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Data Collection Worksheet Data Collection Worksheet Please Note: The Data Collection Worksheet (DCW) is a tool to aid integration of a PhenX protocol into a study. The PhenX DCW is not designed to be a data collection instrument. Investigators will need to decide the best way to collect data for the PhenX protocol in their study. Variables captured in the DCW, along with variable names and unique PhenX variable identifiers, are included in the PhenX Data Dictionary (DD) files. Cigarettes 1. Have you ever smoked a cigarette, even one or two puffs? 1 [ ] Yes 2 [ ] No [GO TO Q6] -8 [ ] DON’T KNOW [GO TO Q6] -7 [ ] REFUSED [GO TO Q6] ASK: All respondents 2. Do you now smoke cigarettes… 1 [ ] Every day 2 [ ] Some days 3 [ ] Not at all [GO TO Q3] -8 [ ] DON’T KNOW [GO TO Q3] -7 [ ] REFUSED [GO TO Q3] ASK: Respondents who have ever smoked a cigarette (Q1 = 1) 3. In the past 30 days, have you smoked a cigarette, even one or two puffs? 1 [ ] Yes 2 [ ] No -8 [ ] REFUSED -7 [ ] DON’T KNOW ASK: Respondents who do not currently smoke every day or some days (Q2 = 3) 4. How many cigarettes have you smoked in your entire life? A pack usually has 20 cigarettes in it. 1 [ ] 1 or more puffs but never a whole cigarette 2 [ ] 1 to 10 cigarettes (about ½ pack total) 3 [ ] 11 to 20 cigarettes (about ½ pack to 1 pack) 4 [ ] 21 to 50 cigarettes (more than 1 pack but less than 3 packs) 5 [ ] 51 to 99 (more than 2 ½ packs but less than 5 packs) 6 [ ] 100 or more cigarettes (5 packs or more) -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have ever smoked a cigarette (Q1 =1) 5. About how long has it been since you completely quit smoking cigarettes? 1 [ ] I___I___I DAYS 2 [ ] I___I___I MONTHS 3 [ ] I___I___I YEARS -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Former users (IF Q1 = 1 AND Q4 = 5 AND Q2 = 3) and Experimental Former users (IF Q1 = 1 AND Q4 = 1, 2, 3, 4 AND Q2 = 3). Else go to next section (Q6). Electronic Cigarettes (E-Cigarettes) The next questions are about electronic cigarettes, often called e-cigarettes. E- cigarettes look like regular cigarettes, but are battery-powered and produce vapor instead of smoke. There are many types of e-cigarettes. Some common brands include NJOY®, Blu™, and Smoking Everywhere. SHOW GENERIC IMAGE OF E-CIGARETTES 6. Have you ever seen or heard of an electronic cigarette or e-cigarette before this study? 1 [ ] Yes 2 [ ] No [GO TO Q13] -8 [ ] DON’T KNOW [GO TO Q13] -7 [ ] REFUSED [GO TO Q13] ASK: All respondents SHOW GENERIC IMAGE OF E-CIGARETTES 7. Have you ever used an e-cigarette, such as NJOY®, Blu™, or Smoking Everywhere, even one or two times? 1 [ ] Yes 2 [ ] No [GO TO Q13] -8 [ ] DON’T KNOW [GO TO Q13] -7 [ ] REFUSED [GO TO Q13] ASK: Respondents who have seen or heard of e-cigarettes (Q6 = 1) SHOW GENERIC IMAGE OF E-CIGARETTES 8. Do you now use e-cigarettes… 1 [ ] Every day 2 [ ] Some days 3 [ ] Not at all -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have used an e-cigarette (Q7 = 1) 9. In the past 30 days, have you used an e-cigarette, even one or two times? 1 [ ] Yes 2 [ ] No -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have used an e-cigarette (Q7 = 1) AND do not currently use e-cigarettes every day or some days (Q8 = 3). 10. How many disposable e-cigarettes or e-cigarette cartridges have you used in your entire life? 1 [ ] 1 or more puffs but never a whole one 2 [ ] 1 to 10 3 [ ] 11 to 20 4 [ ] 21 to 50 5 [ ] 51 to 99 6 [ ] 100 or more -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have used an e-cigarette (Q7 = 1). 11. About how long has it been since you last took a puff from an e-cigarette? (If it was earlier today, enter 1 day). 1 [ ] I___I___I DAYS 2 [ ] I___I___I MONTHS 3 [ ] I___I___I YEARS -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have used e-cigarettes (Q7 = 1) AND do not use every day (Q8 <> 1) GO TO: If Q8 = 3, go to Q12. Else go to Q13. 12. Have you completely quit using e-cigarettes? 1 [ ] Yes 2 [ ] No -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have used e-cigarettes (Q7 = 1) AND currently use not at all (Q8 = 3). Cigars The next questions are about traditional cigars, cigarillos, and filtered cigars. These products go by lots of different names, so please use these descriptions and photos to understand what they are. Traditional cigars contain tightly rolled tobacco that is wrapped in a tobacco leaf. Some common brands of cigars include Macanudo®, Romeo y Julieta®, and Arturo Fuente®, but there are many others. Cigarillos and filtered cigars are smaller than traditional cigars. They are usually brown. Some are the same size as cigarettes, and some come with plastic or wood tips. Some common brands are Black & Mild®, Swisher Sweets®, Dutch Masters®, Phillies Blunts®, Prime Time®, and Winchester®. 13. Have you ever seen or heard of a cigar, cigarillo, or filtered cigar before this study? 1 [ ] Yes 2 [ ] No [GO TO Q26] -8 [ ] DON’T KNOW [GO TO Q26] -7 [ ] REFUSED [GO TO Q26] ASK: All respondents SHOW GENERIC IMAGE OF TRADITIONAL CIGARS, CIGARILLOS, AND FILTERED CIGARS 14. Which type of cigar have you heard of before this study? 1 [ ] Traditional cigars like Macanudo®, Romeo y Julieta®, Arturo Fuente®, or others [GO TO Q15] 2 [ ] Cigarillos or filtered cigars like Black & Mild®, Swisher Sweets®, Dutch Masters®, Phillies Blunts®, Prime Time®, Winchester®, or others [GO TO Q15] -8 [ ] DON’T KNOW [GO TO Q26] -7 [ ] REFUSED [GO TO Q26] ASK: Respondents who have seen or heard of a cigar, cigarillo, or filtered cigar (Q13 = 1) GO TO: If R has not heard of either type of cigar (Q14 NOT IN (1, 2)), go to Q26. 15. Have you ever smoked a traditional cigar, even one or two puffs? 1 [ ] Yes 2 [ ] No -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have heard of a traditional cigar (Q14 IN TRADITIONAL CIGAR) SHOW GENERIC IMAGE OF TRADITIONAL CIGARS 16. Have you ever smoked a cigarillo or filtered cigar, even one or two puffs? 1 [ ] Yes 2 [ ] No -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have heard of a cigarillo/FC (Q14 IN "CIGARILLO OR FILTERED CIGAR") SHOW GENERIC IMAGE OF CIGARILLOS AND FILTERED CIGARS 17. Sometimes people take tobacco out of a cigar, cigarillo or filtered cigar and replace it with marijuana. This is sometimes called a "blunt." Have you ever smoked part or all of a cigar, cigarillo or filtered cigar with marijuana in it? 1 [ ] Yes 2 [ ] No [GO TO Q20] -8 [ ] DON’T KNOW [GO TO Q20] -7 [ ] REFUSED [GO TO Q20] ASK: Respondents who have seen or heard of a cigar, cigarillo or filtered cigar (Q13 = 1 AND Q14 IN (1 or 2) AND Q16 NE -8 or -7). 18. In the past 12 months, have you smoked part or all of a cigar, cigarillo or filtered cigar with marijuana in it? 1 [ ] Yes 2 [ ] No [GO TO Q20] -8 [ ] DON’T KNOW [GO TO Q20] -7 [ ] REFUSED [GO TO Q20] ASK: Respondents who have smoked cigars with marijuana (Q17 = 1). 19. In the past 12 months, when you smoked a cigar, cigarillo or filtered cigar, how often has tobacco been replaced with any marijuana? 1 [ ] Every time 2 [ ] Most of the time 3 [ ] Sometimes 4 [ ] Rarely 5 [ ] Never -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have smoked cigars with marijuana in the past 12 months (Q18 = 1). 20. Which of the following kinds of cigarillos or filtered cigars have you smoked [as blunts]? Choose all that apply. The kind… 1 [ ] With a plastic or wooden tip 2 [ ] With a filter (like a cigarette filter) 3 [ ] Without a tip or filter -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have smoked a cigarillo/FC (Q16 = 1) OR are blunt-only cigar smokers (Q16 = 2 AND Q18 = 1). PROGRAM: Display "as blunts" if Q16 = 2 AND Q18 = 1. SHOW GENERIC IMAGE OF CIGARILLOS WITH TIPS, FILTERED CIGARS, AND CIGARILLOS WITHOUT TIPS 21. Do you now smoke [ [CIGARFILL]s/cigarillos as blunts/filtered cigars as blunts ]… 1 [ ] Every day 2 [ ] Some days 3 [ ] Not at all [GO TO Q22] -8 [ ] DON’T KNOW [GO TO Q22] -7 [ ] REFUSED [GO TO Q22] ASK: Respondents who have smoked at least one type of cigar (regular cigar (Q15 = 1) and/or cigarillo (Q20 = 1 OR 3) and/or FC (Q20 = 2)) OR are blunt-only cigar smokers (Q16 = 2 AND Q18 = 1). PROGRAM: If Q16 = 2 AND Q18 = 1 AND Q20 = 1 OR 3, display "cigarillos as blunts." If Q16 = 2 AND Q18 = 1 AND Q20 = 2, display ‘filtered cigars as blunts’. Else, display [CIGARFILL]s as specified. 22. In the past 30 days, have you smoked a [ [CIGARFILL]/ cigarillos as a blunt/ filtered cigar as a blunt ], even one or two puffs? 1 [ ] Yes 2 [ ] No -8 [ ] DON’T KNOW -7 [ ] REFUSED ASK: Respondents who have smoked at least one type of cigar (regular cigar (Q15=1) and/or cigarillo (Q20 = 1 OR 3) and/or FC (Q20 = 2)) OR are blunt-only cigar smokers (Q16 = 2 AND Q18 = 1) and do not currently smoke every day or some days (Q21 = 3). PROGRAM: If Q16 = 2 AND Q18 = 1 AND Q20 = 1 OR 3, display "cigarillo as a blunt." If Q16 = 2 AND Q18 = 1 AND Q20 = 2, display "filtered cigar as a blunt." Else, display [CIGARFILL] as specified.
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