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[p. 168]


NATIONAL HEALTH INTERVIEW SURVEY
CANCER CONTROL

1. Book ____ of ____ books

2. R.O. number ____

3. Sample ____

4. Control number

PSU ____
Segment ____
Serial ____

5. Beginning time ____

1 [] a.m.
2 [] p.m.

6a. FAMILY ROSTER
List all nondeleted family members 18+ by age (oldest to youngest). ________

6b. Hispanic oversample

1 []

SP1

[lines 1-9]

Line No. ____
Person No. ____
Age ____
Name ____
"X" if Hisp. marked
[] Hisp

SP2-3

[lines 1-9]

Hisp. Line no. ____

Refer to the appropriate section of the sample person selection label and circle as applicable. THEN circle the "SP1" Line No. in item 6a and mark "SP" box on the HIS-1 for the selected sample person, THEN go to Section O.

7. FINAL STATUS

0 [] No person 18+ in this family (Household Page)

Interview
1 [] Complete interview (all appropriate sections completed)
2 [] Partial interview (some but not all appropriate sections completed) - Explain ____
Noninterview
3 [] Refusal (Explain in Notes)
4 [] SP temporarily absent
5 [] SP mentally or physically incapable
8 [] Other - Explain ____

8. Ending time ____

1 [] a.m.
2 [] p.m.

9. Interview mode

1 [] Personal
2 [] Telephone

10. Language of interview

1 [] English
2 [] Spanish
3 [] Both English and Spanish
8 [] Other

11. Interviewer identification

Name ____
Code ____

TRANSCRIPTION FROM COMPLETED HIS-1 ____

12. Sec of SP (Page 2 or 55, question 3)

1 [] M
2 [] F

13. Education of SP (Page 42 or 43, question 2a)

00 [] Never attended or kindergarten (NP)
Elem:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High:
[] 9
[] 10
[] 11
[] 12
College:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6+

Finish grade/year (Question 2b)

1 [] Yes
2 [] No

14. Main race of SP (Page 42 or 43, questions 3a/b)

[] 1
[] 2
[] 3
[] 4
[] 5 - Specify ____

15. Marital status (Page 46 or 47, question 7)

1 [] Married - spouse in HH
2 [] Married - spouse not in HH
3 [] Widowed
4 [] Divorced
5 [] Separated
6 [] Never married

16. Family income (Page 46, question 8b)

00 [] A
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K
11 [] L
12 [] M
13 [] N
14 [] O
15 [] P
16 [] Q
17 [] R
18 [] S
19 [] T
20 [] U
21 [] V
22 [] W
23 [] X
24 [] Y
25 [] Z
26 [] ZZ

(Transcribe from 8a if 8b blank)

27 [] $20,000 or more
28 [] Less than $20,000

17. Person No ____

18. Age ____

19. Booklet type

1 [x] Cancer control

[p. 169]

Section O - ACCULTURATION

O1

SP Status at initial interview

1 [] Available (O2)
2 [] Callback required (Household page)
8 [] Noninterview (Cover page)

O2
Refer to hispanic origin from family roster and expected language for this supplement.

1 [] Hispanic/English Supp. Interview (1a)
2 [] Hispanic/Spanish Supp. Interview (1b)
8 [] Other (section P)

Read to respondent:
I'm going to be asking questions that are related to health concerns, such as smoking, eating practices, doctor visits and so forth. Before I ask these questions I would like to ask a few questions about the language you use most often.


1a. Do you speak any Spanish?

1 [] Yes (2)
2 [] No (4)

Read to respondent:
I'm going to be asking questions that are related to health concerns, such as smoking, eating practices, doctor visits and so forth. Before I ask these questions I would like to ask a few questions about the language you use most often.


b. Do you speak any English?

1 [] Yes
2 [] No (4)


2. Would you say that you speak mostly Spanish, mostly English, or do you speak Spanish and English about the same?

1 [] Mostly Spanish
2 [] Mostly English
3 [] Both about the same


3. What language do you prefer: Spanish only, mostly Spanish, mostly English, English only, or Spanish and English about equally?

1 [] Spanish only
2 [] Mostly Spanish
3 [] Mostly English
4 [] English only
5 [] Spanish and English equally


4. Can you read Spanish?

1 [] Yes
2 [] No


5. Can you read English?

1 [] Yes
2 [] No


If "Yes" to both 4 and 5 ask

6. In which language do you read better?

1 [] Spanish
2 [] English
3 [] Both the same


7. Can you write in Spanish?

1 [] Yes
2 [] No


8. Can you write in English?

1 [] Yes
2 [] No


If "Yes" to both 7 and 8 ask:
9. In which language do you write better?

1 [] Spanish
2 [] English
3 [] Both the same

If self-reported on HIS-1, mark box without asking.
HAND CARD O, read categories if telephone interview.

CARD O

1 - Puerto Rican 5 - Chicano
2 - Cuban 6 - Other Latin American
3 - Mexican/Mexicano 7 - Other Spanish
4 - Mexican American
5 - Chicano
6 - Other Latin American
7 - Other Spanish

10. Which of these groups best describes your ethnic identification?

1 [] Puerto Rican
2 [] Cuban
3 [] Mexican/Mexicano
4 [] Mexican American
5 [] Chicano
6 [] Other Latin American
7 [] Other Spanish
8 [] Other (Specify) ____


11. Which of these groups best describes your mother's ethnic identification?

1 [] Puerto Rican
2 [] Cuban
3 [] Mexican/Mexicano
4 [] Mexican American
5 [] Chicano
6 [] Other Latin American
7 [] Other Spanish
8 [] Other (Specify) ____


12. Which of these groups best describes your father's ethnic identification?

1 [] Puerto Rican
2 [] Cuban
3 [] Mexican/Mexicano
4 [] Mexican American
5 [] Chicano
6 [] Other Latin American
7 [] Other Spanish
8 [] Other (Specify) ____

[p. 170]

Section O - ACCULTURATION - Continued


If self-reported on HIS-1, mark box without asking.

13. In what country or state were you born?

1 [] U.S., except Puerto Rico
2 [] Puerto Rico
3 [] Cuba
4 [] Mexico
8 [] Other (Specify) ____


14. In what country or state was your father born?

1 [] U.S., except Puerto Rico
2 [] Puerto Rico
3 [] Cuba
4 [] Mexico
8 [] Other (Specify) ____


15. In what country or state was your mother born?

1 [] U.S., except Puerto Rico
2 [] Puerto Rico
3 [] Cuba
4 [] Mexico
8 [] Other (Specify) ____

[p. 171]

Section P - MEDICAL CARE

(I'm going to be asking questions that are related to health concerns, such as smoking, eating practices, doctor visits and so forth.)

These questions are about medical care you may have needed in the past year.


1a. During the past 12 months, that is, since (12-month date) a year ago, have you NEEDED any medical care or advice?

1 [] Yes
2 [] No (2)


b. During the past 12 months, was there ever a time when you did not get the medical care or advice that you needed?

1 [] Yes
2 [] No (2)


c. Why didn't you get the care that you needed?

Mark all mentioned, do not probe.

1 [] Procrastination/Put it off
1 [] Did not have health insurance
1 [] Care was not available when needed
1 [] Cost too much
1 [] Didn't know where to go
1 [] Didn't know what kind of doctor to see
1 [] Didn't have a way to get there
1 [] Hours not convenient
1 [] Fear of being treated rudely or unkindly
1 [] Other reason (Specify) ____
1 [] DK


2. Is there a particular doctor's office, clinic, health center, or other place that you usually go to if you are sick or need advice about your health?

1 [] Yes
2 [] No (4)
9 [] DK (4)


3. What kind of place is it -- a doctor's office, a hospital, a clinic, a health center, or some other place?

If hospital: Is this an outpatient clinic or an emergency room?
If clinic: Is this a public health clinic or some other kind of clinic?

1 [] Doctor's office (private group practice or doctor's clinic)
2 [] Hospital emergency room
3 [] Hospital outpatient clinic
4 [] Health center on private neighborhood health clinic } (5)
5 [] Public health clinic
6 [] Health clinic at work
7 [] HMO/prepaid group practice/"Group Health"
8 [] Other (Specify) ____


4. Where do you go when you are sick or need advice about your health?
Mark all mentioned, do not probe.

1 [] Doctor's office (private group practice or doctor's clinic)
1 [] Hospital emergency room
1 [] Hospital outpatient clinic
1 [] Health center on private neighborhood health clinic } (5)
1 [] Public health clinic
1 [] Health clinic at work
1 [] HMO/prepaid group practice/"Group Health"
1 [] Haven't needed a doctor
1 [] Don't go anywhere
1 [] Have two or more doctors or usual places depending on what is wrong
1 [] Other (Specify) ____
1 [] DK


5. Where do you get your most useful information about how to prevent illness and improve your health?
Mark all mentioned, do not probe.

1 [] Telephone information - Public Service or Hotline
1 [] Family
1 [] Friends
1 [] Doctor
1 [] Work
1 [] Television
1 [] Radio
1 [] Books
1 [] Newspaper
1 [] Magazines
1 [] Pamphlets in doctor's office
1 [] Other sources
1 [] Nowhere/Don't get information
1 [] DK

[p. 172]

Section Q - FOOD KNOWLEDGE


1a. Have you ever made any LASTING and MAJOR changes in what you eat and drink for health reasons?

1 [] Yes
2 [] No (2)


b. In making these changes, what foods do you eat MORE of?
Enter responses verbatim, one food per line. Do not probe.

MORE ________
000 [] None
999 [] DK


c. What foods do you eat LESS of?
Enter responses verbatim, one food per line. Do not probe.

LESS ____
000 [] None
999 [] DK


d. Have you made these changes in what you eat and drink in the past 5 years?

1 [] Yes
2 [] No (3)
9 [] DK (3)


e. Did you make these changes in the past year?

1 [] Yes (3)
2 [] No (3)

2. Please tell me whether the following statements are true for you. First -

(a) It seems that everything you eat is bad for you so why bother changing. (Is that true for you?)
1 [] Yes (True)
2 [] No (False)


(b) I enjoy the things I eat and don't want to change.
1 [] Yes (True)
2 [] No (False)




(c) There are so many different recommendations, it's hard for me to know which ones to follow
1 [] Yes (True)
2 [] No (False)


(d) I eat out so much that making changes would be hard
1 [] Yes (True)
2 [] No (False)


(e) Making changes in the kind of food I eat would be expensive.
1 [] Yes (True)
2 [] No (False)




(f) I would like to change but the rest of my family won't change
1 [] Yes (True)
2 [] No (False)


(g) The things I eat and drink are healthy so there is no reason for me to make changes
1 [] Yes (True)
2 [] No (False)


3. I am going to read two (more) statements. Please tell me which one you agree with most.

(a) What people eat or drink has little effect on whether they will develop major diseases
OR
(b) By eating the right kinds of foods, people can reduce their chances of developing major diseases.
1 [] a (7)
2 [] b (4)
9 [] DK (5)


4. Which major diseases do you think may be related to what people eat and drink?
Mark all mentioned, do not probe.

1 [] Cancer
1 [] Heart disease
1 [] Obesity/overweight
1 [] Diabetes
1 [] Hypertension or High Blood Pressure
1 [] Other
1 [] None
1 [] DK


Q1
Refer to 4

1 [] Cancer in 4 (6)
8 [] Other (5)

[p. 173]

Section Q - FOOD KNOWLEDGE - Continued


5. Do you think cancer may be related to what people eat and drink?

1 [] Yes
2 [] No (8)
3 [] Probably/maybe/could be/etc.
9 [] DK (8)


6a. What food do you think people should eat or drink MORE of to help prevent cancer?
Enter responses verbatim, one food per line. Do not probe.

MORE ________
000 [] None
999 [] DK


b. What foods should people eat or drink LESS of to help prevent cancer?
Enter responses verbatim, one food per line. Do not probe.

LESS ________
000 [] None
999 [] DK


c. What kinds of cancer do you think may be related to the things people eat and drink?
Mark all mentioned, do not probe.

1 [] All kinds of cancer
1 [] Breast cancer
1 [] Bladder cancer
1 [] Cancer of the mouth/throat/esophagus
1 [] Cancer of the colon/bowel/intestine/rectum } (8)
1 [] Stomach cancer
1 [] Prostate cancer
1 [] Cancer of the uterus
1 [] Lung cancer
1 [] Liver cancer
1 [] Other
1 [] DK


7a. Have you heard or read ANYTHING about how eating more of some foods and less of other foods can help prevent some major diseases?

1 [] Yes
2 [] No (8)
9 [] DK (8)


b. Which major diseases have you heard may be related to what people eat and drink?
Mark all mentioned, do not probe.

1 [] Cancer
1 [] Heart disease
1 [] Obesity/overweight
1 [] Diabetes
1 [] Hypertension or High Blood Pressure
1 [] Other
1 [] None
1 [] DK


8a. Some foods contain fiber. Have you heard of fiber?

1 [] Yes
2 [] No (9)
9 [] DK (9)


b. Overall, would you say your diet is high, medium, or low in fiber?

1 [] High
2 [] Medium
3 [] Low
9 [] DK


HAND CARD Q1, read list if telephone interview.

CARD Q1

Bran flakes
Corn Flakes
Hamburgers
Lettuce
Baked beans
Carrots
White rice
Raw apples

c. Here is a list of foods. Please tell me which ones you think are high in fiber.
Mark mentioned, do not probe.

1 [] Bran flakes
1 [] Corn flakes
1 [] Hamburgers
1 [] Lettuce
1 [] Baked beans
1 [] Carrots
1 [] White rice
1 [] Raw apples
1 [] None
1 [] DK

[p. 174]

Section Q - FOOD KNOWLEDGE - Continued


9a. Overall, would you say your diet is high, medium, or low in fat?

1 [] High
2 [] Medium
3 [] Low
9 [] DK


HAND CARD Q2, read list of telephone interview.

CARD Q2

Fried chicken
White bread
Soda or soft drinks
Peanut butter
Broiled fish
Bananas
Cold cuts or lunch meats
Doughnuts

b. Here is (a/another) list of foods. Please tell me which ones you think are high in fat
Mark all mentioned, do not probe.

1 [] Fried chicken
1 [] White bread
1 [] Soda or soft drinks
1 [] Peanut butter
1 [] Broiled fish
1 [] Bananas
1 [] Cold cuts or lunch meats
1 [] Doughnuts
1 [] None
1 [] DK


10. Thinking about what you eat and drink, which of the following are IMPORTANT concerns for you?


(a) Avoiding foods with too much salt or sodium. (Is that an important concern for you?)
1 [] Yes
2 [] No


(b) Avoiding foods with too much sugar.
1 [] Yes
2 [] No


(c) Eating foods to lower cholesterol.
1 [] Yes
2 [] No


(d) Not having enough money to buy food.
1 [] Yes
2 [] No


(e) Being overweight.
1 [] Yes (Section R)
2 [] No


(f) Being too thin.
1 [] Yes
2 [] No

[p. 175]

Section R - GENERAL KNOWLEDGE AND ATTITUDES

[Questions 1a-4b]


These next questions are about cancer risks.

Hand Card R1, read categories if telephone interview.

CARD R1

Stress
Inherited make-up or heredity
Exposure to X-Rays
Poor eating practices
Using chewing tobacco, snuff, pipes, or cigars
Air pollution
Some cloth dyes
Exposure to toxic waste dumps
Exposure to toxic substances on the job
Exposure to people with cancer
Excessive drinking of alcoholic beverages
Exposure to the sun
Cigarette smoking
Exposure to nuclear waste
Some strong soaps and detergents
Viruses
Some medicines
Medical procedures using radiation

1a. Which of these things do you think increases a person's chances of getting cancer?
Mark all mentioned in first column, do not probe.

1 [] Stress
1 [] Inherited make-up or heredity
1 [] Exposure to X-Rays
1 [] Poor eating practices
1 [] Using chewing tobacco, snuff, pipes, or cigars
1 [] Air pollution
1 [] Some cloth dyes
1 [] Exposure to toxic waste dumps
1 [] Exposure to toxic substances on the job
1 [] Exposure to people with cancer
1 [] Excessive drinking of alcoholic beverages
1 [] Exposure to the sun
1 [] Cigarette smoking
1 [] Exposure to nuclear waste
1 [] Some strong soaps and detergents
1 [] Viruses
1 [] Some medicines
1 [] Medical procedures using radiation
1 [] DK


If two or fewer responses in 1a, mark 1b without asking and skip to 2.
b. In your opinion, of the things you just mentioned which TWO are responsible for the MOST cases of cancer in this country?

1 [] Stress
1 [] Inherited make-up or heredity
1 [] Exposure to x-rays
1 [] Poor eating practices
1 [] Using chewing tobacco, snuff, pipes or cigars
1 [] Air pollution
1 [] Water pollution
1 [] Some cloth dyes
1 [] Exposure to toxic waste dumps
1 [] Exposure to toxic substances on the job
1 [] Exposure to people with cancer
1 [] Excessive drinking of alcoholic beverages
1 [] Exposure to the sun
1 [] Cigarette smoking
1 [] Exposure to nuclear waste
1 [] Some strong soaps and detergents
1 [] Viruses
1 [] Some medicines
1 [] Medical procedures using radiation
1 [] DK

Hand Card R2

CARD R2

1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
5. No opinion

2. Please tell me whether you strongly agree, agree, disagree, or strongly disagree with this statement, or if you have no opinion -
There is very little a person can do to reduce his or her chances of getting cancer.

1 [] Strongly agree
2 [] Agree
3 [] Disagree
4 [] Strongly disagree
8 [] No opinion


3. What do you think are the warning signs or symptoms of cancer?
Mark all mentioned, do not probe.

1 [] Weight loss/ loss of appetite
1 [] Change in bowel or bladder habits
1 [] Unusual bleeding or discharge
1 [] Lump in breast or elsewhere
1 [] Indigestion
1 [] Difficulty in swallowing
1 [] Change in a wart or mole
1 [] Nagging cough or hoarseness
1 [] Chest pain
1 [] Shortness of breath
1 [] Sores that don't heal
1 [] Tired/fatigued
1 [] Changes on skin/rash/blemish/sunspots/blotches
1 [] Other (Specify) ____
1 [] DK

[p. 176]

Section R - GENERAL KNOWLEDGE AND ATTITUDES - Continued


4a. If you were offered a free 2 hour class on how to reduce your chances of getting cancer, would you be interested in going to it if it were convenient?

1 [] Yes
2 [] No (Section S)
3 [] Maybe
9 [] DK


Hand Card R3, read categories if telephone interview.

CARD R3

Church
Local school
Hospital
Club meeting
Workplace
Home
Senior center
Community center
Other place

b. If you were going to attend such a class, which of these places would be convenient for you?
Mark all mentioned, do not probe.

1 [] Church
1 [] Local school
1 [] Hospital
1 [] Club meeting
1 [] Workplace
1 [] Home
1 [] Senior center
1 [] Community center
1 [] Other place
1 [] DK

[p. 177]

Section S - CANCER SCREENNING KNOWLEDGE AND PRACTICE

S1
Refer to age and sex

1 [] Male, under 40 (41)
2 [] Male, 40+ (21)
3 [] Female (1)

These next questions are about certain kinds of medical tests and examinations.
1a. Have you ever heard of a Pap smear test?

1 [] Yes
2 [] No (7)
9 [] DK (7)


b. Have you ever had a Pap smear?

1 [] Yes
2 [] No (6)
9 [] DK (7)


c. When did you have your last Pap smear?

If 3 years ago or less (2)
if More than 3 years ago (4)

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago


999[] DK (1d)


d. Was it within the past year or a year or more ago?

1 [] Within past year (1a)
2 [] 1 year or more (1f)
9 [] DK (4)


e. Was it less than three months, or 3 or more months ago?

1 [] Less than 3 months
2 [] 3 or more months (2)
9 [] DK


f. Was it 3 years ago or less, between three and 5 years, or 5 or more years ago?

1 [] 3 years or less (2)
2 [] Between 3 and 5 years (4)
3 [] 5 or more years (4)
9 [] DK (4)


2. Where was this Pap smear done -- in a doctor's office, a clinic, a hospital, or some other place?

1 [] Doctor's office
2 [] Clinic
3 [] Hospital
8 [] Other place (Specify) ____
9 [] DK


3a. Did you go for your last Pap smear because of a health problem?

1 [] Yes
2 [] No (3c)
9 [] DK (3c)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Follow-up tests/treatment
1 [] Bleeding
1 [] Pain
1 [] Discharge
1 [] Itching
1 [] Burning
1 [] Infection
1 [] Unrelated medical problem
1 [] Other
1 [] DK


c. How were you told the results of the test - in person, over the telephone, through the mail, or some other way?

1 [] In person
2 [] Telephone
3 [] Through the mail
4 [] Combination of methods
5 [] Never told; meaning results normal
6 [] Never told; DK if problem
8 [] Other


S2
Refer to 3a

1 [] Yes (5)
2 [] No (4)
9 [] DK (4)

4a. Have you EVER had a Pap smear because of a health problem?

1 [] Yes
2 [] No (5)
9 [] DK (5)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Follow-up tests/treatment
1 [] Bleeding
1 [] Pain
1 [] Discharge
1 [] Itching
1 [] Burning
1 [] Infection
1 [] Unrelated medical problem
1 [] Other
1 [] DK

[p. 178]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


5a. Have you ever had a Pap smear where the results were NOT normal?

1 [] Yes
2 [] No (S3)
9 [] DK (S3)


b. Because of the abnormal results, did you have any additional tests?

1 [] Yes
2 [] No
9 [] DK


c. Because of the abnormal results, did you have any surgery or other treatment?

1 [] Yes
2 [] No
9 [] DK


d. Did the (Pap smear/additional tests/surgery or other treatment) indicate that you had cancer?

1 [] Yes
2 [] No (S3)
9 [] DK (S3)


e. When were you diagnosed as having cancer?

Mo. ____
Year 19 _ _
or
1 [] Days ago ____
2 [] Weeks ago ____
3 [] Months ago ____
4 [] Years ago ____
999 [] DK


S3
Refer to 1c and 1f.

1 [] More than 3 years in 1c or 1f (6)
8 [] Other (7)

6. What is the most important reason why you have (never had a Pap smear/not had a Pap smear in the past few years)?

00 [] Procrastination/Put it off
01 [] Had a hysterectomy (8)
02 [] Didn't know I should
03 [] Not needed/not necessary
04 [] Cost too much
05 [] No insurance coverage
06 [] Don't go to doctors
07 [] Don't have a doctor
08 [] Not recommended by doctor/Dr. never said it was needed
09 [] Dr. said it wasn't needed
10 [] Too embarrassing
11 [] Haven't had any problems
12 [] Fear
88 [] Other
99 [] DK


7a. Do you have menstrual periods?

1 [] Yes (8)
2 [] No (7b)
3 [] Never had menstrual periods (7c)


b. Did they stop due to surgery?

1 [] Yes (8)
2 [] No (8)


c. Was this due to surgery?

1 [] Yes
2 [] No


8a. Do you know how to examine your own breasts for lumps?

1 [] Yes
2 [] No (S4)


b. About how often do you examine your breasts for lumps?

_____
Times per
1 [] Day
2 [] Week
3 [] Month
4 [] Year


000 [] Never
888 [] Other (Specify) ____
999 [] DK


c. Who taught you how to examine your breasts?
Mark all mentioned, do not probe.

1 [] Doctor
1 [] Nurse
1 [] Other health professional
1 [] Learned in a class/meeting
1 [] Read in a book, pamphlet, magazine, etc.
1 [] Television
1 [] Other (Specify) ____
1 [] DK

[p. 179]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


S4
Refer to age

1 [] Under 40 (39)
2 [] 40 and over (9)

9a. A breast physical exam is when the breast is felt for lumps by a doctor or medical assistant. Have you ever heard of a breast physical examination?

1 [] Yes
2 [] No (15)
9 [] DK (15)


b. Have you ever had a breast physical exam?

1 [] Yes
2 [] No (14)
9 [] DK (15)


c. When did you have your last breast physical exam?

If 3 years ago or less (10).
If more than 3 years ago (12)

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK (9d)


d. Was it within the past year or a year or more ago?

1 [] Within past year (9e)
2 [] 1 year or more (9f)
9 [] DK (12)


e. Was it less than three months, or 3 or more months ago?

1 [] Less than 3 months (10)
2 [] 3 or more months (10)
9 [] DK (10)


f. Was it 3 years ago or less, between three and 5 years, or 5 or more years ago?

1 [] 3 years or less (10)
2 [] Between 3 and 5 years (12)
3 [] 5 or more years (12)
9 [] DK (12)


10. Where was this exam done -- in a doctor's office, a clinic, a hospital, or some other place?

1 [] Doctor's office
2 [] Clinic
3 [] Hospital
8 [] Other place (Specify) ____
9 [] DK


11a. Did you go for your last breast physical exam because of a health problem?

1 [] Yes
2 [] No (11c)
9 [] DK (11c)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Follow-up tests/treatment
1 [] Soreness
1 [] Swelling
1 [] Lumps
1 [] Pain
1 [] Discharge
1 [] Complications related to breast feeding
1 [] Unrelated medical problem
1 [] Other
1 [] DK


c. How were you told the results of your test?

1 [] In person
2 [] Telephone
3 [] Through the mail
4 [] Combination of methods
5 [] Never told; meaning results normal
6 [] Never told; DK if problem
8 [] Other


S5
Refer to 11a

1 [] Yes (13)
2 [] No (12)
9 [] DK (12)

12a. Have you EVER had a breast physical exam because of a health problem?

1 [] Yes
2 [] No (13)
9 [] DK (13)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Follow-up tests/treatment
1 [] Soreness
1 [] Swelling
1 [] Lumps
1 [] Pain
1 [] Discharge
1 [] Complications related to breast feeding
1 [] Unrelated medical problem
1 [] Other
1 [] DK

[p. 180]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


13a. Have you ever had a breast physical exam where the results were NOT normal?

1 [] Yes
2 [] No (S8)
9 [] DK (S8)


b. Because of the abnormal results, did you have any additional tests?

1 [] Yes
2 [] No
9 [] DK


c. Because of the abnormal results, did you have any surgery or other treatment?

1 [] Yes
2 [] No
9 [] DK


d. Did the (breast physical exam/additional tests/surgery or other treatment) indicate that you had cancer?

1 [] Yes
2 [] No (S6)
9 [] DK (S6)


e. When were you diagnosed as having cancer?

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK


S6
Refer to 9c and 9f.

1 [] More than 3 years in 9c or 9f (14)
8 [] Other (15)

14. What is the most important reason why you have (never had a breast physical exam/not had a breast physical exam in the past few years) by a doctor or other health care professional?

00 [] Procrastination/Put it off
01 [] Didn't know I should
02 [] Not needed/not necessary
03 [] Cost too much
04 [] No insurance coverage
05 [] Don't go to doctors
06 [] Don't have a doctor
07 [] Not recommended by doctor/Dr. never said it was needed
08 [] Dr. said it wasn't needed
09 [] Too embarrassing
10 [] Haven't had any problems
11 [] Fear
12 [] Examine own breasts
88 [] Other
99 [] DK

[p. 181]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


Hand Card S

CARD S

(Sketch of woman receiving a mammogram, caption reads:)
Sketch of woman on whom mammography is being performed using the most common type of X-ray equipment. Other types of X-ray equipment are also used.

15a. A mammogram is when an x-ray is taken only of the breasts by a machine that presses against the breast while the picture is taken. Have you ever heard of a mammogram?

1 [] Yes
2 [] No (21)
9 [] DK (21)


b. Have you ever had a mammogram?

1 [] Yes
2 [] No (20)
9 [] DK (21)


c. When did you have your last mammogram?

(If 3 years ago or less (16), If more than 3 years ago (18))

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK


d. Was it within the past year or a year or more ago?

1 [] Within past year (15e)
2 [] 1 year or more (15f)
9 [] DK (18)


e. Was it less than three months, or 3 or more months ago?

1 [] Less than 3 months (16)
2 [] 3 or more months (16)
9 [] DK (16)


f. Was it 3 years ago or less, between three and 5 years, or 5 or more years ago?

1 [] 3 years or less (16)
2 [] Between 3 and 5 years (18)
3 [] 5 or more years (18)
9 [] DK (18)


16. Where was this test done -- in a doctor's office, a clinic, a hospital, or some other place?

1 [] Doctor's office
2 [] Clinic
3 [] Hospital
4 [] Imaging center
8 [] Other place (Specify) ____
9 [] DK


17a. Did you go for your last mammogram because of a health problem?

1 [] Yes
2 [] No (17c)
9 [] DK (17c)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Thickening
1 [] Soreness
1 [] Swelling
1 [] Lumps
1 [] Pain
1 [] Discharge
1 [] Unrelated medical problem
1 [] Other
1 [] DK


c. How were you told the results of your test -- in person, over the telephone, through the mail, or some other way?

1 [] In person
2 [] Telephone
3 [] Through the mail
4 [] Combination of methods
5 [] Never told; meaning results normal
6 [] Never told; DK if problem
8 [] Other


S7
Refer to 17a

1 [] Yes (19)
2 [] No (18)
9 [] DK (18)

18a. Have you EVER had a mammogram because of a health problem?

1 [] Yes
2 [] No (19)
9 [] DK (19)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Thickening
1 [] Soreness
1 [] Swelling
1 [] Lumps
1 [] Pain
1 [] Discharge
1 [] Unrelated medical problem
1 [] Other
1 [] DK

[p. 182]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


19a. Have you ever had a mammogram where the results were NOT normal?

1 [] Yes
2 [] No (S8)
9 [] DK (S8)


b. Because of the abnormal results, did you have any additional tests?

1 [] Yes
2 [] No
9 [] DK


c. Because of the abnormal results, did you have any surgery or other treatment?

1 [] Yes
2 [] No
9 [] DK


d. Did the (mammogram/additional tests/surgery or other treatment) indicate that you had cancer?

1 [] Yes
2 [] No (S8)
9 [] DK (S8)


e. When were you diagnosed as having cancer?

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK


S8
Refer to 15c and 15f.

1 [] More than 3 years in 15c or 15f (20)
8 [] Other (21)

20. What is the most important reason why you have (never had a mammogram/not had a mammogram in the past few years)?

00 [] Procrastination/Put it off
01 [] Didn't know I should
02 [] Not needed/not necessary
03 [] Cost too much
04 [] No insurance coverage
05 [] Don't go to doctors
06 [] Don't have a doctor
07 [] Not recommended by doctor/Dr. never said it was needed
08 [] Dr. said it wasn't needed
09 [] Too embarrassing
10 [] Haven't had any problems
11 [] Fear
12 [] Fear of radiation
13 [] Painful procedure
14 [] Unpredictable results
88 [] Other
99 [] DK

[p. 183]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued

(These next questions are about certain kinds of medical tests and examinations.)

21a. Have you ever heard of a digital rectal exam, that is when a finger is inserted into the rectum to check for problems?

1 [] Yes
2 [] No (27)
9 [] DK (27)


b. Have you ever had a digital rectal exam?

1 [] Yes
2 [] No (26)
9 [] DK (27)


c. When did you have your last digital rectal exam?

If 3 years ago or less (22), if more than 3 years ago (24)

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK


d. Was it within the past year or a year or more ago?

1 [] Within past year (21e)
2 [] 1 year or more (21f)
9 [] DK (24)


e. Was it less than three months, or 3 or more months ago?

1 [] Less than 3 months (22)
2 [] 3 or more months (22)
9 [] DK (22)


f. Was it 3 years ago or less, between three and 5 years, or 5 or more years ago?

1 [] 3 years or less (22)
2 [] Between 3 and 5 years (24)
3 [] 5 or more years (24)
9 [] DK (24)


22. Where was this test done -- in a doctor's office, a clinic, a hospital, or some other place?

1 [] Doctor's office
2 [] Clinic
3 [] Hospital
8 [] Other place (Specify) ____
9 [] DK


23a. Did you go for your last digital rectal exam because of a health problem?

1 [] Yes
2 [] No (23c)
9 [] DK (23c)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Pain
1 [] Constipation
1 [] Bowel trouble
1 [] Blood in stool
1 [] Difficulty urinating
1 [] Prostate enlargement
1 [] Bleeding
1 [] Hemorrhoids
1 [] Diverticulitus
1 [] Unrelated medical problem
1 [] Other
1 [] DK


c. How were you told the results of your test -- in person, over the telephone, through the mail, or some other way?

1 [] In person
2 [] Telephone
3 [] Through the mail
4 [] Combination of methods
5 [] Never told; meaning results normal
6 [] Never told; DK if problem
8 [] Other


S9
Refer to 23a

1 [] Yes (25)
2 [] No (24)
9 [] DK (24)

24a. Have you EVER had a digital rectal exam because of a health problem?

1 [] Yes
2 [] No (25)
9 [] DK (25)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Pain
1 [] Constipation
1 [] Bowel trouble
1 [] Blood in stool
1 [] Difficulty urinating
1 [] Prostate enlargement
1 [] Bleeding
1 [] Hemorrhoids
1 [] Diverticulitus
1 [] Unrelated medical problem
1 [] Other
1 [] DK

[p. 184]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


25a. Have you ever had a digital rectal exam where the results were NOT normal?

1 [] Yes
2 [] No (S10)
9 [] DK (S10)


b. Because of the abnormal results, did you have any additional tests?

1 [] Yes
2 [] No
9 [] DK


c. Because of the abnormal results, did you have any surgery or other treatment?

1 [] Yes
2 [] No
9 [] DK


d. Did the (digital rectal exam/additional tests/surgery or other treatment) indicate that you had cancer?

1 [] Yes
2 [] No (S10)
9 [] DK (S10)


e. When were you diagnosed as having cancer?

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK


S10
Refer to 21c and 21f.

1 [] More than 3 years in 21c or 21f (26)
8 [] Other (27)

26. What is the most important reason why you have (never had a digital rectal exam/not had a digital rectal exam in the past few years)?

00 [] Procrastination/Put it off
01 [] Didn't know I should
02 [] Not needed/not necessary
03 [] Cost too much
04 [] No insurance coverage
05 [] Don't go to doctors
06 [] Don't have a doctor
07 [] Not recommended by doctor/Dr. never said it was needed
08 [] Dr. said it wasn't needed
09 [] Too embarrassing
10 [] Haven't had any problems
11 [] Fear
12 [] Painful procedure
13 [] Unpredictable results
88 [] Other
99 [] DK

[p. 185]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


27a. A blood stool test is when the stool is examined to determine whether it contains blood. Have you ever heard of a blood stool test?

1 [] Yes
2 [] No (33)
9 [] DK (33)


b. Have you ever had a blood stool test?

1 [] Yes
2 [] No (32)
9 [] DK (33)


c. When did you have your last blood stool test?

If 3 years ago or less (28), if more than 3 years ago (30)

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK (27d)


d. Was it within the past year or a year or more ago?

1 [] Within past year (27e)
2 [] 1 year or more (27f)
9 [] DK (30


e. Was it less than three months, or 3 or more months ago?

1 [] Less than 3 months (28)
2 [] 3 or more months (28)
9 [] DK (28)


f. Was it 3 years ago or less, between three and 5 years, or 5 or more years ago?

1 [] 3 years or less (28)
2 [] Between 3 and 5 years (30)
3 [] 5 or more years (30)
9 [] DK (30)


28. Did you do the blood stool test yourself or was it done by a doctor or other medical person?

1 [] Self-administered
2 [] Doctor/medical person


29a. Was your last blood stool test done because of a health problem?

1 [] Yes
2 [] No (29c)
9 [] DK (29c)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Hemorrhoids
1 [] Bleeding
1 [] Pain
1 [] Constipation
1 [] Bowel trouble
1 [] Blood in stool
1 [] Ulcers
1 [] Unrelated medical problem
1 [] Other
1 [] DK


c. How were you told the results of your test - in person, over the telephone, through the mail, or some other way?

1 [] In person
2 [] Telephone
3 [] Through the mail
4 [] Combination of methods
5 [] Never told; meaning results normal
6 [] Never told; DK if problem
8 [] Other


S11
Refer to 29a

1 [] Yes (31)
2 [] No (30)
9 [] DK (30)

30a. Have you EVER had a blood stool test because of a health problem?

1 [] Yes
2 [] No (31)
9 [] DK (31)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Hemorrhoids
1 [] Bleeding
1 [] Pain
1 [] Constipation
1 [] Bowel trouble
1 [] Blood in stool
1 [] Ulcers
1 [] Unrelated medical problem
1 [] Other
1 [] DK

[p. 186]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


31a. Have you ever had a blood stool test where the results were NOT normal?

1 [] Yes
2 [] No (S12)
9 [] DK (S12)


b. Because of the abnormal results, did you have any additional tests?

1 [] Yes
2 [] No
9 [] DK


c. Because of the abnormal results, did you have any surgery or other treatment?

1 [] Yes
2 [] No
9 [] DK


d. Did the (blood stool test/additional tests/surgery or other treatment) indicate that you had cancer?

1 [] Yes
2 [] No (S12)
9 [] DK (S12)


e. When were you diagnosed as having cancer?

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK


S12
Refer to 27c and 27f.

1 [] More than 3 years in 27c or 27f (32)
8 [] Other (33)

32. What is the most important reason why you have (never had a blood stool test/not had a blood stool test in the past few years)?

00 [] Procrastination/Put it off
01 [] Didn't know I should
02 [] Not needed/not necessary
03 [] Cost too much
04 [] No insurance coverage
05 [] Don't go to doctors
06 [] Don't have a doctor
07 [] Not recommended by doctor/Dr. never said it was needed
08 [] Dr. said it wasn't needed
09 [] Too embarrassing
10 [] Haven't had any problems
11 [] Fear
12 [] Painful procedure
13 [] Unpredictable results
88 [] Other
99 [] DK

[p. 187]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


33a. A proctoscopic exam is when a tube is inserted into the rectum to check for problems. Have you ever heard of a proctoscopic?

1 [] Yes
2 [] No (39)
9 [] DK (39)


b. Have you ever had a proctoscopic exam?

1 [] Yes
2 [] No (38)
9 [] DK (39)


c. When did you have your last proctoscopic exam?

If 3 years ago or less (34), If more than 3 years ago (38)

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK (33d)


d. Was it within the past year or a year or more ago?

1 [] Within past year (33e)
2 [] 1 year or more (33f)
9 [] DK (36)


e. Was it less than three months, or 3 or more months ago?

1 [] Less than 3 months (34)
2 [] 3 or more months (34)
9 [] DK (34)


f. Was it 3 years ago or less, between three and 5 years, or 5 or more years ago?

1 [] 3 years or less (34)
2 [] Between 3 and 5 years (36)
3 [] 5 or more years (36)
9 [] DK (36)


34. Where was the exam done -- in a doctor's office, a clinic, a hospital, or some other place?

1 [] Doctor's office
2 [] Clinic
3 [] Hospital
4 [] Other place (Specify) ____
9 [] DK


35a. Did you go for your last proctoscopic exam because of a health problem?

1 [] Yes
2 [] No (35c)
9 [] DK (35c)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Bleeding
1 [] Pain
1 [] Constipation
1 [] Bowel trouble
1 [] Blood in stool
1 [] Unrelated medical problem
1 [] Other
1 [] DK


c. How were you told the results of your test -- in person, over the telephone, through the mail, or some other way?

1 [] In person
2 [] Telephone
3 [] Through the mail
4 [] Combination of methods
5 [] Never told; meaning results normal
6 [] Never told; DK if problem
8 [] Other


S13
Refer to 35a

1 [] Yes (37)
2 [] No (36)
9 [] DK (36)

36a. Have you EVER had a proctoscopic exam because of a health problem?

1 [] Yes
2 [] No
9 [] DK (37)


b. What was the problem?
Mark all mentioned, do not probe.

1 [] Bleeding
1 [] Pain
1 [] Constipation
1 [] Bowel trouble
1 [] Unrelated medical problem
1 [] Other
1 [] DK

[p. 188]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


37a. Have you ever had a proctoscopic exam where the results were NOT normal?

1 [] Yes
2 [] No (S14)
9 [] DK (S14)


b. Because of the abnormal results, did you have any additional tests?

1 [] Yes
2 [] No
9 [] DK


c. Because of the abnormal results, did you have any surgery or other treatment?

1 [] Yes
2 [] No
9 [] DK


d. Did the (proctoscopic exam/additional tests/surgery or other treatment) indicate that you had cancer?

1 [] Yes
2 [] No (S14)
9 [] DK (S14)


e. When were you diagnosed as having cancer?

Mo. ____
Year 19_ _

OR
_____
1 [] Days ago
2 [] Weeks ago
3 [] Months ago
4 [] Years ago

999 [] DK


S14
Refer to 33c and 33f.

1 [] More than 3 years in 33c or 33f (38)
8 [] Other (39)

38. What is the most important reason why you have (never had a proctoscopic exam/not had a proctoscopic exam in the past few years)?

00 [] Procrastination/Put it off
01 [] Didn't know I should
02 [] Not needed/not necessary
03 [] Cost too much
04 [] No insurance coverage
05 [] Don't go to doctors
06 [] Don't have a doctor
07 [] Not recommended by doctor/Dr. never said it was needed
08 [] Dr. said it wasn't needed
09 [] Too embarrassing
10 [] Haven't had any problems
11 [] Fear
12 [] Painful procedure
13 [] Unpredictable results
88 [] Other
99 [] DK

[p. 189]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


39. A breast physical exam is when the breast is felt for lumps by a doctor or medical assistant. Have you ever heard of a breast physical exam?

1 [] Yes
2 [] No
9 [] DK


Hand Card S

CARD S
(Sketch of woman receiving a mammogram caption reads:)
Sketch of woman on whom mammography is being performed using the most common type of X-ray equipment. Other types of X-ray equipment are also used.

40. A mammogram is when an x-ray is taken only of the breasts by a machine that presses against the breast while the picture is taken. Have you ever heard of a mammogram?

1 [] Yes
2 [] No
9 [] DK


(These next questions are about certain kinds of medical tests and examinations.)
41. A digital rectal exam is when a finger is inserted in the rectum to check for problems. Have you ever heard of a digital rectal exam?

1 [] Yes
2 [] No
9 [] DK


42. A blood stool test is when the stool is examined to determine whether it contains blood. Have you ever heard of a blood stool test?

1 [] Yes
2 [] No
9 [] DK


43. A proctoscopic exam is when a tube is inserted in the rectum to check for problems. Have you ever heard of a proctoscopic exam?

1 [] Yes
2 [] No
9 [] DK


S15
Refer to sex

1 [] Male (47)
2 [] Female (44)

Mark box if "No" or "DK" in 1a.
44. About how often do you think a woman should have a Pap smear test?

000 [] No/DK

Every
______
1 [] Week(s)
2 [] Month(s)
3 [] Year(s)
777 [] Never
888 [] Other (Specify) ____
666 [] Only if problem/symptoms
999 [] DK


Mark box if "No" or "DK" in 9a or 39.
45. About how often do you think a woman age 50 and over should have a breast physical examination done by a doctor or health professional?

000 [] No/DK
Every
______
1 [] Week(s)
2 [] Month(s)
3 [] Year(s)
777 [] Never
888 [] Other (Specify) ____
666 [] Only if problem/symptoms
999 [] DK


Mark box if "No" or "DK" in 15a or 40.

46. About how often do you think a woman age 50 and over should have a mammogram?

000 [] No/DK
Every
______
1 [] Week(s)
2 [] Month(s)
3 [] Year(s)
777 [] Never
888 [] Other (Specify) ____
666 [] Only if problem/symptoms
999 [] DK


Mark box if "No" or "DK" in 21a or 41.
47. About how often do you think a person age 40 and over should have a digital rectal exam?

000 [] No/DK
Every
______
1 [] Week(s)
2 [] Month(s)
3 [] Year(s)
777 [] Never
888 [] Other (Specify) ____
666 [] Only if problem/symptoms
999 [] DK

[p. 190]

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued


48. About how often do you think a person age 40 and over should have a blood stool test?

000 [] No/DK
Every
______
1 [] Week(s)
2 [] Month(s)
3 [] Year(s)
777 [] Never
888 [] Other (Specify) ____
666 [] Only if problem/symptoms
999 [] DK


Mark box if "No" or "DK" in 33a or 43.
49. About how often do you think a person age 40 and over should have a proctoscopic exam?

000 [] No/DK
Every
______
1 [] Week(s)
2 [] Month(s)
3 [] Year(s)
777 [] Never
888 [] Other (Specify) ____
666 [] Only if problem/symptoms
999 [] DK


50. Has a doctor or health professional ever told you that you had any kind of cancer (including any cancer you have already mentioned)?

1 [] Yes
2 [] No (Section 7)


51a. What kind of cancer was it? ____

799 [] DK

b. What part of the body was affected? ____

99 [] DK


52. How old were you when this cancer was first diagnosed by a doctor? ____

99 [] DK


53. Besides this cancer, has a doctor ever told you that you had any other kind of cancer?

1 [] Yes
2 [] No (Section 7)


54a. What kind of cancer was it? ____

799 [] DK (54b)

b. What part of the body was affected? ____

99 [] DK


55. How old were you when THIS cancer was first diagnosed by a doctor? ____

99 [] DK

[p. 191]

Section T - SMOKING HABITS

These questions are about cigarette smoking.


1. Have you smoked at least 100 cigarettes in your entire life?

If asked: approximately 5 packs.

1 [] Yes
2 [] No (4)
9 [] DK (4)


2. How old were you when you started smoking cigarettes fairly regularly? ____

00 [] Never smoked regularly (4)
99 [] DK


3. Do you smoke cigarettes now?

1 [] Yes (Section V)
2 [] No (Section U)


4. When you are inside public places that have no rules about smoking and someone lights up a cigarette, what are you most likely to do - ask the person not to smoke, move away from the person, just do nothing, or something else?

1 [] Ask person not to smoke (Section W)
2 [] Move away (Section W)
3 [] Do nothing (Section W)
8 [] Something else (Section W)

[p. 192]

Section U - FORMER SMOKER


1. About how long has it been since you smoked cigarettes regularly?

000 [] Never smoked regularly (Section W)
______
1 [] Days
2 [] Weeks
3 [] Months
4 [] Years


999 [] DK


2. On the average, how many cigarettes did you usually smoke a day? ____

00 [] Less than one cigarette per day
99 [] DK


3. How many minutes or hours after awakening did you usually have your first cigarette?

000 [] Immediately
1 [] Minutes ____
2 [] Hours ____
999 [] DK


4. Before you quit (entry in 1) ago, did you make any other serious attempts to stop smoking?

1 [] Yes
2 [] No (7)


5. Including the last time you quit smoking, how many times did you make a serious attempt to stop smoking cigarettes? ____

99 [] DK


6. Before you quit smoking (entry in 1) ago, what was the longest period you stayed off cigarettes?

000 [] Less than one day
______
1 [] Days
2 [] Weeks
3 [] Months
4 [] Years


999 [] DK


7. For how many years were you a regular smoker (do not include the time when you stayed off cigarettes)? ____

00 [] Less than one year
99 [] DK


I'm going to read a list of methods which some people use to stop smoking cigarettes.
8a. (When you quit did you ever/In any of your quit attempts did you ever)?


1) switch to lower tar or nicotine cigarettes?
1 [] Yes
2 [] No


2) use special filters or cigarette holders to regulate the amount of smoke inhaled?
1 [] Yes
2 [] No


3) gradually decrease the number of cigarettes you smoked in a day?
1 [] Yes
2 [] No


4) use prescription chewing gum called "nicorette"?
1 [] Yes
2 [] No


5) Participate in the Great American Smoke-out?
1 [] Yes
2 [] No


6) stop smoking with friends or relatives who were also trying to quit?
1 [] Yes
2 [] No


7) stop by following instructions in a booklet or pamphlet?
1 [] Yes
2 [] No


8) stop "cold turkey", that is, stop all at once without cutting down?
1 [] Yes
2 [] No


9) use some other method?
1 [] Yes
2 [] No


If "No" in 4, or only one method in 8a, mark box(es) without asking and skip to 9; otherwise ask:
b. Thinking of the methods you just mentioned, which ones did you use the last time you quit smoking?
Mark all applicable boxes, do not probe.

1 [] Switch to lower tar/nicotine cigarettes
1 [] Use special filters/cigarette holders
1 [] Gradually decrease number smoked
1 [] Use "nicorette"
1 [] Great American Smoke-out
1 [] Stop with friends or relatives
1 [] Follow instructions in pamphlet or book
1 [] Stop "cold turkey"
1 [] Other
1 [] DK

[p. 193]

Section U - FORMER SMOKER - Continued


9. Thinking of the time(s) you tried to quit smoking, please tell me the reasons you tried to quit.
Mark all mentioned, do not probe.
If for health reasons in general, ask:
Was that concern for your health at the time or concern for your future health?

1 [] Health symptom/problem
1 [] Present health
1 [] Future health
1 [] Both present and future health
1 [] Cost of cigarettes
1 [] Pressure from family and friends
1 [] Advice from my doctor
1 [] Setting a good example for children
1 [] Effect my smoking had on others
1 [] Pregnancy
1 [] Lost desire
1 [] Dirty habit
1 [] Other
1 [] DK


10a. Did you ever try to quit smoking because of a health condition you had at the time?

1 [] Yes
2 [] No (11)


b. What was the health condition?
Mark all mentioned, do not probe.

1 [] Heart trouble/problem
1 [] High blood pressure
1 [] Cancer
1 [] Emphysema
1 [] Cough
1 [] Shortness of breath
1 [] Cold/flu/virus
1 [] Other respiratory problem
1 [] Sore throat
1 [] Pregnancy
1 [] Other
1 [] DK


11. Did a doctor ever advise you to quit smoking?

1 [] Yes
2 [] No
9 [] DK


12a. Did you believe your smoking affected your health in any way?

1 [] Yes
2 [] No (13)
9 [] DK (13)


b. How did smoking affect your health?
Mark all mentioned, do not probe.

1 [] Heart trouble/problem
1 [] High blood pressure
1 [] Cancer
1 [] Emphysema
1 [] Cough
1 [] Shortness of breath
1 [] Cold/flu/virus
1 [] Other respiratory problem
1 [] Sore throat
1 [] Pregnancy
1 [] Other
1 [] DK


13. When you are inside public places that have no rules about smoking and someone lights up a cigarette, what are you most likely to do - ask the person not to smoke, move away from the person, just do nothing, something else?

1 [] Ask person not to smoke (Section W)
2 [] Move away (Section W)
3 [] Do nothing (Section W)
8 [] Something else (Section W)

[p. 194]

Section V - CURRENT SMOKER

If telephone interview, skip to 1b.


1a. In order to get an accurate record of the brand of cigarette you smoke most often, I'd like to see the cigarette package. Do you have the pack handy?

[] Yes (Record UPC, THEN 3) ____
[] No

b. What brand or type of cigarette do you smoke most often? ____


2. What type of cigarettes are the (brand in 1b) that you smoke?
Are they -


a. filter tip or non-filter tip?
1 [] Filter tip
2 [] Non-filter tip


b. hard pack or soft pack?
1 [] Hard pack
2 [] Soft pack


c. Menthol or plain?
1 [] Menthol
2 [] Plain


d. regular, king-size, 100, or 120 millimeters?
1 [] Regular
2 [] King-size
3 [] 100 millimeter
4 [] 120 millimeter
9 [] DK


e. regular, lights, or ultra lights?
1 [] regular
2 [] lights
3 [] ultra lights
9 [] DK


3. On the average, how many cigarettes do you usually smoke a day? ____

00 [] Less than one cigarette
99 [] DK


4. How many minutes or hours after awakening do you have your first cigarette?

000 [] Immediately
____
1 [] Minutes
2 [] Hours


999 [] DK


5. What are the reasons you smoke cigarettes?
Mark all mentioned, do not probe.

1 [] Addicted
1 [] Relaxes or calms me/nerves and stress/ helps me cope
1 [] To keep my weight down
1 [] Wakes me up
1 [] Gives me something to do with my hands
1 [] Keeps me going/ helps me concentrate/ excuses to take a break
1 [] Habit
1 [] I like it/enjoy it
1 [] Social reasons
1 [] Other
1 [] DK


6a. Have you ever made a serious attempt to stop smoking cigarettes?

1 [] Yes
2 [] No (12)
9 [] DK (12)

b. Have you made more than one serious attempt?

1 [] Yes
2 [] No (6d)


c. How many times within the last year have you made a seriously attempt to stop smoking cigarettes?

01 [] Once (6d)
00 [] Never (6e)

Times ____ (6e)

99 [] DK (6e)


d. When did you make the serious attempt to quit smoking?

Month ____
Year 19 _ _

Go to 7a


e. When did you last make a serious attempt to quit smoking?

Month ____
Year 19 _ _

Go to 7b


7a. When you tried to quit, how long did you stay off cigarettes?

000 [] Less than a day (Go to 8)

______ (Go to 8)
1 [] Days
2 [] Weeks
3 [] Months
4 [] Years


999 [] DK (Go to 8)
[p. 195]

Section V - CURRENT SMOKER - Continued

7b. When you tried to quit in (entry in 6e), for how long did you stay off cigarettes?

000 [] Less than a day

______
1 [] Days
2 [] Weeks
3 [] Months
4 [] Years


999 [] DK


c. Of all the times you have tried to quit smoking, what was the longest period you stayed off cigarettes?

000 [] Less than a day

______
1 [] Days
2 [] Weeks
3 [] Months
4 [] Years


999 [] DK


I'm going to read a list of methods which some people use to stop smoking cigarettes.
8a. (When you tried to quit did you ever/in any of your attempts did you ever) -


1) switch to lower tar or nicotine cigarettes?
1 [] Yes
2 [] No


2) use special filters or cigarette holders to regulate the amount of smoke inhaled?
1 [] Yes
2 [] No


3) gradually decrease the number of cigarettes you smoked in a day?
1 [] Yes
2 [] No


4) use prescription chewing gum called "nicorette"?
1 [] Yes
2 [] No


5) participate in the Great American Smoke-out?
1 [] Yes
2 [] No


6) stop smoking with friends or relatives who were also trying to quit?
1 [] Yes
2 [] No


7) stop by following instructions in a booklet or pamphlet?
1 [] Yes
2 [] No


8) stop "cold turkey", that is, stop all at once without cutting down?
1 [] Yes
2 [] No


9) use some other method?
1 [] Yes
2 [] No


If "No" in 6b, or only 1 method in 8a, mark box(es) without asking and skip to 9, otherwise ask:
b. Thinking of the methods you just mentioned, which ones did you use the last time you tried to quit smoking?
Mark all applicable boxes, do not probe.

1 [] Switch to lower tar/nicotine cigarettes
1 [] Use special filters/cigarette holders
1 [] Gradually decrease number smoked
1 [] Use "nicorette"
1 [] Great American Smoke-out
1 [] Stop with friends or relatives
1 [] Follow instructions in pamphlet or book
1 [] Stop "cold turkey"
1 [] Other
1 [] DK


9. Thinking of the time(s) you tried to quit smoking, please tell me the reasons you had for trying quit.
Mark all mentioned, do not probe.
If for health reasons in general ask:
Was that concern for your health at the time or concern for your future health?

1 [] Health symptom/problem
1 [] Present health
1 [] Future health
1 [] Both present and future health
1 [] Cost of cigarettes
1 [] Pressure from family and friends
1 [] Advice from my doctor
1 [] Setting a good example for children
1 [] Effect my smoking had on others
1 [] Pregnancy
1 [] Lost desire
1 [] Dirty habit
1 [] Other
1 [] DK


10a. Did you ever try to quit smoking because of a health condition you had at the time?

1 [] Yes
2 [] No (11)


b. What was the health condition?
Mark all mentioned, do not probe.

1 [] Heart trouble/problem
1 [] High blood pressure
1 [] Cancer
1 [] Emphysema
1 [] Cough
1 [] Shortness of breath
1 [] Cold/flu/virus
1 [] Other respiratory problem
1 [] Sore throat
1 [] Pregnancy
1 [] Other
1 [] DK

[p. 196]

Section V - CURRENT SMOKER - Continued


11a. After you attempt(s) to quit, what were the reasons you started to smoke again?
Mark all mentioned, do not probe.

00 [] Fear of gaining weight
01 [] Actual weight gain
02 [] Headaches/irritability/difficulty concentrating/drowsiness
03 [] Bored/blue/depressed
04 [] Nervous/tense/angry/frustrated/stress
05 [] Stressful life event
06 [] Pressure from others to smoke
07 [] No support from others
08 [] Habit/situation where used to smoke regularly
09 [] Addiction/craving
10 [] Pleasure of smoking/enjoy it
11 [] Others smoking around me
12 [] Not ready to quit/didn't want to quit
13 [] Didn't try hard enough/no will power
14 [] Any mention of alcohol
88 [] Other
99 [] DK


If only one reason in 11a, mark box without asking and skip to 12; otherwise ask:
b. Of the reasons you have told me, which of these was the MOST IMPORTANT to you as a reason for starting to smoke again.
MOST IMPORTANT

00 [] Fear of gaining weight
01 [] Actual weight gain
02 [] Headaches/irritability/difficulty concentrating/drowsiness
03 [] Bored/blue/depressed
04 [] Nervous/tense/angry/frustrated/stress
05 [] Stressful life event
06 [] Pressure from others to smoke
07 [] No support from others
08 [] Habit/situation where used to smoke regularly
09 [] Addiction/craving
10 [] Pleasure of smoking/enjoy it
11 [] Others smoking around me
12 [] Not ready to quit/didn't want to quit
13 [] Didn't try hard enough/no will power
14 [] Any mention of alcohol
88 [] Other
99 [] DK


12. Have you ever switched to a lower tar and nicotine cigarette just to reduce your health risk?

1 [] Yes
2 [] No


13a. Do you believe your smoking has affected your health in any way?

1 [] Yes
2 [] No (14)
9 [] DK (14)


b. How has smoking affected your health?
Mark all mentioned, do not probe.

1 [] Heart trouble/problem
1 [] High blood pressure
1 [] Cancer
1 [] Emphysema
1 [] Cough
1 [] Shortness of breath
1 [] Cold/flu/virus
1 [] Other respiratory problem
1 [] Other
1 [] DK


14. Has a doctor ever advised you to quit smoking?

1 [] Yes
2 [] No


15. For how many years have you been a regular smoker (do not include the times when you stayed off cigarettes)?

00 [] Less than one year

_____ Years

99 [] DK


16a. Could you quit smoking permanently if you wanted to?

1 [] Yes
2 [] No (17)
9 [] DK


b. How hard do you think it would be to quit smoking cigarettes entirely - very hard, somewhat hard, or not hard at all?

1 [] Very hard
2 [] Somewhat hard
3 [] Not hard at all
9 [] DK


17. When you are inside public places that have no rules about smoking, what are you most likely to do - light up a cigarette if you wish, look around to see if others are smoking and then light up, ask if others would mind, just not smoke, or something else?

1 [] Light up
2 [] Look around
3 [] Ask others
4 [] Not smoke
8 [] Something else

[p. 197]

Section W - OTHER TOBACCO USE

These next questions are about the use of other tobacco products.


1a. Have you ever used chewing tobacco, such as Redman, Levi Garrett, or Beechnut?

1 [] Yes
2 [] No (6)
9 [] DK Chewing tobacco (6)


b. Have you used chewing tobacco at least 20 times?

1 [] Yes
2 [] No (6)
9 [] DK (6)


2. How old were you when you first used chewing tobacco?

____ Age

99 [] DK


3. Do you use chewing tobacco now?

1 [] Yes
2 [] No



4. Altogether, about how long (did you use/have you used) chewing tobacco?

000 [] Less than one month
______
1 [] Months
2 [] Years


999 [] DK



5a. On the average, how many days per month (did/do) you use some chewing tobacco?

00 [] Less than one day a month
97 [] Never used regularly (6)
98 [] Everyday

_____ Days per month

99 [] DK


b. On the days that you use(d) chewing tobacco, how many times (did/do) you use it?

____ Times per day

99 [] DK


6a. Have you ever used snuff, such as Skoal, Skoal Bandits, or Copenhagen?

1 [] Yes
2 [] No (12)
9 [] DK Snuff (12)


b. Have you used snuff at least 20 times?

1 [] Yes
2 [] No (12)
9 [] DK (12)


7. How old were you when you first used snuff?

____ Age

99 [] DK


8. Do you use snuff now?

1 [] Yes
2 [] No


9. Altogether, about how long (did you use/have you used) snuff?

000 [] Less than one month

_____
1 [] Months
2 [] Years


999 [] DK


10a. On the average, how many days per month (did/do) you use snuff?

00 [] Less than one day a month
97 [] Never used regularly (12)
98 [] Everyday

_____ Days per month

99 [] DK


b. On the days you use(d) snuff, how many times (did/do) you use it?

_____ Times per day

99 [] DK


11. (Did/Do) you use snuff by sniffing it or by placing it in your mouth?

1 [] Sniffing
2 [] Mouth
3 [] Both


12a. Have you ever smoked a pipe?

1 [] Yes
2 [] No (17)


b. Have you smoked a pipe at least 50 times?

1 [] Yes
2 [] No (17)
9 [] DK (17)


13. How old were you when you first smoked a pipe?

____ Age

99 [] DK

[p. 198]

Section W - OTHER TOBACCO USE - Continued


14. Do you smoke a pipe now?

1 [] Yes
2 [] No


15. Altogether, about how long (did you smoke/have you smoked) a pipe?

000 [] Less than one month

____
1 [] Months
2 [] Years


999 [] DK


16a. On the average, how many days per month (did/do) you smoke a pipe?

00 [] Less than one day a month
97 [] Never used regularly (17)
98 [] Everyday

____ Days per month

99 [] DK


b. On the days you smoke(d) a pipe, how many pipefuls of tobacco (did/do) you smoke?

____ Pipefuls per day

99 [] DK


17a. Have you ever smoked cigars?

1 [] Yes
2 [] No (22)


b. Have you smoked at least 50 cigars in your entire life?

1 [] Yes
2 [] No (22)
9 [] DK (22)


18. How old were you when you first smoked cigars?

____ Age

99 [] DK


19. Do you smoke cigars now?

1 [] Yes
2 [] No


20. Altogether, about how long (did you use/have you smoked) cigars?

000 [] Less than one month

______
1 [] Months
2 [] Years


999 [] DK


21a. On the average, how many days per month (did/do) you smoke cigars?

00 [] Less than one day a month
97 [] Never smoked cigars regularly (22)
98 [] Everyday

____ Days per month

99 [] DK


b. On the days you smoke(d) cigars, how many times (did/do) you smoke?

00 [] Less than one

____ Cigars per day

99 [] DK

[p. 199]

Section W - OTHER TOBACCO USE - Continued


22a. Do you believe cigarette smoking is related to -


1) emphysema?
1 [] Yes (2)
2 [] No (2)
3 [] Maybe (2)
9 [] DK (2)


2) gallstones?
1 [] Yes (3)
2 [] No (3)
3 [] Maybe (3)
9 [] DK (3)


3) lung cancer?
1 [] Yes (4)
2 [] No (4)
3 [] Maybe (4)
9 [] DK (4)


4) chronic bronchitis?
1 [] Yes (5)
2 [] No (5)
3 [] Maybe (5)
9 [] DK (5)


5) diabetes?
1 [] Yes (6)
2 [] No (6)
3 [] Maybe (6)
9 [] DK (6)


6) cancer of the mouth and throat?
1 [] Yes (7)
2 [] No (7)
3 [] Maybe (7)
9 [] DK (7)


7) heart disease?
1 [] Yes (22b)
2 [] No (22b)
3 [] Maybe (22b)
9 [] DK (22b)

HAND CARD W

CARD W

1. Strong
2. Moderate
3. Slight

ASK 22b for each "Yes" in 22a.
b. Do you think there is a strong, moderate, or slight relationship between cigarette smoking and (condition)?


(1) emphysema
1 [] Strong (2)
2 [] Moderate (2)
3 [] Slight (2)
9 [] DK (2)


(2) gallstones
1 [] Strong (3)
2 [] Moderate (3)
3 [] Slight (3)
9 [] DK (3)


(3) lung cancer
1 [] Strong (4)
2 [] Moderate (4)
3 [] Slight (4)
9 [] DK (4)


(4) chronic bronchitis
1 [] Strong (5)
2 [] Moderate (5)
3 [] Slight (5)
9 [] DK (5)


(5) diabetes
1 [] Strong (6)
2 [] Moderate (6)
3 [] Slight (6)
9 [] DK (6)


(6) cancer of the mouth and throat?
1 [] Strong (7)
2 [] Moderate (7)
3 [] Slight (7)
9 [] DK (7)


(7) heart disease?
1 [] Strong (22c)
2 [] Moderate (22c)
3 [] Slight (22c)
9 [] DK (22c)


ASK 22c for each "Yes" in 22a.
c. Do you believe that if a person stops smoking completely, his chances of getting (condition) are reduced?


(1) emphysema
1 [] Yes
2 [] No
9 [] DK


(2) gallstones
1 [] Yes
2 [] No
9 [] DK


(3) lung cancer
1 [] Yes
2 [] No
9 [] DK


(4) chronic bronchitis
1 [] Yes
2 [] No
9 [] DK


(5) diabetes
1 [] Yes
2 [] No
9 [] DK


(6) cancer of the mouth and throat
1 [] Yes
2 [] No
9 [] DK


(7) heart disease
1 [] Yes
2 [] No
9 [] DK

W1
Mark appropriate box

1 [] Sample 871 (23)
2 [] Sample 872 - 874 (W2)
W2
Mark race. Refer to question 3, page 42 or page 43 on HIS-1.

1 [] White (section X)
8 [] All other (23)

23a. Do you think that using chewing tobacco on a regular basis can increase a person's chances of getting mouth and throat cancer?


1) Using chewing tobacco?
1 [] Yes (2)
2 [] No (2)
9 [] DK (2)


What about -

2) Using snuff by mouth?
1 [] Yes (3)
2 [] No (3)
9 [] DK (3)


3) Smoking a pipe?
1 [] Yes (4)
2 [] No (4)
9 [] DK (4)


4) Smoking cigars?
1 [] Yes (23b)
2 [] No (23b)
9 [] DK (23b)


HAND CARD W

CARD W

1. Strong
2. Moderate
3. Slight

Ask 23b for each "Yes" in 23a.
b. Do you think there is a strong, moderate or slight connection between mouth and throat cancer and (YES in 23a)?
What about (YES in 23a)?


(1) Using chewing tobacco?
1 [] Strong
2 [] Moderate
3 [] Slight
9 [] DK


(2) Using snuff by mouth?
1 [] Strong
2 [] Moderate
3 [] Slight
9 [] DK


(3) Smoking a pipe?
1 [] Strong
2 [] Moderate
3 [] Slight
9 [] DK


(4) Smoking cigars?
1 [] Strong
2 [] Moderate
3 [] Slight
9 [] DK

[p. 200]

Section W - OTHER TOBACCO USE - Continued


HAND CARD R2
CARD R2

1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
5. No opinion

24. Now I'm going to read a list of statements about cigarette smoking. After I read each one, please tell me whether you strongly agree, agree, disagree, or strongly disagree, or if you have no opinion.


a. Everything causes cancer anyway so it doesn't really matter if you smoke.

1 [] Strongly agree
2 [] Agree
3 [] Disagree
4 [] Strongly disagree
5 [] No opinion




b. Smoking by a pregnant woman may harm the baby.

1 [] Strongly agree
2 [] Agree
3 [] Disagree
4 [] Strongly disagree
5 [] No opinion




c. The smoke from someone else's cigarette is harmful to you.

1 [] Strongly agree
2 [] Agree
3 [] Disagree
4 [] Strongly disagree
5 [] No opinion




d. Most deaths from lung cancer are caused by cigarette smoking.

1 [] Strongly agree
2 [] Agree
3 [] Disagree
4 [] Strongly disagree
5 [] No opinion




e. People who smoke low tar and nicotine cigarettes are less likely to get cancer than people who smoke high tar and nicotine cigarettes.

1 [] Strongly agree
2 [] Agree
3 [] Disagree
4 [] Strongly disagree
5 [] No opinion




f. If people want to smoke, they should not do so in public places where it might disturb others.

1 [] Strongly agree
2 [] Agree
3 [] Disagree
4 [] Strongly disagree
5 [] No opinion

[p. 201]

Section X - OCCUPATIONAL EXPOSURE

X1
Refer to HIS-1, C1

1 [] Wa/Wb box marked (1)
8 [] All others (6)

1. On your current job, are you exposed to any substances that would be harmful if you breathed them or got them on your skin?

1 [] Yes
2 [] No (3a)
9 [] DK (3a)


2a. Do you know how these substances could affect your health?

1 [] Yes
2 [] No (3a)


b. Where did you learn how these substances could affect your health?
Mark all mentioned, do not probe.

1 [] Employer
1 [] Union
1 [] Health clinic at work
1 [] Magazines
1 [] Newspapers
1 [] Notices posted at work
1 [] Doctor
1 [] Television
1 [] Read container label
1 [] Other
1 [] DK


3a. Do you spend at least half your work day in an office building or some other type of building or do you work mostly outside?

1 [] Inside
2 [] Outside (6)
9 [] DK (6)


b. Are there at least five other people working in the building?

1 [] Yes
2 [] No (6)
9 [] DK (6)


4a. Is smoking allowed where you work?

1 [] Yes
2 [] No (4c)
9 [] DK (6)


b. Do you have smoking and non-smoking areas where you work?

1 [] Yes
2 [] No (5)
9 [] DK (5)


c. Does your employer restrict smoking (to certain areas) for health reasons and personal comfort, or for some other reasons?

1 [] Health/personal comfort
2 [] Other reasons
3 [] Both
9 [] DK


If "No" in 4a, skip to 6; otherwise ask:
5. Would you say your immediate work area is very smoky from tobacco, somewhat smoky, or not smoky at all?

1 [] Very smoky
2 [] Somewhat smoky
3 [] Not smoky at all
9 [] DK


6. In general, would you say the smoke from other people's cigarettes is very annoying to you, somewhat annoying to you, or not at all annoying to you?

1 [] Very annoying
2 [] Somewhat annoying
3 [] Not at all annoying

[p. 202]

Section Y - HEIGHT AND WEIGHT

[Questions 1-3]


1. About how tall are you without shoes?

Feet ____
Inches ____


2. About how much do you weigh without shoes?

Pounds ____


3. When you weighed the most, how much did you weigh (do not include pregnancy)?

Pounds ____