Demographics

These survey measures are presented here to assist tobacco control researchers in identifying standard questions to utilize in their research. This information is available for any researcher to use, and the original source is listed as a footnote, where applicable. When source is not listed, the item was created by the AAP Richmond Center Measurement Core team.

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Note: survey items marked with an asterisk are optional.

  1. Today's Date (mm/dd/yyyy): ____________________

  2. What is your/your child’s birthdate? (mm/dd/yyyy): ____________________
    • Age: ________________ years/months
  3. What is your/your child’s gender?
    • Male
    • Female
  4. *Are you/Is your child Hispanic or Latino?d
    • Yes
    • No
    • Don't know
    • Prefer not to answer
    • *If yes, of what origin?b
      • Puerto Rican
      • Cuban/Cuban American
      • Dominican (Republic)
      • Mexican
      • Mexican American
      • Central or South American
      • Other Latin American (specify): ______________________
      • Other Hispanic/Latino/Spanish (specify): _______________
      • Don't know
      • Prefer not to answer
  5. What is your/your child’s race? Would you say:d
    • White
    • Black or African-American
    • Asian or Pacific Islander
    • American Indian or Alaska Native
    • Multiracial (specify): ______________________________
    • Other (specify): __________________________________
    • Don't know
    • Prefer not to answer
  6. *Are you:d
    • Married
    • A member of an unmarried couple
    • Single
    • Divorced
    • Widowed
    • Separated
    • Prefer not to answer
  7. *Do you own or rent your home?
    • Own home
    • Rent home
    • Don't know
    • Prefer not to answer
  8. Which of the following best describes where you live?a
    • A mobile home, trailer, or manufactured home
    • A house detached from any other house (a standalone home)
    • A house attached to one or more houses (duplex, triplex, townhouse, or rowhouse)
    • An apartment building
    • A dormitory or similar boarding house
    • Don't know
    • Prefer not to answer
    1. *Which of the following best describes your apartment or attached housing policies?d
      • Smoking is allowed on the property in shared areas and inside the apartments or units
      • Smoking is only allowed inside apartments or units
      • Smoking is not allowed at all - not even inside individual apartments or units
      • There is no policy - smoking is permitted anywhere
      • Don’t know
      • Prefer not to answer
    2. Do you ever smell smoke in your apartment, dormitory or similar boarding house, or attached home?
      • Yes
      • No
      • Don’t know
      • Prefer not to answer
  9. Including yourself, how many people live in your household?d _____________

  10. *Who lives in the same home as your child?
    Check respondent Person's first name Relationship to child Age (years) Gender (male/female) Smokes (Yes/No) Smokes inside? (Yes/No)
        Child        
                 
                 
                 
                 
                 
                 
                 

  11. *How many adults live in the home? ___________

  12. *How many children live in the home?d ______________

  13. *What are the ages of the children?d _________________________________

  14. *What is the highest grade or year of school you have completed?
    • Never attended high school
    • Grades 9 through 11 (Some high school)
    • Grade 12 or GED (High school graduate)
    • College 1 year to 3 years (Some college or technical school)
    • College 4 years or more (College graduate)
    • Don’t know
    • Prefer not to answer
  15. What is your zip code?
    • ___________
    • Don't Know
    • Prefer not to answer
  16. *Do you receive any government assistance to pay for your rent or housing?d
    • Yes
    • No
    • Don't Know
    • Prefer not to answer
  17. *Do you qualify for any of the following types of financial support?c
    1. WIC
      • Yes
      • No
      • Don't Know
      • Prefer not to answer
    2. Food stamps
      • Yes
      • No
      • Don't Know
      • Prefer not to answer
    3. Housing
      • Yes
      • No
      • Don't Know
      • Prefer not to answer
    4. Day care
      • Yes
      • No
      • Don't Know
      • Prefer not to answer
    5. Medicaid
      • Yes
      • No
      • Don't Know
      • Prefer not to answer
  18. *Which of the following categories best describe your household income from all sources BEFORE taxes last year?d
    • Less than $10,000
    • $10,000 to $15,000
    • $15,000 to $20,000
    • $20,000 to $25,000
    • $25,000 to $35,000
    • $35,000 to $50,000
    • $50,000 to $75,000
    • $75,000 or more
    • Don't know
    • Prefer not to answer


Sources
a) 2005-2006 National Health and Nutrition Examination Survey. Centers for Disease Control and Prevent Web site. http://www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed February 1, 2012.

b) 2010 National Health Interview Survey. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm. Accessed February 1, 2012.

c) Groner JA, Huang H, Nicholson L, Kuck J, Boettner B, Bauer JA. Secondhand smoke exposure and hair nicotine in children: age dependent differences, Nicotine & Tobacco Research (2011); doi: 10.1093/ntr/ntr269

d) National Social Climate Survey of Tobacco Control. The Social Climate of Tobacco Control Web site. http://www.socialclimate.org/. Accessed February 1, 2012.
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