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					                                                                       Survey cycle: 22
                                                                       Participant name:

                                                                       Date of birth:

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1. What is today’s date?                                                                6. How many close friends do you have (i.e. people
                                                                                        you feel at ease with and can talk to about what is on
                                                                                        your mind)?
       Day                Month                  Year
                                                                                                     Close friends
2. What is your home postal code?
                                                                                        7. How many of your close friends smoke
                                                                                        cigarettes?

3. Do you currently live alone?                                                                      Close friends smoke

        Yes  Go to question 5
        No                                                                              8. Even if you do not currently smoke cigarettes,
                                                                                        how often do you…?

4. Do you live with your…? Check all that apply.                                                                        Never     Rarely     Sometimes     Often

                                                 Yes                                    Want to smoke a cigarette

Biological mother                                                                       Need a cigarette

Biological father                                                                       Crave a cigarette

Step-mother
Step-father
                                                                                        9. Even if you do not currently smoke cigarettes, how
Sister(s), step-sister(s), half sister(s)              How many?                        addicted to smoking cigarettes are you…?
Brother(s), step-brother(s), half brother(s)           How many?
                                                                                                                         Not at   A little
Husband, wife                                                                                                                                 Quite      Very
                                                                                                                          all       bit
Partner (girlfriend, boyfriend)
                                                                                        Physically
Son(s), step-son(s)                                    How many?                        Mentally
Daughter(s), step-daughter(s)                          How many?
Roomate(s)                                             How many?
Other (specify)                                        How many?                        10. Have you ever in your life smoked a cigarette,
                                                                                        even just a puff (drag, hit, haul)?
                                                                                               No  Go to question 52
5. Does this person currently smoke cigarettes?
Your….                                                                                         Yes, 1 or 2 times
                                                                                               Yes, 3 or 4 times
                                            Yes he/she smokes cigarettes
                                                                                               Yes, 5 to 10 times
Biological mother
                                                                                               Yes, more than 10 times
Biological father
Step-mother
Step-father                                                                             11. Check the box that describes you best…
Sister(s), step-sister(s), half
sisters(s)                                      How many smoke?                                I have smoked cigarettes, but not at all in the past 12
Brother(s), step-brother(s), half                                                              months
brother(s)                                      How many smoke?
                                                                                               I smoked cigarettes once or a couple of times in the past
Husband, wife                                                                                  12 months
Partner (girlfriend, boyfriend)                                                                I smoke cigarettes once or a couple of times each month
Son(s), step-son(s)                             How many smoke?                                I smoke cigarettes once or a couple of times each week
Daughter(s), step-daughter(s)                   How many smoke?                                I smoke cigarettes every day
Roomate(s)                                      How many smoke?
Other (specify)                                 How many smoke?


NDIT Questionnaire Version Nov 2010                                             -1-
12. How old were you when you puffed on a                                     19. On the days that you smoked during       (last
cigarette for the first time?                                                 month), how many cigarettes did you usually smoke
                                                                              each day?
I was           years old
                                                                                  Less than 1 cigarette (one or a few puffs)
                                                                                  1 cigarette                  16-20 cigarettes
13. How old were you when you smoked a whole
                                                                                  2-3 cigarettes               21-25 cigarettes
cigarette down to or close to the filter for the first
time?                                                                             4-5 cigarettes               More than 25
                                                                                  6-10 cigarettes              Don’t know
I was          years old
                                                                                  11-15 cigarettes
        I have never done this

                                                                              20. During      (2 months ago), on how many days
14. Have you smoked 100 or more whole cigarettes                              did you smoke cigarettes, even just a puff?
(4 packs of 25) in your life?
                                                                                  None  Go to question 22
        No
                                                                                   1 day                      16-20 days
        Yes
                                                                                   2-3 days                   21-30 days
                                                                                   4-5 days                   Every day
15. How old were you when you took cigarette                                       6-10 days                  Don’t know
smoke into your lungs for more than one puff?
                                                                                  11-15 days
I was           years old
        I have never done this  Go to question 17
                                                                              21. On the days that you smoked during      (2
                                                                              months ago), how many cigarettes did you usually
                                                                              smoke each day?
16. The first few times you took cigarette smoke into
your lungs, did you experience...?                                                Less than 1 cigarette (one or a few puffs)
                                                                                  1 cigarette                  16-20 cigarettes
                                      Not at all        A bit   A lot
                                                                                  2-3 cigarettes               21-25 cigarettes
Relaxation
                                                                                  4-5 cigarettes               More than 25
Nausea
                                                                                  6-10 cigarettes              Don’t know
Dizziness                                                                         11-15 cigarettes
Rush or buzz

Coughing                                                                      22. During      (3 months ago), on how many days
                                                                              did you smoke cigarettes, even just a puff?
Burning in your throat
                                                                                  None  Go to question 24
Upset stomach
                                                                                   1 day                      16-20 days
Heart racing/pounding
                                                                                   2-3 days                   21-30 days
Other (specify)___________                                                         4-5 days                   Every day
                                                                                   6-10 days                  Don’t know
                                                                                  11-15 days
17. Did you smoke cigarettes (even just a puff) in the
past three months?
     No  Go to question 26                                                   23. On the days that you smoked during      (3
                                                                              months ago), how many cigarettes did you usually
     Yes
                                                                              smoke each day?
                                                                                  Less than 1 cigarette (one or a few puffs)
18. During     (last month), on how many days did
                                                                                  1 cigarette                  16-20 cigarettes
you smoke cigarettes, even just a puff?
                                                                                  2-3 cigarettes               21-25 cigarettes
        None  Go to question 20
                                                                                  4-5 cigarettes               More than 25
         1 day                                     16-20 days
                                                                                  6-10 cigarettes              Don’t know
         2-3 days                                  21-30 days
                                                                                  11-15 cigarettes
         4-5 days                                  Every day
         6-10 days                                 Don’t know
        11-15 days

NDIT Questionnaire Version Nov 2010                                     -2-
24. Did you smoke any cigarettes in the past 7                  29. In the past 12 month, how often did you use the
days, even just a puff?                                         following contraband tobacco products…?
       No  Go to question 26                                                                                      Less        1-3       1-6
                                                                                                                   than      times     times    Every
                                                                                                          Never
       Yes                                                                                                        once a       per       per     day
                                                                                                                  month      month     week

                                                                “Discount” cigarettes (Peter
25. Starting with yesterday, indicate how many                  Jackson, MacDonald, Viceroy)
cigarettes you smoked on each of the past 7 days,
                                                                Indian brand cigarettes
even just a puff. Write “0” if you did not smoke any
cigarettes on that day.                                         Indian brand cigarillos

                                                                Foreign cigarette brands
                                                                (Gauloises, Camel, Malboro)

                                                                Foreign cigarillo brands (Prime
                                                                Time, Bullseye)
                           Sunday      Monday




             Saturday                           Tuesday
                                                                30. When you cut down or stop using cigarettes, or
                                                                when you are not able to smoke for a long period (like
                                                                most of the day), how often do you experience…?
                  Friday                   Wednesday                                                                                 Some-
                                                                                                              Never    Rarely                  Often
                                                                                                                                     times

                                Thursday                        Feeling irritable or angry


                                                                Feeling restless
26. How long ago did you smoke your last
cigarette?                                                      Feeling nervous, anxious, or tense

        minute(s) ago                                           Trouble concentrating
        hour(s) ago
                                                                Feeling a strong urge or need to
        day(s) ago                                              smoke
        month(s) ago
                                                                Trouble sleeping
        year(s) ago
        Don’t know
                                                                31. How well do each of the following describe you? If
                                                                I go too long without smoking…
27. Do you smoke cigarettes now because it is really
hard to quit?                                                                                                              Describes me……

                                                                                                              Not at                           Very
       No                                                                                                      all
                                                                                                                       A little      Well
                                                                                                                                               well
       Sometimes
                                                                The first thing I notice is a mild desire
       Often/always                                             to smoke that I can ignore
       Never tried to quit
                                                                The desire to smoke becomes so
       Other (please explain)                                   strong that it is hard to ignore and it
       Don’t know (I smoke so little)                           interrupts my thinking

                                                                I just can’t function right, and I know I
                                                                will have to smoke just to feel normal
28. How much of a cigarette do you usually smoke?               again

       One or a few puffs
       Less than half of it                                     32. When you see other people smoking cigarettes,
       About half of it                                         how easy is it for you not to smoke?
       Most of the cigarette
                                                                       Very easy
       Right down to or near the filter
                                                                       Quite easy
       Don’t know (I smoke so little)
                                                                       A bit difficult
                                                                       Very difficult


NDIT Questionnaire Version Nov 2010                       -3-
33. How long can you go without smoking before             38. Do you smoke more frequently during the first
you feel a strong desire to smoke that is hard to          hours after waking, compared with the rest of the
ignore?                                                    day?
        Less than an hour                                        No
        1-2 hours                                                Yes
        3-5 hours
        6-10 hours                                         39. If you are sick with a bad cold or sore throat, do
        11-15 hours                                        you smoke?
        16-23 hours                                              No, I stop smoking when I’m sick
        1 day                                                    Yes, but I cut down on the amount I smoke
        2 days                                                   Yes, I smoke the same amount as when I’m not sick
        More than 2 days, less than a week
        A week or more
                                                           40. How true is each of the following for you?
        Other (specify)
                                                                                                                                       A
                                                                                                                          Not at            Very
                                                                                                                                      bit
34. How often do you smoke cigarettes when you                                                                            all true
                                                                                                                                     true
                                                                                                                                            true
are alone?
                                                           Cigarettes are good for dealing with boredom
       Never
       Sometimes                                           A cigarette gives me energy when I'm tired

       Often                                               When I'm feeling down, a cigarette makes me feel good
       Always
                                                           Smoking cigarettes calms me down when I feel nervous

                                                           Smoking cigarettes helps me control my weight
35. How deeply do you usually inhale?
       Just into my mouth                                  Smoking cigarettes helps me concentrate on my
                                                           work/homework
       Back into my throat
                                                           Smoking cigarettes relieves tension when I am stressed
       Into my lungs shallow
       Into my lungs deep                                  I consider myself to be a social smoker
       Don’t know (I smoke so little)
                                                           I avoid going to a friend's house where you're not allowed
                                                           to smoke even though I might enjoy hanging out with
                                                           him/her
36. On the days that you smoke, how soon after you
wake up do you smoke your first cigarette?                 In situations where I need to go outside to smoke, it's
                                                           worth it even in cold or rainy weather
       Within 5 minutes
                                                           I have cut down or stopped physical activities or sports
       6 - 30 minutes after waking                         because of my smoking
       31 - 60 minutes after waking
                                                           I can function much better in the morning after I've had a
       More than 60 minutes after waking                   cigarette

                                                           Compared to when I first started smoking, I need to
37. Do you find it difficult to refrain from smoking in    smoke a lot more now to be satisfied
places where it is forbidden?                              Compared to when I first started smoking, I can smoke
                                                           much more now before I start to feel nauseated or ill
       Not at all difficult
                                                           OR
       A bit difficult
                                                              I've never felt nauseated or ill from smoking
       Very difficult
                                                           I often run out of cigarettes quicker than I thought I would

                                                           I spend a lot of time getting cigarettes (going out of my
                                                           way to buy cigarettes)

                                                           I spend a lot of time smoking cigarettes (chain smoking,
                                                           smoking a lot throughout the day)

                                                           I’ve stopped hanging out with certain people because of
                                                           my smoking




NDIT Questionnaire Version Nov 2010                  -4-
41. How often do you have cravings to smoke                 48. Think about the last time you tried to quit
cigarettes?                                                 smoking. Did you quit smoking completely (for a
                                                            while)?
       Never  Go to question 43
       Very rarely                                                 Never tried to quit
       Sometimes                                                   No, but I cut down a lot
       Often                                                       No, but I cut down a little
       Very often                                                  No, the amount I smoke didn’t change at all
                                                                   Yes  I quit completely for                     days

42. How strong are your cravings to smoke                          Yes  I quit completely and have remained non-smoking
                                                                   ever since
cigarettes?
       Not at all strong
                                                            49. How important to you are each of the following
       A bit strong
                                                            reasons to quit smoking?
       Quite strong
       Very strong                                                                               Not at all     A little     Quite       Very
                                                                                                important     important    important   important

                                                            I walk up stairs and I’m out of
43. Which cigarette would you most hate to give             breath

up?                                                         I’m coughing up stuff every day

       The first one of the day
                                                            I can’t breathe when exercising
       Another one
                                                            I feel like cigarettes are
       Don’t know (I smoke so little)                       controlling my life

                                                            Other people think that I smell
44. At this point in time, how much do you really           or look bad (yellow teeth, bad
                                                            breath)
want to quit smoking cigarettes completely and
                                                            I get sick more often because of
forever?                                                    smoking
       Not at all                                           Smoking gets me into trouble
       A little bit
                                                            My stuff gets damaged because
       Quite a bit                                          of my smoking (my clothes get
       A whole lot                                          burned)

                                                            I keep smoking cigarettes out of
                                                            habit, even though I don’t want
45. In the past 12 months, did you seriously try to         to
quit smoking completely and forever?                        People I date or go out with
                                                            don’t like me smoking
       No
                                                            My friends who don’t smoke
       Yes, once                                            give me a hard time
       Yes, two or more times                               My parents are really upset
                                                            about me smoking

                                                            Joining a group or organization
46. When was the last time you made a serious               that doesn’t like my smoking
attempt to quit smoking?                                    (sports team, youth group)

                                                            I don’t want to get sick when I’m
     Never made a serious attempt to quit smoking           older (get cancer, lung damage)
       day(s) ago                                           I don’t want to be smoking
       month(s) ago                                         when I am older

       year(s) ago

                                                            50. In the past 12 months, did your doctor…?
47. How confident are you that you can or you have
                                                                                                                                          Not
quit smoking completely and forever?                                                                                   No      Yes
                                                                                                                                       applicable

     Very confident                                         Ask if you smoke
     Fairly confident
                                                            Advise you to quit smoking
     Not very confident
     Not at all confident                                   Give you any specific help or information to help
                                                            you quit smoking


NDIT Questionnaire Version Nov 2010                   -5-
51. In the past 12 months, did you try any of the                                        56. Which one of the following best describes the
following to help you quit smoking?                                                      level of physical activity you had when you were in
                                                                                         grade 7 (Secondary I)?
                                     Yes                                    Yes

                                            Participated in a Quit and
                                                                                              All or most of my free time was spent doing things that
Nicotine patch                                                                                involved little physical effort
                                            Win contest

                                            Used other drugs more                             I sometimes (1-2 times/week) did physical activities in my
Nicotine gum (Nicorettes)                   often (alcohol, marijuana,                        free time (played sports, went running, swimming, bike
                                            sleeping pills)                                   riding, did aerobics)
                                            Spent time with friends who                       I often (3-4 times/week) did physical activities in my free
Nicotine inhaler
                                            don’t smoke
                                                                                              time
                                            Kept myself occupied by
Zyban, Wellbutrin, Bupropion                                                                  I did physical activities in my free time quite often (5-6
                                            doing other things
                                                                                              times/week)
Stopped all at once (Cold                   Attended a « Centre
Turkey)                                     d’abondon du tabagisme »                          I did physical activities in my free time very often (7 or
                                                                                              more times/week)
Cut down by only smoking at
certain times or during certain             Called a telephone help line
situations
                                                                                         57. During the last 7 days, on how many days did you
Tried not to have cigarettes
with me (threw them out)
                                            Other (specify)                              do vigorous physical activities (heavy lifting, digging,
                                                                                         aerobics, fast bicycling) for at least 10 minutes at a
                                                                                         time?
52. Are there any restrictions on smoking cigarettes                                          None  Go to question 59
in your home? Check all that apply.
          No                                                                                     days in the last 7 days
          Smoking is not allowed at all in my home
          Smoking is allowed in certain rooms only                                       58. On the days that you did vigorous physical
          Smoking is restricted in the presence of young children                        activities, how many minutes did you usually spend
          Other (specify)                                                                per day?
                                                                                                 minutes per day
53. How many people smoke inside your home
everyday or almost everyday?                                                             59. In the last 7 days, on how many days did you do
          None              OR                people                                     moderate physical activities (carrying light loads,
                                                                                         bicycling at a regular pace, doubles tennis) for at least
                                                                                         10 minutes? Do not include walking.
54. In the past month, how often were you exposed
to second-hand smoke...?                                                                      None  Go to question 61

                                                      Some-      Fairly    Very                  days in the last 7 days
                                    Never   Rarely
                                                      Times      often     often

At home                                                                                  60. On the days that you did moderate physical
In a car or other private
                                                                                         activities, how many minutes did you usually spend
vehicle                                                                                  per day?
In public places (bars,                                                                          minutes per day
restaurants, shopping malls,
arenas)

When visiting friends or                                                                 61. In the last 7 days, on how many days did you walk
relatives                                                                                for at least 10 minutes at a time?
At work or school
                                                                                              None  Go to question 63

                                                                                                 days in the last 7 days
55. In the past 12 months, how many organized
sports teams did you belong to (where you practice
with teammates or play against other teams)?                                             62. On the days that you walked, how many minutes
                                                                                         did you usually spend walking per day?
             None              OR                 teams
                                                                                                 minutes per day



NDIT Questionnaire Version Nov 2010                                                -6-
    63. In the past month, how many days per week did                                   64. People engage in physical activity for many
    you do each of the following activities? Write “0”                                  reasons. To what extent is each of the following is
    days if you did not do this. On average how many                                    true for you?
    minutes did you spend each time you did this?                                                                                                  Some-    Often     Very
                                                                                                                                   Not    Rarely
    What was your level of effort when you did the                                                                                 true    true
                                                                                                                                                    times   true      often
    activity?                                                                                                                                        true    for    true for
                                                                                                                                 for me   for me
                                                                                                                                                   for me    me        me
                                                       Number of                        I exercise because other people
Commuting/Leisure time                  Number of      minutes on                       say I should
                                                                     Level of effort
activities                              days/week         each
                                                        occasion                        I feel guilty when I don’t exercise
                                                                       Light
Walk to/from work or school
                                             days          minutes     Moderate         I value the benefits of exercise
(round trip)
                                                                       Intense

                                                                       Light            I exercise because it’s fun
Bicycle to/from work or school
                                             days          minutes     Moderate
(round trip)
                                                                       Intense          I don’t see why I should exercise

                                                                       Light            I take part in exercise because my
Walking                                      days          minutes     Moderate         friends/family/partner say I should
                                                                       Intense          I feel ashamed when I miss an
                                                                                        exercise session
                                                                       Light
Bicycling                                    days          minutes     Moderate         It’s important to me to exercise
                                                                                        regularly
                                                                       Intense
                                                                                        I can’t see why I should bother
                                                                       Light            exercising
Gardening                                    days          minutes     Moderate
                                                                       Intense          I enjoy my exercise sessions

                                                                       Light            I exercise because others will not
Odd jobs                                     days          minutes     Moderate         be pleased with me if I don’t
                                                                       Intense
                                                                                        I don’t see the point of exercising

                                                                                        I feel like a failure when I haven’t
Sports/physical activity (specify)                                                      exercised for a while

                                                                       Light            I think it’s important to make the
1                                            days          minutes
                                                                       Moderate         effort to exercise regularly
                                                                       Intense
                                                                                        I find exercise a pleasurable activity

                                                                       Light            I feel under pressure from my
2                                            days          minutes
                                                                       Moderate         friends and family to exercise
                                                                       Intense
                                                                                        I get restless if I don’t exercise
                                                                                        regularly
                                                                       Light
3                                            days          minutes                      I get pleasure and satisfaction from
                                                                       Moderate
                                                                       Intense          participating in exercise

                                                                                        I think exercising is a waste of time
                                                                       Light
4                                            days          minutes
                                                                       Moderate
                                                                       Intense
                                                                                        65. Do you consider yourself….?
                                                                                               Too thin
                                            Number of       Number of minutes on
Household work/school activities
                                            days/week         each occasion
                                                                                               Just about right
Light household work (cooking,
                                                                                               A little too heavy
                                                    days              minutes
washing dishes, ironing, child care)                                                           Much too heavy
Intense household work (scrubbing
                                                    days              minutes
floor, walking with heavy bags)
                                                                                        66. How much do you weigh?
Light work (sitting/standing with some
                                                    days              minutes
walking, e.g., desk job)                                                                        pounds             OR                     kilograms
Intense work (regularly lifting heavy
                                                    days              minutes
objects at work)
                                                                                        67. How tall are you without your shoes on?
                                                                                                feet            inches         OR              meters               cm


    NDIT Questionnaire Version Nov 2010                                           -7-
                                                                        74. In general, how would you rate…?
68. Currently, what are you doing about your
weight?                                                                                                         Exc-     Very
                                                                                                                                  Good    Fair    Poor
                                                                                                                ellent   good
       I’m trying to lose weight                                        Your health
       I’m trying to gain weight
                                                                        Your mental health
       I want to maintain my weight
       I’m not doing anything about my weight                           Your ability to handle unexpected
                                                                        and difficult problems (a family or
                                                                        personal crisis)
                                                                        Your ability to handle day-to-day
69. How many hours of television (including video                       demands in your life (work, family
movies) do you usually watch in a single day? Write                     responsibilities)
“0” if none. Write “LT ½” if less than ½ hour.                          The overall quality of your sleep at
                                                                        night
On weekdays, I usually watch            hour(s) of television a day
                                                                        The quality of your sleep in the
                                                                        past month
On weekends, I usually watch            hour(s) of television a
day
                                                                        75. In the last 6 months, how often did you experience
70. How many hours do you usually spend on a                            each of the following?
computer in a single day for school or at work?                                                                Never     Rarely
                                                                                                                                  Some-
                                                                                                                                          Often   Always
                                                                                                                                  times
Write “0” if none. Write “LT ½” if less than ½ hour.
                                                                        When I have eaten more than
On weekdays, I usually use the computer             hour(s) a day       what I want, I experience
                                                                        feelings of guilt
for work or school
                                                                        When I am in a situation where
On weekends, I usually use the computer             hour(s) a day       others can see my body (pool,
                                                                        changing room), I feel ashamed
for work or school
                                                                        When I eat fattening food, I get
                                                                        distressed by the feeling that I
                                                                        did something wrong
71. How many hours do you usually spend on a
computer in a single day during your leisure time                       The appearance of my body is
                                                                        embarrassing for me in front of
(playing computer games, using the Internet)? Write                     others
“0” if none. Write “LT ½” if less than ½ hour.
                                                                        When I can’t manage to work
On weekdays, I usually use the computer                                 out physically, I feel guilty
hour(s) a day in my leisure time                                        When I think of the possibility
                                                                        that others can see my naked
                                                                        body, I would rather hide
On weekends, I usually use the computer                                 somewhere
hour(s) a day in my leisure time
                                                                        I am ashamed of myself when
                                                                        others get to know how much I
                                                                        really weigh
72. How many hours do you usually spend reading
                                                                        When I can’t get a grip on my
(books, magazines, newspapers, homework) in a                           weight, I blame myself
single day? Write “0” if none. Write “LT ½” if less
                                                                        I blame myself when I break a
than ½ hour.                                                            good resolution concerning my
                                                                        eating
On weekdays, I usually read            hour(s) a day
                                                                        I avoid exerting myself
                                                                        physically in front of others
On weekends, I usually read            hour(s) a day                    since I feel embarrassed

                                                                        When I see myself in the mirror,
73. How many minutes do you usually spend                               I feel guilty and decide to do
                                                                        more for my figure
talking on your cell phone in a single day? Write “0”
                                                                        Since the size of my clothes is
if none. Write “LT ½” if less than ½ hour.                              embarrassing for me, I would
                                                                        rather avoid shopping for new
On weekdays, I usually talk           minutes(s) a day on my cell       clothes
phone

On weekends, I usually talk           minutes(s) a day on my cell
phone




NDIT Questionnaire Version Nov 2010                               -8-
   76. Please indicate your level of agreement with the                                           78. Have you ever in your life had a period lasting 2
   following statements.                                                                          weeks or longer when most of the day, nearly ever
                                                                                                  day, you…
                                                Strongly                Dis-      Strongly
                                                             Agree
                                                 agree                 agree      disagree
                                                                                                                                                        Yes     Age first happened
On the whole, I am satisfied with myself
                                                                                                   Felt sad, empty or depressed                                          years

At times, I think I am no good at all                                                              Were very discouraged about how things
                                                                                                                                                                         years
                                                                                                   were going in your life
I feel that I have a number of good
qualities                                                                                          Lost interest in most things you usually enjoy
                                                                                                                                                                         years
                                                                                                   like work, hobbies, personal relationships
I am able to do things as well as most
other people

I feel I do not have much to be proud of                                                          79. In the past month, did you take any of the
                                                                                                  following medications, either prescription or over-the-
I certainly feel useless at times                                                                 counter?
I feel that I’m a person of worth, at least
on an equal place with others                                                                                                                                              Yes

I wish I could have more respect for                                                              Pain relievers (aspirin, Tylenol, arthritis medicine, anti-
myself                                                                                            inflammatories)

All in all, I am inclined to feel that I am a                                                     Tranquilizers (Valium, Ativan)
failure
                                                                                                  Diet pills (Ponderal, Fastin)
I take a positive attitude toward myself                                                          Anti-depressants (Prozac, Paxil, Effexor)

                                                                                                  Codeine, Demerol or morphine

                                                                                                  Allergy medicine (Allegra, Reactine)
   77. Has a health professional ever diagnosed you
   with any of the following? How old were you when                                               Asthma medications (inhalers, nebulizers)

   first diagnosed?                                                                               Cough or cold remedies

                                                                                                  Penicillin or other antibiotics
                                                                                Age first
                                                                 Yes
                                                                               diagnosed          Mood stabilizers (Lithium, Epival)
Asthma                                                                              years         Major tranquilizers, anti-psychotics, neuroleptics (Risperidol,
                                                                                                  Olanzapine, Seroquel)
Migraine headaches                                                                  years
                                                                                                  Thyroid medication (Synthroid, Levothyroxine)
Food allergies                                                                      years
                                                                                                  Steroids
Other allergies                                                                     years
                                                                                                  Insulin
Thyroid condition                                                                   years
                                                                                                  Pills to control blood sugar levels
Mood disorder (depression, bipolar disorder)                                        years
                                                                                                  Sleeping pills (Imovane, Nytol, Starnoc, melatonin)
Anxiety disorder (phobia, fear of social situations,
obsessive-compulsive disorder, panic disorder,                                      years         Stomach remedies
generalized anxiety disorder)
                                                                                                  Laxatives
Learning disability (attention deficit disorder, dyslexia)                          years
                                                                                                  Birth control pills
Eating disorder (anorexia, bulimia)                                                 years
                                                                                                  Blood pressure medication
Back problems                                                                       years
                                                                                                  Other (specify)
Intestinal or stomach ulcers                                                        years

Bowel disorder (Crohn’s disease, ulcerative colitis,
                                                                                    years
irritable bowel)                                                                                  80. Have you ever had a period lasting 4 or more
Cholesterol or lipid problems                                                       years         days when you felt much more excited and full of
Diabetes                                                                            years         energy than usual AND experienced other unusual
                                                                                                  changes (mind went too fast, you talked a lot, you
High blood pressure                                                                 years
                                                                                                  were very restless, you needed less sleep, you were
Insomnia                                                                            years         more social, you drove too fast, you spent too much
Obstructive sleep apnea                                                             years         money)?
Other sleep disorder                                                                years
                                                                                                       No
Other (specify)                                                                     years              Yes  This first happened when I was                         years old




   NDIT Questionnaire Version Nov 2010                                                      -9-
  81. Have you ever seriously considered committing                                84. In the past two weeks, how much of the time have
  suicide or taking your own life?                                                 you…?
          No                                                                                                                     Slightly
                                                                                                                                             Slightly
                                                                                                                                  less
          Yes                                                                                                      At   Some
                                                                                                                                  that
                                                                                                                                              more      Most
                                                                                                                                                                 All the
                                                                                                                   no   of the                than      of the
                                                                                                                                 half of                          time
                                                                                                                 time    time                half of     time
                                                                                                                                   the
                                                                                                                                            the time
  82. Thinking about the amount of stress in your life,                                                                           time
  would you say that most days are…?                                               Felt low in spirits or sad
          Not at all stressful                                                     Lost interest in, or could
          Not very stressful                                                       no longer enjoy your
                                                                                   daily activities
          A bit stressful                                                          Felt lacking in energy
          Quite stressful                                                          and strength

          Extremely stressful                                                      Felt less self-confident

                                                                                   Had a bad conscience or
                                                                                   feelings of guilt
  83. Have you ever had any of the following? How
  old were you when you first experienced this? Did                                Felt that life wasn’t worth
                                                                                   living
  you experience it in the past 12 months?
                                                                                   Had difficulty
                                                                 Experienced       concentrating (when
                                         Ever        Age first                     reading the newspaper
                                                                  in past 12
                                        had this   experienced                     or watching TV)
                                                                    months

Attack of fear or panic when all of                                                Felt very restless
a sudden you felt very frightened,                       years
anxious or uneasy                                                                  Felt subdued or slowed
                                                                                   down
Attack when all of a sudden, you                                                   Had trouble sleeping at
became dizzy, very uncomfortable,                                                  night or waking up too
short of breath, dizzy, nauseous,                                                  early
                                                         years
your heart pounded, or you
thought that you might lose control,                                               Suffered from reduced
die or go crazy                                                                    appetite
                                                                                   Suffered from increased
A time when you were a “worrier”                                                   appetite
(when you worried a lot more
                                                         years
about things than other people with
the same problems)
                                                                                   85. How hungry are you in the morning?
A period lasting 6 month or longer
when you were anxious or worried                         years
                                                                                          Not at all
most days                                                                                 A little
                                                                                          Somewhat
A time when you were much more
nervous or anxious than most                                                              Moderately
                                                         years
other people with the same
problems                                                                                  Very

A time when you felt very afraid or
really shy meeting new people,                           years                     86. In the past month, how often did you eat
going to parties, going on a date                                                  (snacks)…?
A time when you felt very afraid or                                                                                        Never      Rarely     Sometimes       Often
uncomfortable when you had to do
something in front of a group of                         years
people (giving a speech, speaking                                                  After breakfast, but before lunch
in class)
                                                                                   After lunch, but before supper
A time in your life when you felt
afraid of being in crowd, going to                       years                     After supper, but before bedtime
public places, traveling alone

                                                                                   When you woke up at night
A time in your life when you
became very upset or nervous in                          years
crowds, public places, or traveling




  NDIT Questionnaire Version Nov 2010                                     - 10 -
87. Did you experience any of the following in the                                  88. In the past 12 months, how often did you…?
past 12 months? If yes, how stressed were you by
                                                                                                                                Less      1-3     1-6
the experience?                                                                                                                 than    times   times   Every
                                                                                                                       Never
                                                                                                                               once a     per     per    day
                                               Stressed by experience                                                          month    month   week

                                            Not at              Some-               Smoke cigars
                                      Yes            A little           A lot
                                             all                 what
                                                                                    Smoke cigarellos
Break-up of relationship or
marriage                                                                            Smoke a pipe

Kicked out of school                                                                Use Bidis (a tobacco product
                                                                                    from India)
Serious car accident
                                                                                    Use chewing tobacco
Pregnancy
                                                                                    Use snuff
Lost a job
                                                                                    Use a waterpipe (hubble bubble,
Major health problem                                                                nargilé, shisha)

Major and/or chronic financial                                                      Drink alcoholic beverages (beer,
                                                                                    wine, liquor)
problems
                                                                                    Drink 5 or more alcoholic
Began college or university
                                                                                    beverages on one occasion
Sought psychological or psychiatric
                                                                                    Use marijuana, cannabis,
care
                                                                                    hashish
Established a new steady
relationship with a partner                                                         Use cocaine

Got married                                                                         Use speed (amphetamines)

Problems at work (with boss or co-                                                  Use ecstasy (MDMA) or other
workers)                                                                            similar drugs

Changed job                                                                         Use hallucinogens (PCP, LSD
                                                                                    (acid), mushrooms)
Problems with the law
                                                                                    Use inhalants (glue, gasoline)
Death of a parent or other family                                                   Use heroin (smack, junk)
member

Major argument with parents                                                         Use another illicit drug

Birth of a child                                                                    Play physically active video
                                                                                    games (WII, WII fit, Dance
A close relative or friend had a                                                    Dance Revolution, EyeToy)
serious illness or injury
                                                                                    Felt suicidal
Your spouse, parent, sibling or
child died
                                                                                    Seriously considered committing
Another close relative died                                                         suicide or taking your own life

You had serious problems with a
close friend, neighbour or relative
                                                                                    89. Have you ever in your life used a waterpipe
You became much better off                                                          (hubble bubble, nargilé, shisha)?
financially
                                                                                           No  Go to question 94
Other stressful event (specify)
___________________________                                                                Yes, 1 or 2 times
                                                                                           Yes, 3 or 4 times
                                                                                           Yes, 5 to 10 times
                                                                                           Yes, more than 10 times

                                                                                    90. When you use a waterpipe, how long does each
                                                                                    waterpipe session usually last?
                                                                                         Less than one hour
                                                                                         1-2 hours
                                                                                         More than 2 hours
NDIT Questionnaire Version Nov 2010                                        - 11 -
91. How old were you when you used a waterpipe                                          98. Do you play any of the following active video
for the first time?                                                                     games…. in your own home or at a friend’s home?
        years
                                                                                        Check all that apply
                                                                                                                                                                      At a
                                                                                                                                                       At home     friend’s
92. How often do you use a waterpipe…?                                                                                                                              house

                                                                                         Wii Sports (ex.: Snowboarding)
                                      Never     Rarely      Sometimes   Often

                                                                                         Boxing (ex. : Punchout)
Alone

                                                                                         Dance Dance Revolution
In your home

                                                                                         Pump it up
At a café or restaurant

                                                                                         Eye toy (ex. : Groove)
At a friend’s house

Sharing the waterpipe hose with                                                          Jenny McCarthy «in shape»
other people
                                                                                         EA active

93. Do you buy tobacco for the waterpipe…?                                               Wii Fit:Yoga


                                      Never     Rarely      Sometimes   Often            Powergrid Fitness Kilowatt


On the Internet                                                                          Yourself Fitness!


In a tobacco shop                                                                        Cyclescore


At a convenience store                                                                   Other:


Other (specify)
                                                                                        99. How often do you play active video games…?

94. Compared to smoking cigarettes, smoking a                                                                                 Never        Rarely     Sometimes      Often
waterpipe is…
                                                                                         Alone
                              Strongly                              Strongly
                                              Agree      Disagree
                               agree                                disagree             With friends
 Less harmful

 Less addictive
                                                                                        100. How true is each of the following for you…?

                                                                                                                                                Not at     A bit     Very
95. In the past month, how many days per week did                                                                                               all true   true      true
you play active video games (Wii, Dance Dance
Revolution)?                                                                             I like to play active video games

        None  Go to question 100                                                        I prefer to play active video games more than
                                                                                         outdoor sports
            days per week                                                                I prefer to play active video games more than
                                                                                         indoor sports

96. On average how many minutes did you spend                                            I like to play active video games with friends
each time you did this?
                                                                                         I like to play active video games with my family
            minutes
                                                                                         I think that playing active video games is a
                                                                                         good way to integrate physical activity into my
                                                                                         life
97. What was your level of effort when you did the
                                                                                         I think that I will play active video games for
activity?                                                                                many years

        Light
        Moderate
        Intense



NDIT Questionnaire Version Nov 2010                                            - 12 -
101. In the past 12 months, how often did you play                                     103. In contrast to just feeling tired, how likely are you
each of the following games for money?                                                 to doze off or fall asleep….?
                                                   Less      1-3      1-6                                                Not at
                                                   than    times    times   Every                                                 A little   Quite    Very
                                        Never                                                                              all
                                                  once a     per      per    day                                                  likely     likely   likely
                                                                                                                         likely
                                                  month    month    week
Lottery                                                                                 Sitting and reading

Horse racing                                                                            Watching TV

Betting on professional sports                                                          Sitting inactive in a public
                                                                                        place (theatre, meeting)
Betting on college sports
                                                                                        As a passenger in a car for an
Bingo                                                                                   hour without a break
Slot machines
                                                                                        Lying down to rest in the
                                                                                        afternoon
Video Lottery Terminals (VLTs)

Casino table games (Blackjack,                                                          Sitting and talking to someone
poker)
                                                                                        Sitting quietly after a lunch
Dice/Craps                                                                              without alcohol

Poker                                                                                   In a car, while stopped for a
                                                                                        few minutes in traffic
Blackjack

Internet gambling (includes online
poker)                                                                                 104. Have you ever received treatment for a sleep
Other (specify)                                                                        disorder?
                                                                                            No  Go to question 106
102. During the past 12 months, how often…?                                                 Yes

                                                                    Some-
                                                   Never   Rarely           Often
                                                                    times              105. What type of treatment did you receive? Check all
Have you been preoccupied with gambling
                                                                                       that apply.
(thinking about gambling, planning to gamble,
thinking about ways to get money to gamble)                                                 CPAP (Continuous Positive Airway Pressure)
                                                                                            Surgery
Have you needed to gamble with more and
more money in order to get the amount of                                                    Medication (specify)
excitement you want

Have you tried to control, cut back or stop                                            106. During the past month, what time did you usually
gambling without being able to
                                                                                       go to bed at night?
Have you felt restless or irritable when
attempting to cut down or stop gambling

Have you gambled to escape from problems                                               107. During the past month, how long has it usually
or when you were feeling bad
                                                                                       taken you to fall asleep at night?
After losing money gambling, did you return
another day to get even (try to win back
                                                                                                minutes
money you lost)

Has your gambling led to lying to family
members, your therapist, or other people, in                                           108. During the past month, what time did you usually
order to conceal your involvement with                                                 get up in the morning?
gambling

Has your gambling led you to commit illegal
acts such as forgery, fraud, theft, or
embezzlement to finance it                                                             109. During the past month, how many hours of actual
                                                                                       sleep did you usually get at night?
Has your gambling led you to jeopardize or
lose a significant relationship, job, or career                                                 hours of sleep
or educational opportunity

Have you had to rely on others to provide
money to relieve a desperate financial
situation caused by gambling




NDIT Questionnaire Version Nov 2010                                           - 13 -
110. People react to difficult, stressful, or upsetting                           112. How often in the past month did your roommate
situations in different ways. How often do you do                                 or bed partner mention that you had…?
each of the following when you experience such a                                                                                Less      1-2      3 or
situation?                                                                                                             Not      than    times      more
                                                                                                                      at all   once a     per   times per
                                                                                                                                week    week      week
                                                       Some-           Very
                                      Never   Rarely           Often
                                                       times           Often       Loud snoring

Focus on the problem and see                                                       Long pauses between breaths
how I can solve it                                                                 while asleep

Blame myself for having gotten                                                     Legs twitching or jerking while
into this situation                                                                you sleep

Treat myself to a favorite food or                                                 Episodes of disorientation or
snack                                                                              confusion during sleep

Think about how I have solved                                                      Other restlessness while you
similar problems                                                                   sleep (specify)

Feel anxious about not being able
to cope
                                                                                  113. During the past month, how often did you
Go out for a snack or meal
                                                                                  experience each of the following?
Determine a course of action and                                                                                                Less      1-2      3 or
follow it                                                                                                                       than    times      more
                                                                                                                      Never
                                                                                                                               once a     per   times per
Blame myself for being too                                                                                                      week    week      week
emotional about the situation
                                                                                   Unable to get to sleep within 30
                                                                                   minutes
Buy myself something
                                                                                   Woke up in the middle of the
Work to understand the situation                                                   night or early morning

Become very upset                                                                  Had to get up to use the
                                                                                   bathroom
Visit a friend
                                                                                   Could not breathe comfortably
Take corrective action
immediately                                                                        Coughed or snored loudly

Blame myself for not knowing                                                       Felt too cold while sleeping
what to do
                                                                                   Felt too hot while sleeping
Spend time with a special person
                                                                                   Had bad dreams
Think about the event and learn
from my mistakes
                                                                                   Had pain while sleeping
Wish that I could change what has
happened or how I felt                                                             Took medicine to help you sleep
                                                                                   (prescribed or “over the
Phone a friend                                                                     counter”)

                                                                                   Had trouble staying awake while
Analyze the problem before                                                         driving, eating meals, engaging
reacting                                                                           in social activities

Focus on my general
inadequacies
                                                                                  114. During the past month, has it been a problem for
Take time off and get away from
the sitaution
                                                                                  you to keep up enough enthusiasm to get things
                                                                                  done?
                                                                                       Not problem at all
111. Do you have a bed partner or roommate?
                                                                                       Only a very slight problem
       No bed partner or roommate  Go to question 113                                 Somewhat of a problem
       Partner/roommate in other room                                                  A very big problem
       Partner in same room, but not same bed
       Partner in same bed




NDIT Questionnaire Version Nov 2010                                      - 14 -
  115. How true is each of the following for you?                                  117. How far have you gone in school?
                                                       Not at                           Attended high school, but did not graduate
                                                                A bit   Very
                                                         all
                                                        true
                                                                true    true            Graduated high school
I make mistakes because I don’t pay attention or I
                                                                                        Attended CEGEP, community/technical college, but did not
have difficulty paying attention to detail                                              graduate
I have difficulty concentrating when I work or play
                                                                                        Graduated CEGEP, community/technical college
                                                                                        Attended university (or teacher's college), but did not
I have difficulty listening to what people say to me                                    graduate
I have difficulty finishing my school work or other                                     Graduated university with a Bachelor’s degree
tasks I have to do                                                                      Graduated university with a Master’s degree
I have difficulty organizing tasks and activities                                       Graduated university with a PhD
I do not like school or other work where I need to                                      Other (specify)
think a lot

I lose things necessary for me to complete tasks or
activities (pencils, book, tools)                                                  118. What is your current marital status?
I am distracted when things happen around me                                            Single
                                                                                        Married
I am distracted during my daily activities
                                                                                        Living as married (common-law)
I squirm and fidget nervously with my hands and                                         Divorced
feet or I wriggle in my chair
                                                                                        Separated
I leave my seat even though I am not supposed to
(at school)                                                                             Other (specify)

I am agitated or very active
                                                                                   119. Are you currently enrolled as a full- or part-time
I have difficulty doing leisure activities calmly
                                                                                   student?
I am always moving around (to do things)                                                No
I talk too much
                                                                                        Yes, Full-time. Where?
                                                                                        Yes, Part-time. Where?
I answer questions even before people finish asking
the question

I have difficulty waiting in line or waiting my turn                               120. Are you currently working at a job or business
                                                                                   (paid or unpaid)?
I interrupt others while they are working
                                                                                        No  Go to question 122
                                                                                        Yes
  116. People living in Canada come from many
  cultural and racial backgrounds. Are you… ?
                                                                                   121. About how many hours per week do you usually
          White                                                                    work at your job/business (paid or unpaid)?
          Chinese                                                                        hours per week
          South Asian (East Indian, Pakistani, Sri Lankan)
          Black
                                                                                   122. What is your best estimate of the total income,
          Latin American
                                                                                   before taxes and deductions, of all household
          Southeast Asian (Cambodian, Indonesian, Laotian,                         members from all sources in the past 12 months?
          Vietnamese)
                                                                                        Less than $20 000           70 000$ - 79 999$
          Arabic
                                                                                        20 000$ - 29 999$           80 000$ - 99 999$
          West Asian (Afghan, Iranian)
                                                                                        30 000$ - 39 999$           100 000$ - 119 999$
          Other (specify)
                                                                                        40 000$ - 49 999$           120 000$ - 149 999$
                                                                                        50 000$ - 59 999$           150 000$ or more
                                                                                        60 000$ - 69 999$           Don’t know




  NDIT Questionnaire Version Nov 2010                                     - 15 -
To help us locate you for the next follow-up, what is your….?

 Home address:
 Home telephone number:
 Cell phone number:
 E-mail address:

 Work address:
 Work telephone number:


Name and contact information for one friend/relative whom we could contact in case we have difficulty
contacting you?
 Name of friend or relative:
 Relation to this person
 Address:



 Telephone number:
 E-mail address:



Any comments for us:




                                              End of questions
                                      Thank you so much for responding!




NDIT Questionnaire Version Nov 2010                 - 16 -