………………… 13
11-12 bottles a day …………………………………14
More than 12 bottles a day …………………………15
I drank more than I could count….………………… 16
On the days when you drank liquor in the last 12 months, how many mickeys or small
flask bottles did you USUALLY drink?
53
1 flask a day…………………………………………………………17
2 flasks a day……………………………………………………… 18
3 flasks a day……………………………………………………… 19
4 flasks a day……………………………………………………… 20
More than 4 flasks a day………………………………………… 21
I drank more than I could count….………………………………….22
On the days when you drank liquor in the last 12 months, how many pints or large flask
bottles did you USUALLY drink?
1 pint a day……………………………………………………… 23
2 pints a day……………………………………………………… 24
3 pints a day……………………………………………………… 25
4 pints a day……………………………………………………… 26
More than 4 pints a day……………………………………………. 27
I drank more than I could count….………………………………….28
On the days when you drank liquor in the last 12 months, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 29
Half a bottle to less than one bottle a day………………………… 30
One bottle to less than one and a half bottles a day……………… 31
One and a half to less than two bottles a day……………………… 32
Two bottles a day………………………………………………… 33
More than 2 bottles a day…………………………………………. 34
I drank more than I could count….………………………………….35
On the days when you drank liquor in the last 12 months, how many quarts did you
USUALLY drink?
Less than half a bottle a day………………………………………. 36
Half a bottle to less than one bottle a day………………………… 37
One bottle to less than one and a half bottles a day……………… 38
One and a half to less than two bottles a day……………………… 39
Two bottles a day………………………………………………… 40
More than 2 bottles a day…………………………………………. 41
I drank more than I could count….………………………………….42
On the days when you drank liquor in the last 12 months, how many half gallon bottles
did you USUALLY drink?
Less than half a bottle a day………………………………………. 43
Half a bottle to less than one bottle a day………………………… 44
54
One bottle to less than one and a half bottles a day……………… 45
One and a half to less than two bottles a day……………………… 46
Two bottles a day………………………………………………… 47
More than 2 bottles a day…………………………………………. 48
I drank more than I could count….………………………………….49
Please think about the different times in your life that you drank alcohol.
The next questions ask about how much alcohol you drank at different times in your
life. The period of time will be shown at the top of the screen. For example, “from
age 18 to 21 years old.”
Questions need to be started at the age reported in D1c. Questions will only be asked
up to the age of the person taking the questionnaire (to the period of life they are
currently in) or age at quit per question D2).
From age at start to 17 years old
D20. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to question D24. If YES, proceed to question D21.
D21. How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D22 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ………………………..……………………….
01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
55
If the response to D22a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D22b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D22a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D22b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D22a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D22b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D22a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D22b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D22a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D22b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
If the response to D22a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D22b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D22(b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
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2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D23. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
From age 18 to 21 years old
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D24. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to D28. If YES, proceed to question D25.
D25. How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D26 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ………………………..……………………….
01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
If the response to D26a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D26b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D26a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D26b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D26a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D26b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D26a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D26b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D26a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D26b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
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If the response to D26a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D26b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D26 (b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
59
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D27. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
From age 22 to 25 years old
D28. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to D32. If YES, proceed to D29.
D29. How often did you drink alcohol during this time in your life
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D30 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
60
Drink or shot ……………………….……………………….
01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
If the response to D30a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D30b, only responses in ‘Shot or drink’ (01- 07) will appear.
If the response to D30a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D30b, only responses in ‘Mickey or small flask bottle’
(08- 12) will appear.
If the response to D30a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D30b, only responses in ‘Pint or large flask bottle’ (1317) will appear.
If the response to D30a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D30b, only responses in ‘Fifth or standard size bottle’
(18- 22) will appear.
If the response to D30a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D30b, only responses in ‘Quart bottle’ bottle (23- 27) will appear.
If the response to D30a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D30b, only responses in ‘Half gallon’ bottle (28- 32) will appear.
D30 (b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
61
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
62
D31. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
From age 26 to 30 years old
D32. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to D36. If YES, proceed to D33.
D33. How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D34 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ……………………………..………………………. 01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
63
If the response to D34a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D34b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D34a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D34b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D34a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D34b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D34a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D34b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D34a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D34b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
If the response to D34a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D34b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D34 (b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
64
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D35. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
From age 31 to 40 years old
65
D36. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to D40. If YES, proceed to D37.
D37. How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D38 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ………………………………………………………. 01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
If the response to D38a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D38b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D38a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D38b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D38a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D38b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D38a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D38b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D38a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D38b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
66
If the response to D38a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D38b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D38 (b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
67
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D39. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
From age 41 to 50 years old
D40. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to D44. If YES, proceed to D41.
D41. How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
68
D42 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ……………………………..………………………. 01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
If the response to D42a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D34b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D42a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D42b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D42a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D42b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D42a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D42b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D42a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D42b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
If the response to D42a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D42b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D42 (b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
69
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
70
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D43. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
From age 51 to 60 years old
D44. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to D48. If YES, proceed to D45.
D45. How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D46 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ……………………………..………………………. 01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
71
If the response to D46a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D46b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D46a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D46b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D46a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D46b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D46a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D46b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D46a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D46b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
If the response to D46a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D46b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D46 (b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
72
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D47. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
73
From age 61 to 70 years old
D48. During this time in your life, did you drink alcohol (beer, wine, liquor) at least once
a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to question D52. If YES, proceed to D49.
D49. How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D50 (a). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ………………………………………………………. 01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
74
If the response to D50a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D50b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D50a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D50b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D50a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D50b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D50a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D50b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D50a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D50b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
If the response to D50a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D50b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D50 (b). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
75
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D51. What type of alcohol did you USUALLY drink during this time in your life? You
may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
From age 71 to current age or age at quit years old
76
D51. (a) During this time in your life, did you drink alcohol (beer, wine, liquor) at least
once a month?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to question D52. If YES, proceed to D49.
D51. (b) How often did you drink alcohol during this time in your life?
About once a month………………………………………………... 01
2 to 3 times a month………………………………………………...02
1 to 2 days a week…………………………………………………. 03
3 to 4 days a week…………………………………………………. 04
5 to 6 days a week…………………………………………………. 05
Every day………………………………………………………….. 06
D51 (c). When you drank alcohol during this time in your life, would you say you drank
it by the
Drink or shot ………………………………………………………. 01
(A drink is one can, bottle, or glass of beer, a glass of wine, a shot
of liquor, or one mixed drink)
Mickey or small flask bottle (200 ml)………………………………02
Pint or large flask bottle (375 ml)………………………………… 03
Fifth or standard size bottle (750 ml)……………………………….04
Quart bottle (about 1 liter)………………………………………..…05
Half gallon bottle (1.75 liters)……………………………………… 06
If the response to D50a is ‘Shot or drink’ (01), then for the potential responses to the
next question, D50b, only responses in ‘Shot or drink’ (01- 08) will appear.
If the response to D50a is ‘Mickey or small flask bottle’ (02), then for the potential
responses to the next question, D50b, only responses in ‘Mickey or small flask bottle’
(09-14) will appear.
If the response to D50a is ‘Pint or large flask bottle’ (03), then for the potential
responses to the next question, D50b, only responses in ‘Pint or large flask bottle’ (1520) will appear.
If the response to D50a is ‘Fifth or standard size bottle’ (04), then for the potential
responses to the next question, D50b, only responses in ‘Fifth or standard size bottle’
(21-27) will appear.
If the response to D50a is ‘Quart bottle’ (05), then for the potential responses to the
next question, D50b, only responses in ‘Quart bottle’ bottle (28-34) will appear.
77
If the response to D50a is ‘Half gallon bottle’ (06), then for the potential responses to
the next question, D50b, only responses in ‘Half gallon’ bottle (35-41) will appear.
D51 (d). On the days that you drank alcohol during this time in your life, how many
drinks or shots did you USUALLY drink?
1-2 drinks or shots a day……………………………………………01
3-4 drinks or shots a day……………………………………………02
5-6 drinks or shots a day……………………………………………03
7-8 drinks or shots a day……………………………………………04
9-10 drinks or shots a day…………………………………………..05
11-12 drinks or shots a day…………………………………………06
More than 12 drinks or shots a day………………………………….07
I drank more than I could count….………………………………….08
On the days that you drank alcohol during this time in your life, how many mickeys or
small flask bottles did you USUALLY drink?
1 flask a day…………………………………………………………09
2 flasks a day……………………………………………………… 10
3 flasks a day……………………………………………………… 11
4 flasks a day……………………………………………………… 12
More than 4 flasks a day………………………………………… 13
I drank more than I could count….………………………………….14
On the days that you drank alcohol during this time in your life, how many pints or large
flask bottles did you USUALLY drink?
1 pint a day……………………………………………………… 15
2 pints a day……………………………………………………… 16
3 pints a day……………………………………………………… 17
4 pints a day……………………………………………………… 18
More than 4 pints a day……………………………………………. 19
I drank more than I could count….………………………………….20
On the days that you drank alcohol during this time in your life, how many fifths did you
USUALLY drink?
Less than half a bottle a day………………………………………. 21
Half a bottle to less than one bottle a day………………………… 22
One bottle to less than one and a half bottles a day……………… 23
One and a half to less than two bottles a day……………………… 24
Two bottles a day………………………………………………… 25
More than 2 bottles a day…………………………………………. 26
I drank more than I could count….………………………………….27
On the days that you drank alcohol during this time in your life, how many quarts did you
USUALLY drink?
78
Less than half a bottle a day………………………………………. 28
Half a bottle to less than one bottle a day………………………… 29
One bottle to less than one and a half bottles a day……………… 30
One and a half to less than two bottles a day……………………… 31
Two bottles a day………………………………………………… 32
More than 2 bottles a day…………………………………………. 33
I drank more than I could count….………………………………….34
On the days that you drank alcohol during this time in your life, how many half gallon
bottles did you USUALLY drink?
Less than half a bottle a day………………………………………. 35
Half a bottle to less than one bottle a day………………………… 36
One bottle to less than one and a half bottles a day……………… 37
One and a half to less than two bottles a day……………………… 38
Two bottles a day………………………………………………… 39
More than 2 bottles a day…………………………………………. 40
I drank more than I could count….………………………………….41
D51 (e). What type of alcohol did you USUALLY drink during this time in your life?
You may choose more than one.
Beer or wine (red , white, or pink)…………………………………. 01
Fortified wine (like Thunderbird, Wild Irish Rose, sherry, port)….. 02
Hard liquor (like whiskey, gin, rum, tequila, cognac, vodka)……. 03
Aperitif (schnapps, crème de menthe, Irish Cream, Kahlua)……… 04
D52. Have you EVER had any health problems as a result of your drinking (for
example: seizures, withdrawal, bleeding ulcer, hepatitis, pancreatitis, or blackouts)?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
D52. Have you EVER drunk cough syrup or mouthwash to get drunk?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
D53. Have you EVER felt you should cut down on you drinking?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
D54. Have you EVER felt bad or guilty about your drinking?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
D55. Do you EVER drink first thing in the morning to steady your nerves or get rid of a
hangover?
NO………………………………………………………………… 01
79
YES…………………………………………………………….…. 02
D56. Have you EVER cut down your drinking because of a drinking problem?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
D57. Have you EVER had or has anyone ever said you had a drinking problem?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
D58. Have people EVER annoyed you by criticizing your drinking?
NO………………………………………………………………… 01
YES…………………………………………………………….…. 02
You are almost done with the questionnaire! We know that the questions are often
hard to answer, but the time you are contributing today will help us learn more
about cancer. Keep going, and thank you so much for the time and effort you are
giving today.
E. SEXUAL HABITS (FOR WOMEN)
The following section asks questions about your sexual history. We know this is
very private information. Please do your best to answer the questions.
E1. What is your sexual preference or choice?
Sex with a man (heterosexual)……………………………………... 01
Sex with a woman (homosexual)………………………………….. 02
Sex with a man or a woman (bisexual)…………………………….. 03
E2.(a) In your lifetime, with how many men have you had sex? Sex means a man’s penis
in your vagina, mouth or butt.
None…………………………………………………………….. 01
1 partner.…………………………………………………………. 02
2-5 partners……………………………………………………….. 03
6-10 partners ……………………………………………………… 04
11-15 partners ………….…………………………………………..05
16-25 partners ……………………………………………………. 06
26-50 partners …………………………………………………….. 07
50-100 partners ………………………………………………..….. 08
More than 100 partners ………………………………………….. 09
E2. (b) In your lifetime, how many sexual partners have you had? Sexual partner means a
man who has put his penis in your vagina, mouth or butt OR a women who has put her
vagina on your vagina or mouth.
80
None…………………………………………………………….. 01
1 partner.…………………………………………………………. 02
2-5 partners……………………………………………………….. 03
6-10 partners ……………………………………………………… 04
11-15 partners ………….…………………………………………..05
16-25 partners ……………………………………………………. 06
26-50 partners …………………………………………………….. 07
50-100 partners ………………………………………………..….. 08
More than 100 partners ………………………………………….. 09
E3. Have you ever had vaginal sex with a man? Vaginal sex means a man’s penis in your
vagina.
NO………………………………………………………………….01
YES…………………………………………………………………02
If NO, skip to question E8. If YES, proceed to E4.
E4. How old were you when you first had vaginal sex with a man? Vaginal sex means a
man’s penis in your vagina. _______________________years old
E6. In your lifetime, with how many men have you had vaginal sex? Vaginal sex means a
man’s penis in your vagina.
1 man………………………………………………………………. 01
2-5 men…………………………………………………………….. 02
6-10 men…………………………………………………………… 03
11-15 men………….………………………………………………..04
16-25 men…………………………………………………………. 05
26-50 men………………………………………………………….. 06
50-100 men……………………………………………………..….. 07
More than 100 men……………………………………………….. 08
E7. How often would you use protection, like a condom, when having vaginal sex with a
new male partner? Vaginal sex means a man’s penis in your vagina.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E8. Have you ever had anal sex with a man? Anal sex means a man’s penis in your anus
or butt.
NO………………………………………………………………….01
YES…………………………………………………………………02
81
If NO, skip to question E12. If YES, proceed to question E9.
E9. How old were you when you first had anal sex with a man? Anal sex means a man’s
penis in your anus or butt. ______________________________
E10. In your lifetime, with how many men have you had anal sex? Anal sex means a
man’s penis in your anus or butt.
1 man………………………………………………………………. 01
2-5 men…………………………………………………………….. 02
6-10 men…………………………………………………………… 03
11-15 men………….………………………………………………..04
16-25 men…………………………………………………………. 05
26-50 men………………………………………………………….. 06
50-100 men……………………………………………………..….. 07
More than 100 men……………………………………………….. 08
E11. How often would you use protection, like a condom, when having anal sex with a
new male partner? Anal sex means a man’s penis in your anus or butt.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E12. Have you ever performed oral sex on a man? Performing oral sex means your
mouth on a man’s genitals.
NO………………………………………………………………… 01
YES………………………………………………………………… 02
If NO. skip to E16. If YES, proceed to E13..
E13. How old were you when you first performed oral sex on a man? Performing oral sex
means your mouth on a man’s genitals. _______________
E14. In your lifetime, on how many men have you performed oral sex? Performing oral
sex means your mouth on a man’s genitals.
1 man………………………………………………………………. 01
2-5 men…………………………………………………………….. 02
6-10 men…………………………………………………………… 03
11-15 men………….………………………………………………..04
16-25 men…………………………………………………………. 05
82
26-50 men………………………………………………………….. 06
50-100 men……………………………………………………..….. 07
More than 100 men……………………………………………….. 08
E15. How often would you use protection, like a condom, when performing oral sex on a
new male partner? Performing oral sex means your mouth on a man’s genitals.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E20. Have you ever had sex with a woman (sexual contact with another woman's
genitals)?
NO………………………………………………………………… 01
YES……………………………………………………………….. 02
If NO, skip to question E31. If YES, proceed to E21.
E21. How old were you when you first had sex with a woman (sexual contact with
another woman's genitals)? ____________________
E22. In your lifetime, with how many women have you had sex (sexual contact with
another woman's genitals)?
1 woman……………………………………………………………. 01
2-5 women…………………………………………………………. 02
6-10 women…………………………………………………………03
11-15 women………….…………………………………………….04
16-25 women………………………………………………………..05
26-50 women………………………………………………………..06
50-100 women………..………………………………………..….. 07
More than 100 women…..……………………………………….. 08
E23. Have you ever performed oral sex on a woman? Performing oral sex means your
mouth in or on her vagina.
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO. skip to E27. If YES, proceed to E24.
E24. How old were you when you first performed oral sex on a woman? Performing oral
sex means your mouth in or on her vagina. ________________
E25. In your lifetime, on how many women have you performed oral sex? Performing
oral sex means your mouth in or on her vagina.
83
1 woman……………………………………………………………. 01
2-5 women…………………………………………………………. 02
6-10 women…………………………………………………………03
11-15 women………….…………………………………………….04
16-25 women………………………………………………………..05
26-50 women………………………………………………………..06
50-100 women…………..……………………………………..….. 07
More than 100 women….………………………………………….. 08
E26. How often would you use protection, like a dental dam, saran wrap, or a female
condom, when performing oral sex on a new female partner? Performing oral sex means
your mouth in or on her vagina.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E31. Have you ever had sex with someone who had genital warts? Sex means a man has
put his penis in your vagina, mouth or butt OR a women has put her vagina on your
vagina or mouth.
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
E32. (a). To your knowledge, have any of your sexual partners had cancer of the mouth,
tongue, throat, voice box (larynx), cervix, vulva, anus, or penis? Sexual partner means a
man who has put his penis in your vagina, mouth or butt OR a women who has put her
vagina on your vagina or mouth.
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to question E33. If YES, proceed to E32b.
E32. (b). Which type of cancer did your sexual partner have?
Mouth, tongue, throat, voice box (larynx)………………………….01
Cervical….………………………………………………………….02
Vulvar..……………………………………………………………..03
Anal…..……………………………………………………………..04
Penile………………………... ……………………………………..05
Don’t know…………………………………………………………06
84
E33. Have you ever had 'casual sex' or a 'one-night stand' (sex with a person you did not
know)?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO, skip to E36a. If YES, proceed to E34.
E34. In your lifetime, with how many individuals have you had 'casual' sex or a ‘onenight stand’ (sex with a person you did not know)?
1 person……………………………………………………………. 01
2-5 people…………………………………………………………. 02
6-10 people…………………………………………………………03
11-15 people………….…………………………………………….04
16-25 people………………………………………………………..05
26-50 people………………………………………………………..06
50-100 people……………………………………………………….07
More than 100 people………………………………………………08
E35. How often would you use protection, like a condom, when having sex with a person
you did not know?
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E36. (a). Have you ever paid anyone money for sex?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to E38. If YES, proceed to E37b.
E37. (b). How many people have you paid for sex?
1 person……………………………………………………………. 01
2-5 people…………………………………………………………. 02
6-10 people…………………………………………………………03
11-15 people………….…………………………………………….04
16-25 people………………………………………………………..05
26-50 people………………………………………………………..06
50-100 people……………………………………………………….07
More than 100 people………………………………………………08
85
E38. Has anyone ever paid you money for sex?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
E39. How often do you wash your hands after going to the bathroom?
Never…………………………..01
Rarely………………………….02
Usually………………………. 03
Always……………………….. 04
Unsure…………………………05
E40. (a) Have you ever masterbated (touched your own genitals for sexual pleasure)?
No ………01
Yes………02
Unsure…..03
If NO, skip to end. If YES, proceed to E41b.
E41 (b) In your lifetime, how often would you USUALLY masterbate?
About once a year…………………………………………………. 01
Once a month………………………………………………………..02
2 to 3 times a month………………………………………………...03
1 to 2 days a week…………………………………………………. 04
3 to 4 days a week…………………………………………………. 05
5 to 6 days a week…………………………………………………. 06
Every day………………………………………………………….. 07
E. SEXUAL HABITS (FOR MEN)
The following section asks questions about your sexual history. We know this is
very private information. Please do your best to answer the questions.
E1. What is your sexual preference or choice?
Sex with a woman (heterosexual)………………………………… 01
Sex with a man (homosexual)…………………………………..
02
Sex with a man or a woman (bisexual)…………………………….. 03
E2.(a) In your lifetime, with how many women have you had sex? Sex means your penis
in a woman's vagina, mouth or butt.
None…………………………………………………………….. 01
1 partner.…………………………………………………………. 02
2-5 partners……………………………………………………….. 03
86
6-10 partners ……………………………………………………… 04
11-15 partners ………….…………………………………………..05
16-25 partners ……………………………………………………. 06
26-50 partners …………………………………………………….. 07
50-100 partners ………………………………………………..….. 08
More than 100 partners ………………………………………….. 09
E2. (b) In your lifetime, how many total sexual partners have you had? A sexual partner
is a woman OR a man with whom you have had sex. Sex means your penis in a woman’s
vagina, mouth, or butt OR your penis in a man’s mouth or butt, OR another man’s penis
in your butt or mouth.
None…………………………………………………………….. 01
1 partner.…………………………………………………………. 02
2-5 partners……………………………………………………….. 03
6-10 partners ……………………………………………………… 04
11-15 partners ………….…………………………………………..05
16-25 partners ……………………………………………………. 06
26-50 partners …………………………………………………….. 07
50-100 partners ………………………………………………..….. 08
More than 100 partners ………………………………………….. 09
E3. Have you ever had vaginal sex with a woman? Vaginal sex means your penis in a
woman's vagina.
NO………………………………………………………………….01
YES…………………………………………………………………02
If NO, skip to question E8. If YES, proceed to E4.
E4. How old were you when you first had vaginal sex with a woman. Vaginal sex means
your penis in a woman's vagina. _______________________years old
E6. In your lifetime, with how many women have you had vaginal sex? Vaginal sex
means your penis in a woman's vagina.
1 woman……………………………………………………………….
2-5 women……………………………………………………………..
6-10 women……………………………………………………………
11-15 women………….………………………………………………..
16-25 women………………………………………………………….
26-50 women…………………………………………………………..
50-100 women……………………………………………………..…..
More than 100 women………………………………………………..
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01
02
03
04
05
06
07
08
E7. How often would you use protection, like a condom, when having vaginal sex with a
new female partner? Vaginal sex means your penis in a woman's vagina.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E8. Have you ever had anal sex with a woman? Anal sex means your penis in a woman's
anus or butt.
NO………………………………………………………………….01
YES…………………………………………………………………02
If NO, skip to question E12. If YES, proceed to question E9.
E9. How old were you when you first had anal sex with a woman? Anal sex means your
penis in a woman's anus or butt. ______________________________
E10. In your lifetime, with how many women have you had anal sex? Anal sex means
your penis in a woman's anus or butt.
1 woman……………………………………………………………….
01
2-5 women……………………………………………………………..
02
6-10 women……………………………………………………………
03
11-15 women………….………………………………………………..
04
16-25 women………………………………………………………….
05
26-50 women…………………………………………………………..
06
50-100 women……………………………………………………..…..
07
More than 100 women………………………………………………..
08
E11. How often would you use protection, like a condom, when having anal sex with a
new woman partner? Anal sex means your penis in a woman's anus or butt.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E12. Have you ever performed oral sex on a woman? Performing oral sex means your
mouth on a woman’s genitals.
NO………………………………………………………………… 01
YES………………………………………………………………… 02
If NO. skip to E16. If YES, proceed to E13..
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E13. How old were you when you first performed oral sex on a woman? Performing oral
sex means your mouth on a woman’s genitals._______________
E14. In your lifetime, on how many women have you performed oral sex? Performing
oral sex means your mouth on a woman’s genitals.
1 woman……………………………………………………………….
2-5 women……………………………………………………………..
6-10 women……………………………………………………………
11-15 women………….………………………………………………..
16-25 women………………………………………………………….
26-50 women…………………………………………………………..
50-100 women……………………………………………………..…..
More than 100 women………………………………………………..
01
02
03
04
05
06
07
08
E15. How often would you use protection, like a dental dam, saran wrap, or a female
condom, when performing oral sex on a new female partner? Performing oral sex means
your mouth on a woman’s genitals.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E20. Have you ever had sex with another man? Sex means your penis in a man’s mouth
or butt OR a man’s penis in your mouth or butt.
NO………………………………………………………………… 01
YES……………………………………………………………….. 02
If NO, skip to question E31. If YES, proceed to E21.
E21. How old were you when you first had sex with a man? Sex means your penis in a
man’s mouth or butt OR a man’s penis in your mouth or butt.
____________________ years old
E22. In your lifetime, with how many men have you had sex? Sex means your penis in a
man’s mouth or butt OR a man’s penis in your mouth or butt.
1 man………………………………………………………………. 01
2-5 men…………………………………………………………….. 02
6-10 men…………………………………………………………… 03
11-15 men………….………………………………………………..04
16-25 men…………………………………………………………. 05
26-50 men………………………………………………………….. 06
50-100 men……………………………………………………..….. 07
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More than 100 men……………………………………………….. 08
E23. Have you ever had anal sex with a man? Anal sex means your penis in a man’s butt
OR a man’s penis in your butt.
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO, skip to E27 . If YES, proceed to E24.
E24. How old were you when you first had anal sex with a man? Anal sex means your
penis in a man’s butt OR a man’s penis in your butt.
__________________ years old
E25. In your lifetime, with how many men have you had anal sex? Anal sex means your
penis in a man’s butt OR a man’s penis in your butt.
1 man………………………………………………………………. 01
2-5 men…………………………………………………………….. 02
6-10 men…………………………………………………………… 03
11-15 men………….………………………………………………..04
16-25 men…………………………………………………………. 05
26-50 men………………………………………………………….. 06
50-100 men……………………………………………………..….. 07
More than 100 men……………………………………………….. 08
E27. Have you ever performed oral sex on a man? Performing oral sex means your
mouth on a man’s penis.
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
If NO. skip to E31. If YES, proceed to E28.
E28. How old were you when you first performed oral sex on a man? Performing oral sex
means your mouth on a man’s penis. ________________
E29. In your lifetime, on how many men have you performed oral sex? Performing oral
sex means your mouth on a man’s penis.
1 man………………………………………………………………. 01
2-5 men…………………………………………………………….. 02
6-10 men…………………………………………………………… 03
11-15 men………….………………………………………………..04
16-25 men…………………………………………………………. 05
26-50 men………………………………………………………….. 06
50-100 men……………………………………………………..….. 07
More than 100 men……………………………………………….. 08
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E30. How often would you use protection, like a condom, when performing oral sex on a
new male partner? Performing oral sex means your mouth on a man’s penis.
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E35. Have you ever had sex with someone who had genital warts? Sex means your penis
in a woman’s vagina, mouth, or butt OR your penis in a man’s mouth or butt, OR another
man’s penis in your butt or mouth.
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
E36. (a). To your knowledge, have any of your sexual partners had cancer of the mouth,
tongue, throat, voice box (larynx), cervix, vulva, anus, or penis? Sexual partner means
either a woman or a man with whom you have had sex. Sex means your penis in a
woman’s vagina, mouth, or butt OR your penis in a man’s mouth or butt, OR another
man’s penis in your butt or mouth.
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to question E33. If YES, proceed to E32b.
E36. (b). Which type of cancer did your sexual partner have?
Mouth, tongue, throat, voice box (larynx)………………………….01
Cervical….………………………………………………………….02
Vulvar..……………………………………………………………..03
Anal…..……………………………………………………………..04
Penile………………………... ……………………………………..05
Don’t know…………………………………………………………06
E37. Have you ever had 'casual sex' or a 'one-night stand' (sex with a person you did not
know)?
NO…………………………………………………………………. 01
91
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO, skip to E36a. If YES, proceed to E34.
E38. In your lifetime, with how many individuals have you had 'casual' sex or a ‘onenight stand’ (sex with a person you did not know)?
1 person……………………………………………………………. 01
2-5 people…………………………………………………………. 02
6-10 people…………………………………………………………03
11-15 people………….…………………………………………….04
16-25 people………………………………………………………..05
26-50 people………………………………………………………..06
50-100 people……………………………………………………….07
More than 100 people………………………………………………08
E39. How often would you use protection, like a condom, when having sex with a person
you did not know?
Never……………………………………………………………….. 01
Rarely………………………………………………………………. 02
Usually……………………………………………………………... 03
Always……………………………………………………………... 04
Unsure……………………………………………………………… 05
E40. (a). Have you ever paid anyone money for sex?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
If NO or UNSURE, skip to E38. If YES, proceed to E37b.
E41. (b). How many people have you paid for sex?
1 person……………………………………………………………. 01
2-5 people…………………………………………………………. 02
6-10 people…………………………………………………………03
11-15 people………….…………………………………………….04
16-25 people………………………………………………………..05
26-50 people………………………………………………………..06
50-100 people……………………………………………………….07
More than 100 people………………………………………………08
E42. Has anyone ever paid you money for sex?
NO…………………………………………………………………. 01
YES………………………………………………………………… 02
UNSURE…………………………………………………………... 03
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E43 How often do you wash your hands after going to the bathroom?
Never…………………………..01
Rarely………………………….02
Usually………………………. 03
Always……………………….. 04
Unsure…………………………05
E44 Have you ever masturbated (touched your own genitals for sexual pleasure)?
No ………01
Yes………02
Unsure…..03
If NO, skip to end. If YES, proceed to E45.
E45 In your lifetime, how often would you USUALLY masturbate?
About once a year…………………………………………………. 01
Once a month………………………………………………………..02
2 to 3 times a month………………………………………………...03
1 to 2 days a week…………………………………………………. 04
3 to 4 days a week…………………………………………………. 05
5 to 6 days a week…………………………………………………. 06
Every day………………………………………………………….. 07
THE END!
THANK YOU FOR COMPLETING THIS SURVEY.
This survey will be kept confidential and separate from your medical record. Only
people directly involved in this study will be able to look at it. It will never be given
to anyone for any other purpose.
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