1.What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

2.What is your zip code?

3.Do you currently smoke cigarettes, or not?

Yes, I do

No, I do not

4.What is your gender?

Female

Male

5.What is your race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Other

6.At what age did you start smoking cigarettes?

7.Do any of your family members smoke cigarettes/cigars/milds/etc?

Yes

No

8.Which of the following have you experienced in the last month? (choose all that apply)

I have been upset because of something that happened unexpectedly.

I felt that I was unable to control the important things in my life.

I have felt nervous and “stressed”.

I felt that things were going my way.

I found that I could not cope with all the things that I had to do.

I have often been able to control irritations in my life.

I felt that I was on top of things.

I have been angered because of things that were outside of my control.

I felt difficulties were piling up so high that I could not overcome them.

9.Which of the following applies to you?

I am interested in quitting smoking/want to quit smoking.

I need help to quit smoking.

I want to quit smoking.

I use cigarettes/cigars/milds/pipe as a coping mechanism for stress.

One or more family members who smoke or used to smoke have smoking related diseases.

I have been diagnosed with a mental health disorder.

None of the above

10.How would you rate the degree of crime where you most often purchase cigarettes?

High

Somewhat high

Somewhat low

 Low