Validity Study of Tobacco Consumption Items

TCLT Survey 2005 Page 1

CONFIDENTIAL PSU Sample reference All information collected in this survey Royal Government of Cambodia number of is strictly confidential and will be used NIS/ADRA Cambodia household for statistical purposes only

TCLT SURVEY 2005 l. Face Page A. To be completed by supervisor before interview B. To be completed by interviewer

Province /City Name of household head Address (house No., District /Khan street….) of other identification) Commune/Sangkat Date of the interview Day: Month: Year: Sample Village/Mondol Date of last visit Day: Month: Year: Domain number (1 to 17) Interviewer’s name: Id: Sector (Urban=1, Rural=2) Interviewer’s signature: (indicates survey completed and consent obtained) Sample reference number of household Team Number:

C. To be completed by supervisor after checking completed questionnaire thoroughly D: To be completed after re-interview (when required)

Supervisor’s name: Id: Name of re-interviewer: Id:

Date checked by supervisor Day: Month: Year: Date of re-interview Day: Month: Year:

Date of re-interview (if necessary) Day: Month: Year: Interviewer’s signature: Remarks of re- Supervisor’ s signature: interviewer:

Reception Preparation Data Entry Approval

Id: Date: Id: Date: Id: Date Date: TCLT Survey 2005 Page 2

II. Demographics Please provide the following information on all members ages 18 years and older usually residing in this household. Try to ask each member individually Sex Date of Birth What is.. Ethnicity Religion Only for Education Only for members aged 18 1=Male, [NAME] members Only for members aged 18 and above and above ID Name 2=Female Write '98' if don't know, for ...’s age in (see (see aged 18 and No (Enter day or month and '9998' for completed ethnicity Religion above Code) Year years? codes) Codes) Day Month Year Marital Can [NAME] Has [NAME] What is the Is ..[NAME].. What’s Is Reason for Write '96' Status ... read and ... ever highest level currently in the ..[NAME]'s.. ..[NAME]'s.. not present at if 96 years write a attended ..[NAME].. school system? current grade? present at home during or more (see marital simple school? successfully home during the entire and 98 if status codes) message in completed? 1 = Yes the entire period of the don't know any 1=yes 2 = No period of the survey? language? 2=no survey? (if no >>Col. 14A) Enter code 1=yes (if no >>Col. 1 = Yes 2=no 14A) If the child is on (if yes holidays, he/she must >>Col. 15) be considered as being 2 = No in the school system

(1) (2) (3) (4A) (4B) (4C) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14A) (14B)

Ethnicity codes (Col 6) 1= Khmer, 2= Cham, 3=Other local ethnic group, 4= Chinese, 5=Vietnamese, 6=Thai, 7=Lao , 8=Other (specify) Religion codes (Col 7) 1=Buddhist, 2=Islamic ,3 = Christian, 4 = Other, 5 = None Marital status ( Col. 8 ) 1 = Never Married, 2 = Currently Married, 3 = Live Together, 4 = Widowed , 5 = Divorced , 6 = Separated Grade level codes (Col 11 and Col.13) 99= none; 0 = preschool/kindergarten, 1= class one, 2=class two………..11=class eleven, 12=class twelve, 13= secondary , 14=technical/vocational pre-secondary, 15=technical/vocational post-secondary, 16= college undergraduate, 17= college graduate, 18=post graduate, 19=other (specify) Reason for not present at home (Col. 14B) 1=Study away from home, 2=Work away from home, 3=Seeking for work away from home, 4=Visit relatives away from home, 5=Vacation away from home, 6=Medical treatment away from home, 7=Working mission away from home, 8=Stay away from home for security reason, 9=Go abroad, 10= Other (Specify)

TCLT Survey 2005 Page 3

Demographics (Continued) ACTIVITY STATUS DURING THE PAST MONTH Please provide information on all members aged 18 years and older who usually reside in this household. Try to ask each member individually Primary Economic Activity Secondary Economic Activity Did ..[NAME].. do What Under What was your income Did ..[NAME].. do What Under (in riels) from the ID any work at all, even In what kind of primary was what type (in riels) from the any work at all, even In what kind of was what secondary occupation No What was ..[NAME].. What was one hour (if no but 's primary occupation economic activity, like ..[NAM of primary occupation one hour (if no but ..[NAME].. 's secondary economic ..[NA type of during the past month? having a job), for during the past month? agriculture, E]..'s employer during the past month? having a job), for secondary activity, like agriculture, ME]..'s employe (Write in amount in riel) primary occupation (Write specific manufacturing, employ did (Write in amount in riel secondary occupation during manufacturing, emplo r did during the past occupation in col. 16A) construction, trade or ment ..[NAME ) occupation during the past month? construction, trade or yment ..[NAM Enter "98" if no income month service, did ..[NAME].. status? ].. work? the past month (Write specific service, did ..[NAME].. status? E].. from secondary Note: beggar and sex work in the past Enter "98" if no income occupation in col. work in the past month? work? occupation worker are occupations month? Enter Enter from primary 19A) Enter 1=yes code code occupation 1=yes code Enter

2=no 2=no Note: beggar and sex code (if no >>Col.2 of (if no >>Col.2 of worker are Q20 of next section) Q20 of next section) occupations

Occupation Code Industry Code In cash In kind Occupation Code Industry Code In cash In kind description (NIS) description (NIS) description (NIS) description (NIS) *

(1) (15) (16A) (16B) (16C) (16D) (16E) (16F) (17A) (17B) (18) (19A) (19B) (19C) (19D) (19E) (19F) (20A) (20B)

Employment status Codes (Col.16E and Col.19E) 1=Paid employee, 2=Employer, 3=Own account worker, /self-employed, 4=Unpaid family worker, 5=Other(specify) Type of employer Codes (Col.16F and Col.19F) 01 = Government, 02 = State enterprise, 03 = Private enterprise, 04 = Joint venture, 05 = Foreign govt, international organization and NGO, 06 = Local NGO, 07 = Self-employed farm , 08 = Non- farm self-employed, 09 = Domestic servant, 10 = Other (specify) TCLT Survey 2005 Page 4

III. Tobacco Use III.A Cigarettes Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID 20. 21.Have 22. Do you 23. What 24. What 25. On the 26. On the day or 27. On the 28. On the day 29. On the 30. What 31. 31a. How 32. How 33. 34. 35. 36. Where did No Have you currently is your is your day or days you smoked a day or days or days you day or days brand of What is do you much did Amount Amount of Amount you obtain the you smoked smoke best best days you cigarette in the past you smoked smoked a you smoked a commercial the cost purchase you of the the of the cigarettes? smoked daily for cigarettes? estimate of estimate of smoked 30 days, did you a “Hand cigarette in the commercial (i.e. (in riels) commerc spend on TOTAL TOTAL TOTAL at least at least the number the number cigarettes smoke a “Hand Rolled past 30 days, brand (i.e. packaged) of each ial cigarettes purchas “taken in from 1 = purchased 100 six 1=yes of days of days during the Rolled by own- Cigarette” in did you smoke packaged) in cigarette do commer cigarettes in the ed trade” gifts at store cigarette months 2=no (go you you past 30 self” cigarette? the past 30 a commercial the past 30 you most cial (i.e. ? past 2 = “in kind” s in your during to next smoked smoked a days, how days indicate (i.e. packaged) days what often package week? Enter Enter price Enter trade lifetime your section) during the cigarette many 1 = yes what material brand? TYPE of smoke? d) Enter price in in Riels price in 3 = I grow the ? life? past 30 during the cigarettes 2 = no (>> go to was most cigarette did cigarette Enter Riels '00' if don't Riels tobacco for my days? past 30 did you col.10) frequently 1 = yes you use? Enter code you 1=as price in smoke cigarettes 1=yes 1=yes days? smoke per 9 = don’t used to roll 2 = no (>> go smoked single Riels Enter cigarette Enter 4 = gift 2=no 2=no Enter code day, on know/refuse to the cigarette. to col.14) 1 = Lights Enter '999' ? cigarettes '00' if taken in '00' if 9 = don’t 1 to 30 = average? answer (>> go to 9 = don’t 2 = Full if don't 2=in a (14)=(15)+ don't trade don't know/refuse to number of col.10) Enter code know/refuse to Flavor know/ Enter pack (16)+(17) smoke smoke answer days Enter answer (>> go 3 = Menthol refuse to price in 3=both purchas cigarette 99 = don’t code to col.14) 9 = don’t answer Riels 9= don’t ed received know/refus know/refuse know/ref cigarette from e to Picture card 1 to answer Picture card use to gift answer 1 answer

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (13A) (14) (15) (16) (17) (18)

1 = 1 day, 2 = 2 to 5 days, 3 = 6 to 9 days, 4 = 10 to 19 days, 5 = 20 to 29 days, 6 = All 30 days, 9 = don’t know/refuse to answer Code (Col.5) Code (Col.7) 1 = Less than one cigarette per day, 2 = 1 cigarette per day, 3 = 2 to 5 cigarettes per day, 4 = 6 to 15 cigarettes per day (about ½ pack), 5 = 16 to 25 cigarettes per day (about 1 pack), 6 = 26 to 35 cigarettes per day (about 1 ½ packs), 7 = More than 35 cigarettes per day (about 2 packs or more), 9 = don’t know/refuse to answer Code ( Col.9 ) 1 = Paper, 2 = Banana Leaf, 3 = Tobacco leaf, 4 = Other Leaf (Sanke Tree), 9 = don’t know/refuse to answer Code (Col.12) (Picture card 1) 1=Angkor, 2=Ara, 3=Haknuman, 4=Bareycheat, 5=Phnom Meas, 6= Wat Phnom, 7= Victory, 8=Tonle Sap, 9=Elephant, 10= Luxury, 11=Romdoh, 12=Bayon, 13=Pich, 14=Prasatmeas, 15=Olympic, 16=OKI, 17=Century, 18=Crown, 19=Liberty, 20=Cambo, 21=Hand-rolled with filter, 22=Hand-rolled no filter, 23=Fine, 24=555, 25=Dunhill, 26=Nise, 27=Hero, 28=Naga, 29=Mild Seven, 30=Marlboro, 31=Gold Seal, 32=Fortune, 33=5A, 34=Marchedes, 35=Alain Delon, 36=London, 37=Royal, 38=L&M, 39=West, 40=Eagle, 41=Hand-rolled cigarette in plastic bag with label TCLT Survey 2005 Page 5

Tobacco Use (Continued) III.B Chewing Tobacco Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 37. Have you 38. Do you 39. What is 40. During the past 41. On the day or 42. On the day or days you 43. How much did 44. Amount of the 45. Amount of the 46. Amount of the 47. Where did chewed currently chew your best 30 days, on how days you chewed chewed tobacco during the past you spend TOTAL TOTAL purchased TOTAL “taken in trade” TOTAL from gifts you obtain the tobacco daily tobacco? estimate of many days did you tobacco during 30 days, how much tobacco did on chewing tobacco chewing tobacco? for at least six the number of chew tobacco? the past 30 days, you chew each time? in the past week? Enter price in Riels Enter price in Riels Enter price in Riels months days you how many times Enter code during your 1=yes chewed 1 to 30 = number of per day did you Picture card 2 Enter price in Riels Enter '00' if don't Enter '00' if don't chew Enter '00' if don't life? 2=no (go to tobacco days chew? (ADRA will provide) chew purchased chewing tobacco taken chew chewing next section) during the 99 = don’t (Amount of Chewing Tobacco) (8)=(9)+(10)+(11) chewing tobacco in trade tobacco received 1=yes past 30 days? know/refuse to Number of times from gift 2=no answer Enter code Enter code 1= more than this amount, 2= about this amount, 3 = less than this amount (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

1 = 1 day, 2 = 2 to 5 days, 3 = 6 to 9 days, 4 = 10 to 19 days, 5 = 20 to 29 days, 6 = All 30 days, 9 = don’t know/refuse to answer Codes (Col. 4)

Code (Col.12) 1 = purchased at store, 2 = “in kind” trade, 3 = I grow the tobacco I chew, 4 = gift, 9 = don’t know/refuse to answer

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Tobacco Use (Continued) III.C Pipe Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 48. Have 49. Do you 50. What is 51. During 53. On the day or days 54. On the day or days 56. How 57. 58. 59. 60. Where you currently your best the past 30 you smoked a tobacco you smoked a tobacco much did you Amount of Amount of Amount of did you smoked a smoke a estimate of days, on how pipe during the past 30 pipe during the past 30 spend the the the obtain the tobacco tobacco the number many days days, how many times days, list the type of TOTAL on TOTAL TOTAL TOTAL tobacco for pipe pipe? of days you did you did you fill the tobacco tobacco pipe you smoked pipe tobacco purchased “taken in from gifts your pipe? daily for smoked a smoke a pipe each day? 1 = water pipe (Picture in the past trade” at least 1=yes tobacco pipe tobacco pipe? Card 4) week? Enter price Enter price six 2=no (go during the 2 = other tobacco pipe in Riels Enter price in Riels months to next past 30 1 to 30 = Enter number of times (Picture Card 5) Enter price in in Riels during section) days? number of days Picture Card 3 Riels Enter '00' if Enter '00' if your life? 99 = don’t 9 = don’t know/refuse to don't smoke Enter '00' don't smoke know/refuse to (8)=(9)+(10)+(11) Enter code (picture of pipe + answer purchased if don't pipe tobacco answer 1=yes amount of tobacco to pipe smoke received 2=no fill a pipe) tobacco pipe from gift tobacco taken in trade (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

1 = 1 day, 2 = 2 to 5 days, 3 = 6 to 9 days, 4 = 10 to 19 days, 5 = 20 to 29 days, 6 = All 30 days, 9 = don’t know/refuse to answer Codes (Col. 4)

Code (Col. 12) 1 = purchased at store, 2 = “in kind” trade, 3 = I grow the tobacco for my pipe, 4 = gift, 9 = don’t know/refuse to answer TCLT Survey 2005 Page 7

Tobacco Use (Continued) III.D Age at Initiation Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 61. How old were you the first time you smoked 62. How old were you the first time you 63. How old were you the first time you smoked a 64. How old were you the first time you used any a cigarette? (A cigarette=part or all of a chewed tobacco? tobacco pipe? tobacco? (Any tobacco=cigarette, chewing tobacco or cigarette) pipe) Age in complete years Age in complete years Age in complete years (Use Age Conversion Chart to Determine (Use Age Conversion Chart to Determine Ag a t Age in complete years (Use Age Conversion Chart to Determine Age Age at Initiation) Initiation) (Use Age Conversion Chart to Determine Age at at Initiation) Initiation) If no chewing tobacco enter '00' If no smoking tobacco pipe enter '00' If no smoking enter '00' If no using any tobacco enter '00' (1) (2) (3) (4) (5)

Cross-Check Age Question (Not for Data Entry) Year

ID No

01 02 03 04 05 06 07 08 What year were you born? (Compare the year to the responses above as a Cross-Check)

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Tobacco Use (Continued) III.E Reasons for Starting/Continuing to Use Tobacco (among tobacco users only!) Ask all members aged 18 and over individually who are present during the entire period of the survey the cross check question and then follow skip instructions. (Please copy all ID's from page 2 for col. 14A=1).

Cross-Check Tobacco Question (Not for Data Entry) Have you ever used any tobacco (cigarette, chewing 1=Yes >> go to col.2 of question 65, 2=No >> go to next section tobacco, pipe)? ID No 01 02 03 04 05 06 07 08

65. Indicate your reasons for STARTING to use any tobacco (cigarette, chewing tobacco, pipe)

ID No 1 = yes , 2 = no , 9 = don’t know/refuse to answer

(65a) (65b) (65c) (65d) Get (65e) To keep (65f) Warmth (65g) (65h) (65i) To (For women only) (65k) Due to (65l) (65m) (65n) Experim Fashionable Social Rid of insects during Influence of Sorrow/Depre appear being given Stress Easier to Decreases enting Pressure Fatigue (example: Agricultural Older ssion more (65j) To help with “free meet new hunger for mosquitoes) Work during the Relatives attractive “Morning Sickness” cigarettes” people food away Rain Season while in the (decrease army appetite) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15)

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Tobacco Use (Continued) Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). 66. Indicate your reasons for CONTINUING to use any tobacco (cigarette, chewing tobacco, pipe)

ID No 1 = yes , 2 = no , 9 = don’t know/refuse to answer

(66a) (66b) Social (66c) Get (66d) To keep (66e) Warmth during (66f) Influence of (For women only) (66h) (66i) To appear more (66j) Decreases Fashionable Pressure Rid of insects (example: Agricultural Work Older Relatives Sorrow/Depression attractive hunger for food Fatigue mosquitoes) away during the Rain (decrease appetite) Season (66g) To help with “Morning Sickness”

(1) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25)

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IV. Knowledge and Attitudes about Tobacco Use Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1).

IV.A Knowledge and Attitudes about Harmful Effects IV.B Attitudes towards Tobacco Use

67. Answer the following questions 68. Smoking causes the following 71. It is a 71a. For those who indicate ID No 72. Read the statements and determine about your beliefs on smoking diseases: “Buddhist” religion on the sin for a Harming cigarette or your body subjects opinion survey 1 = agree ID Choose one of the following: 1 = agree (Code 1 in col. 7 of page 2, pipe with No 2 = disagree 2 = disagree repeat question to confirm) smoker to tobacco is a 1= No, not harmful 9 = don’t know/refuse to answer produce sin 9 = don’t know/refuse to answer 2= Yes, a little harmful or moderately harmful smoke that 3= Yes, seriously harmful is inhaled 1 = agree 9= Don’t know or refuse to answer by other 2 = persons. disagree (67a) “Is (67b) “Is (67c) “Is (68a) (68b) (68c) (68d) 69. A 70. Some 9 = don’t (72a) “A man (72b) “It is (72c) Smoking smoking breathing smoking Bronch Lung Heart Any smoker metals are 1 = agree know/refus who does not fashionable that a can enhance harmful the smoke during itis Cancer Disease Illness cannot reach harmful and 2 = e to answer smoke is not young woman is work efficiency to your from pregnancy “Sel Doub” should not be disagree a real man” a smoker” for exhausted health?” someone harmful to used in bowls 9 = don’t people” else’s the health of 1 = agree that monks use know/refus cigarette the fetus?” 2 = disagree to collect food e to answer or pipe 9 = don’t harmful to know/refuse 1 = agree Picture your to answer 2 = disagree Card 6 health?” 9 = don’t know/refuse to Picture answer Card 6

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (1) (2) (3) (4)

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Knowledge and Attitudes about Tobacco Use (Continued) IV.C Attitudes about Tobacco Use in the Community Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 73. Read the statements and determine subjects opinion about whether certain persons in the community For those who indicate “Buddhist” religion on the survey should NOT use any tobacco (Cigarette, chewing tobacco, pipe) (Code 1 in col. 7 of page 2, repeat question to confirm) 1 = agree 2 = disagree 74. Use of Tobacco among Monks 9 = don’t know/refuse to answer 1 = agree 2 = disagree 9 = don’t know/refuse to answer (73a) (73b) “A (73c) “Kru (73d) (73e) (73f) (73g) (73h) (74a) “Monks use of (74b) “Monks should (74c) Monks should “Doctors Nurse or Khmer should “Traditional “Teachers “Monks “Parents “Children tobacco will affect not buy tobacco” not accept cigarettes should not Village not use tobacco” birth should not should not should not should not community use of as an offering; it is an use tobacco” Health attendant use tobacco” use tobacco” use tobacco use tobacco” tobacco” addictive (ngien) Worker should not in front of offering that gives no should not use tobacco” children” benefit to the use tobacco” “offerer”

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

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Knowledge and Attitudes about Tobacco Use (Continued) IV.D Attitudes about Anti-Smoking Policies Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 75. Anti-smoking policies 76. Smoking should not be allowed at the following places 1 = agree 1 = agree 2 = disagree 2 = disagree 9 = don’t know/refuse to answer 9 = don’t know/refuse to answer 75a-h and 75 j are for all religions. 75i is for those who indicate “Buddhist” religion on the survey (Code 1 in col. 7 of page 2, repeat question to confirm)

(75a) (75b) (75c) (75d) (75e) (75f) There (75g) The (75h) (75i) (75j) Selling (76a) (76b) (76c) School (76d) (76e) (76f) “Smoking “Cigarette “Tobacco “Cigarette Warning should be a price of Cigarettes Monks of “single Wat Hospital or Restaurant Bar/Night Workplace should be advertisem company promotion signs that law that bans cigarettes should not commit a cigarettes” Health club banned in ent by sponsorshi by tobacco “Smoking the sale of should be be offered “sin” when (in “sticks”) Facility public tobacco p should companies is harmful cigarettes to raised to to Monks they throw should be places” companies be banned” should be to your youth encourag away or do banned should be banned” health” e people not accept banned” should be (Youth=Under to stop an offering printed on 18 years of age) smoking of cigarette cigarettes packs (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

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Knowledge and Attitudes about Tobacco Use (Continued) Ask all members aged 18 and over individually who are present during the entire period of the survey V. Second hand Smoke (Please copy all ID's from page 2 for col. 14A=1). (Please copy all ID's from page 2 for col. 14A=1). Second hand Smoke IV.E Attitudes about Addiction 77a is for those who indicate “Buddhist” religion on the survey. 75b-f are for all religions. (Code 1 in col. 7 of page 2, repeat question to confirm)

ID No 77. Addiction ID No 1 = agree 2 = disagree 9 = don’t know/refuse to answer (77a) Buddhism (77b) Gambling, (77c) (77d) Opium (77e) Tobacco is 78. Do you inhale the 79. How many days 80. Where do you prohibits opium, and Alcohol is is “ngien” “ngien” smoke from any smoker per week do you inhale the smoke gambling, alcohol, are “ngien” (other than yourself) for inhale the smoke from from any smoker opium, and “ngien” more than 15 minutes any smoker (other than (other than per day, and more than 1 yourself)? yourself)? alcohol day per week? 1 = yes 1 = 7 days per week 1 = Home 2 = no (>>next section) 2 = 3-6 days per week 2 = Work Place 9 = don’t know/refuse to 3 = 1-3 days per week 3 = Public Place answer (>>next section)

(1) (2) (3) (4) (5) (6) (1) (2) (3) (4)

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TCLT Survey 2005 Page 14

VI. Smoking Cessation Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No Smoking Cessation

81. Have you 82. “Doctors who 83. “Doctors 84. Have you ever (at 85. Have you 86. Do you (86a) Do you (86b) At what age did (86c) Since age __ have you (86d) What was tried to advise a do not use have the power any time in your life) used any currently use any plan to stop you start using ever stopped using any your primary smoker to quit? tobacco will be (or influence) to used any tobacco tobacco tobacco? using tobacco tobacco? tobacco for 2 years or more? reason for more effective in encourage the EVERY DAY for at during the in the future? quitting tobacco 1 = yes educating others public to quit least SIX MONTHS? past 2 years? 1 = yes 1 = yes Write in “Age start in use? 2 = no to quit tobacco smoking” 2 = no (>> go to 2 = no completed years” (quitting during 9 = don’t use” 1 = yes 1 = yes col.9) 9 = don’t Insert 1 = yes the time know/refuse to 1 = yes 2 = no 2 = no 9 = don’t know/refuse 998 = never started age 2 = no (>> go to described in answer 1 = yes 2 = no 9 = don’t know/refuse 9 = don’t know/refuse to to answer (>> go to col.12 of determin col.12 of Q87) 86c) 2 = no 9 = don’t to answer know/refuse answer (>> go to Q87) ed in 86b 9 = don’t 9 = don’t know/refuse to to answer col.9) 999 =Don’t know/refuse to Enter code know/refuse to answer Know/refuse to answer answer (>> go answer (>> go to col.12 of to col.12 of Q87) Q87) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10A) (10B) (11)

1= Illness (at or before time of quitting), 2 = Healthy (at or before time of quitting) but wanted to prevent illness, 3 = Seeing Illness develop in other smokers, 4 = Family Codes for Col. 11 Disapproval, 5 = Health Education Program, 6 = Not enough money to buy tobacco, 7 = Disapproval of friends and co-workers, 9=don’t’ know/refuse to answer

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Smoking Cessation (Continued) Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 87. Indicate which of the following persons have talked to you about the harms of tobacco use: 1 = yes , 2 = no , 9 = don’t know/refuse to answer (87a) Doctor (Kru (87b) Medical (87c ) (87d) Kru Khmer (87e) Midwife/Traditional (87f) Teacher (87g) Family (87h) Monk Pet) Assistant Nurse/Village Birth Attendant Member Health Worker (1) (12) (13) (14) (15) (16) (17) (18) (19)

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Smoking Cessation (Continued) Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 88. Indicate which of the following persons have talked to you about quitting tobacco use: 1 = yes , 2 = no , 9 = don’t know/refuse to answer (88a) Doctor (Kru (88b) Medical (88c ) (88d) Kru Khmer (88e) Midwife/Traditional (88f) Teacher (88g) Family (88h) Monk Pet) Assistant Nurse/Village Birth Attendant Member Health Worker (1) (20) (21) (22) (23) (24) (25) (26) (27)

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VII. Life Style Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1).

ID No VII.A Anthropometrics VII.B Diet (Rice consumption for yesterday) How much rice did you eat yesterday? 91A. Show the plate and enter number of plates. If a person didn’t eat rice, enter “0” for that meal. D No Enter “99” if data is not available for a person. Note: If the quantity of rice is less than one plate, please record a half (0.5) or a quarter (0.25) of plate

89. Height in 90. Mid upper arm For breakfast For lunch For dinner Other Total centimeters circumference in (6)=(2)+(3)+(4)+(5) Write-in millimeters Write-in (1) (2) (3) (1) (2) (3) (4) (5) (6)

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Life Style (Continued) Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1).

VII.B Diet (Other Foods and Drink Consumption for the past 7 days) 91B Note: a palm is approximately 50 grams

Eggs (any) Fish/fish paste, squid, Other meat (beef, pork, Green leafy Orange vegetables Orange fruits (Ripe Alcoholic beverages Non-alcoholic beverages shrimp and prawns, etc. chicken, duck, etc.) vegetables (pumpkin, carrot, orange mango, ripe papaya, (beer, wine, whisky, (canned or bottles soft NUMBER KILOGRAM KILOGRAM KILOGRAM sweet potato, etc.) jackfruit, etc.) scotch, other distilled drink, mineral water, fruit ID KILOGRAM KILOGRAM No spirits) juice, fruit syrup, etc.) KILOGRAM KILOGRAM 2. How many 3. How 2. How 3. How much 2. How many 3. How much 2. How 3. How 2. How many 3. How much 2. How 3. How 2. How 3. How 2. How many 3. How much times in the much in many in total did times in the in total did many much in times in the in total did many much in many much in times in the in total did past 7 days total did times in you past 7 days you times in total did past 7 days you times in total did times in total did past 7 days you con- did you you the past 7 consume of did you consume of the past 7 you did you consume of the past 7 you the past 7 you did you sume of this consume consume days did this food in consume this food in days did consume consume this food in days did consume days did consume consume food in the ..[FOOD of this you the last 7 ..[FOOD the last 7 you of this ..[FOOD the last 7 you of this you of this ..[FOOD last 7 days? ITEM]. ? food in the consume days? ITEM]. ? days? consume food in the ITEM]. ? days? consume food in the consume food in the ITEM]. ? last 7 ..[FOOD ..[FOOD last 7 ..[FOOD last 7 ..[FOOD last 7 days? ITEM]. ? ITEM]. ? days? ITEM]. ? days? ITEM]. ? days? (1) (7A) (7B) (8A) (8B) (9A) (9B) (10A) (10B) (11A) (11B) (12A) (12B) (13A) (13B) (14A) (14B)

TCLT Survey 2005 Page 19

Life Style (Continued) VII.C Current Health Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 92. How 93. 94. Have you 95. Has a doctor or other health worker EVER diagnosed or told you that you are suffering from the following: would you Compared experienced any evaluate your with others of the following current health of the same illnesses, 1 = yes , 2 = no , 9 = don’t know/refuse to answer during the past age would injuries or other 4 weeks? you say that health problems your health in the past 4 Enter code during the weeks? (95a) (95b) (95c) (95d) (95e) (95f) (95g) (95h) (95i) (95j) (95k) (95l) past 4 (if more than Disease Any Lung Oral Bronchitis Tubercul Nutritio Malaria HIV/AID Leprosy Typhoid Dengue weeks is….. one refer to the of the Cancer Cancer Cancer osis nal S Fever Fever most important) Heart Deficie Enter code ncy (i.e. Enter code Avitami nosis) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16)

1=Very good, 2=Good, 3=Average, 4=Bad, 5=Very bad, 6=Don't know Codes for Col. 2

Codes for Col. 3 1 = Much better, 2 = Some what better, 3 = About the same, 4 = Some what worse, 5 = Much worse , 6 = Don't know

Codes for Col.4 1=stomach ache, 2=back pain, 3=headache, 4=ear pain, 5=eye pain, 6=fever, 7=diarrhoea, 8=cold & cough without ,rapid or difficult breathing, 9=cold & cough with rapid or difficult breathing, 10=mine injury, 11=road accident, 12=food-borne disease, 13=water-borne disease, 14=dropsy (swollen belly) 15 = Other Care Need (Specify) 16= No care, 17=No diseases

TCLT Survey 2005 Page 20

Life Style (Continued) Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No VII.D Access to ID VII.E Women’s Health Health Care (For all women aged 18 and older)

96. Where was advice or 97. Are you currently pregnant? (97a) Describe your use of tobacco (cigarette, (97b) Have you experienced (97c) Did you use any treatment first sought for your chewing tobacco, pipe) during this pregnancy? “morning sickness” during this tobacco (= cigarettes, illness/injury? 1=pregnant pregnancy? chewing tobacco, or pipe) 2=not pregnant (>> next 1= do not use tobacco to help with the “morning Enter code section) 2 = started using tobacco (did not use before the 1 = yes sickness” during this 9=unsure (>> next section) pregnancy) 2 = no pregnancy? 3= increased use of tobacco (did use before 9 = don’t know/refuse to pregnancy) answer 4= decreased use of tobacco (did use before 1 = yes pregnancy) 2 = no 5= quit use of tobacco (did use before pregnancy) 9 = don’t know/refuse to answer (1) (2) (1) (2) (3) (4) (5)

01 01

02 02

03 03

04 04

05 05

06 06

07 07

08 08

Codes for Col.2 of VIID

Not Medical Sector 13=Private Pharmacy Public Medical Sector 1=National Hospital (PP) Private Medical Sector 8=Private Hospital 14=Shop Selling Drugs/Market 2=Provincial Hospital (RH) 9=Private Clinic 15=Kru Khmer/Magician 3=District Hospital (RH) 10=Home/Office of Trained Health Worker/Nurse 16=Monk/Religious Leader 4=Health Center 11=Visit of Trained Health Worker/Nurse 17=Traditional Birth Attendant 5=Health Post 12= Other Private Medical (Specify) 18=Other not Medical (specify) 6=Outreach 7=Other Public (specify) TCLT Survey 2005 Page 21

Life Style (Continued) 98. List children who were born to women aged 18 and older living in the household and present at home during the entire period of the survey

1=yes , 2=No (Go to next section)

SRN Mother ID (Record from Child ID Child name Indicate whether How old was Current Vital Status Died before the Died before 1 year of ID No. (Col.1) of (Record from ID child was born alive? mother at the time age of 5 years age Demographics in page 2) No. (Col.1) of (If no name of their Enter code Demographics in enter Enter '3' to indicate childbirth? Enter Enter page 2) 'NONAME') the child born alive 1=Alive (>>next 1=Yes 1=Yes

(Age in child) 2=No (>> next 2=No Note: Write '00' if child is not living in (born alive=showed completed years) 2=Dead child) the household/child any sign of life after 9=Do not died birth) If do not know know/Unsure enter '99' (>>next child) (6) (7) (8) (9) (10) (11) (12) (13) (14)

TCLT Survey 2005 Page 22

VIII. Media Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No Media

99. During the past 100. During the past 30 101. During the past 30 (101a) Newspaper (101b) Billboard/ (101c) Other Printed 30 days how many days how many anti- days how many anti- Signs/ Posters Material anti-tobacco ads have tobacco ads have you heard tobacco ads have you seen Enter no. of time you seen on TV? on the radio? in print? If not seen newspaper Enter no. of time Enter no. of time enter '0' If not seen If not seen other printed Enter no. of times Enter no. of times subject Enter no. of times subject billboard/ Signs/ material enter '0' subject has seen anti- has heard anti-tobacco ads has seen anti-tobacco ads Posters enter '0' tobacco ads otherwise otherwise enter '0' otherwise enter '0' enter '0' (4)=(5)+(6)+ (7)

(1) (2) (3) (4) (5) (6) (7)

TCLT Survey 2005 Page 23

IX. Miscellaneous Questions Ask all members aged 18 and over individually who are present during the entire period of the survey (Please copy all ID's from page 2 for col. 14A=1). ID No 103. Other Attitude Questions 1 = agree 2 = disagree 9 = don’t know/refuse to answer

(103a) “In order to (103b) “Medical school (103c) “Men (103d) “It is (103e) In the (103f) “It is (103g) “It is (103h) Machea effectively encourage a faculty members should smoke when they disrespectful to cities only shameful for shameful for means “ngien” patient to follow a set a good example for are younger to ask an older “easy” women women in the women in the healthy life style, a doctor medical students by gain status” male to quit smoke villages to smoke villages to must follow one practicing a healthy smoking” cigarettes” chew tobacco” him/herself” lifestyle” (1) (2) (3) (4) (5) (6) (7) (8) (9)

END OF QUESTIONNAIRE