Attachment C - Questionnaire v2

OMB Control #0910-0810

Exp. Date: 10/31/2021

Hookah Purchase Journey: Online Hookah User Survey

QUESTIONNAIRE

The following questions are about your hookah use and purchases as they relate to your in-home use only. There are additional questions related to hookah use outside the home, e.g., at a hookah bar, restaurant, or lounge, later in the survey.

We are interested in the purchases you make each year. Disregarding the brands of hookah tobacco or herbal (non-tobacco) shisha, please provide the following information.

1. Which do you normally buy, hookah tobacco or herbal (non-tobacco) shisha? (SELECT ALL THAT APPLY)

   1. Tobacco

   2. Herbal (non-tobacco) shisha

For in-home use	a. How often do you purchase hookah shisha?	b. Each time you make a purchase, how many packs of shisha do you buy?	c. What is the typical pack size you buy? (SELECT ONE)	d. How much do you spend per pack, on average? (This should be the cost per pack, not the total expenditure)
[ASK IF CODE Q.2/1] Tobacco shisha	_____times per year	______ packs of tobacco each time	50g 100g 200g 250g 1,000g	$________.00
[ASK IF Q.2/2] Herbal (non-tobacco) shisha	_____times per year	______ packs of herbal (non-tobacco) shisha each time	50g 100g 200g 250g 1,000g	$________.00

[ASK IF Q.2/1]

1. Based on the information you just provided, your total annual expenditure per year for hookah tobacco is $ (INSERT CALCULATED AMOUNT). Please think about where you spend this money on hookah tobacco purchases for in-home use, and provide the approximate percentages below, based on your normal purchasing behavior. NOTE: The percentages must equal 100%.

Purchase Outlets	Allocate Percentage of Dollars Spent on Hookah Tobacco
Chain Convenience Stores (such as 7-11, Circle K, Wawa, etc.)
Independent Convenience Stores (such as small neighborhood shops)
Specialty Tobacco Stores
Online
From a restaurant, hookah bar, or lounge (for in-home use)
Mass merchandisers (such as Wal-Mart, K-Mart, Sam’s Club, etc.)
Drug Stores (such as Walgreens, Rite-Aid, etc.)
Grocery Stores
Other (PLEASE SPECIFY)
Total (CALCULATED)	100%

[ASK IF Q.2/2]

3. Based on the information you just provided, your total annual expenditure per year for hookah herbal (non-tobacco) shisha is $ (INSERT CALCULATED AMOUNT). Please think about where you spend this money on herbal (non-tobacco) shisha purchases for in-home use, and provide the approximate percentages below, based on your normal purchasing behavior. NOTE: The percentages must equal 100%.

Purchase Outlets	Allocate Percentage of Dollars Spent on Hookah Herbal (non-tobacco) Shisha
Chain Convenience Stores (such as 7-11, Circle K, Wawa, etc.)
Independent Convenience Stores (such as small neighborhood shops)
Specialty Tobacco Stores
Online
From a restaurant, hookah bar, or lounge (for in-home use)
Mass merchandisers (such as Wal-Mart, K-Mart, Sam’s Club, etc.)
Drug Stores (such as Walgreens, Rite-Aid, etc.)
Grocery Stores
Other (PLEASE SPECIFY)
Total (CALCULATED)	100%

1. Do you also purchase charcoal for your hookah? (SELECT ONE)

1. Yes [CONTINUE]

2. No [SKIP TO Q.9]

1. Do you normally buy quick-light charcoal, regular/natural charcoal, or both? (SELECT ONE)

1. Quick-light

2. Regular/natural

3. Both [IF SELECTED, ASK A-H IN Q.7]

6. Thinking about your in-home use only, please tell us about your hookah charcoal purchases. Disregarding the brands, please provide the following information:

For in-home use	a. How often do you purchase hookah quick-light charcoal?	b. Each time you purchase hookah charcoal, how many packs of quick-light charcoal do you buy?	c. How many pieces are normally in a pack of quick-light charcoal that you buy? (SELECT ONE)	d. How much do you spend per pack of quick-light charcoal, on average? (This should be the cost per pack, not the total expenditure)
[ASK IF QUICK-LIGHT IN Q.6] Hookah quick-light charcoal	_____times per year	______ packs of quick-light charcoal each time	10 18 24 48 60 64 72 96 100 or more Other (specify number per pack)	$________.00
	e. How often do you purchase hookah regular charcoal?	f. Each time you purchase hookah charcoal, how many packs of regular charcoal do you buy?	g. How many pieces are normally in a pack of regular charcoal that you buy? (SELECT ONE)	h. How much do you spend per pack of regular charcoal, on average? (This should be the cost per pack, not the total expenditure)
[ASK IF REGULAR IN Q.6] Hookah regular charcoal	_____times per year	______ packs of regular charcoal each time	10 18 24 48 60 64 72 96 100 or more Other (specify number per pack)	$________.00

1. Based on the information you just provided, your total annual expenditure per year for charcoal is $ (INSERT CALCULATED AMOUNT). Please think about where you spend this money on hookah charcoal purchases for in-home use, and provide the approximate percentages below, based on your normal purchasing behavior. NOTE: The percentages must equal 100%.

   Purchase Outlets	Allocate Percentage of Dollars Spent on Charcoal
   Chain Convenience Stores (such as 7-11, Circle K, Wawa, etc.)
   Independent Convenience Stores (such as small neighborhood shops)
   Specialty Tobacco Stores
   Online
   From a restaurant, hookah bar, or lounge (for in-home use)
   Mass merchandisers (such as Wal-Mart, K-Mart, Sam’s Club, etc.)
   Drug Stores (such as Walgreens, Rite-Aid, etc.)
   Grocery Stores
   Other (PLEASE SPECIFY)
   Total (CALCULATED)	100%

2. Do you ever buy hookah additives, like nicotine or flavor enhancers?

1. Yes [CONTINUE]

2. No [SKIP TO Q.12]

8. Thinking just about the hookah additives like nicotine or flavor enhancers you buy for in-home use:

For in-home use	a. How often do you purchase hookah additives?	b. Each time you purchase hookah additives, how many bottles do you buy?	c. How much do you spend per bottle, on average? (This should be the cost per bottle, not the total expenditure)
Hookah additives (like nicotine or flavor enhancers)	_____times per year	______ bottles of hookah additives each time	$________.00

8. Based on the information you just provided, your total annual expenditure per year for hookah additives is $ (INSERT CALCULATED AMOUNT). Please think about where you spend this money on hookah additives for in-home use, and provide the approximate percentages below, based on your normal purchasing behavior. NOTE: The percentages must equal 100%.

   Purchase Outlets	Allocate Percentage of Dollars Spent on Hookah Additives
   Chain Convenience Stores (such as 7-11, Circle K, Wawa, etc.)
   Independent Convenience Stores (such as small neighborhood shops)
   Specialty Tobacco Stores
   Online
   From a restaurant, hookah bar, or lounge (for in-home use)
   Mass merchandisers (such as Wal-Mart, K-Mart, Sam’s Club, etc.)
   Drug Stores (such as Walgreens, Rite-Aid, etc.)
   Grocery Stores
   Other (PLEASE SPECIFY)
   Total (CALCULATED)	100%

9. Do you ever buy hookah pipes (entire unit)?

1. Yes (CONTINUE)

2. No (SKIP TO Q.15)

8. Thinking just about the hookah pipes (entire unit) you buy for in-home use:

For in-home use	a. How often do you purchase hookah pipes (entire unit)?	b. Each time you purchase a hookah pipe (entire unit), how many do you normally buy?	c. How much do you spend per pipe (entire unit), on average? (This should be the cost per pipe (entire unit))
Hookah pipes (entire unit)	_____times per year	______ hookah pipes each time	$________.00

8. Based on the information you just provided, your total annual expenditure per year on hookah pipes (entire unit) is $ (INSERT CALCULATED AMOUNT). Please think about where you spend this money on hookah pipe (entire unit) purchases for in-home use, and provide the approximate percentages below, based on your normal purchasing behavior. NOTE: The percentages must equal 100%.

   Purchase Outlets	Allocate Percentage of Dollars Spent on Hookah Pipes (entire unit)
   Chain Convenience Stores (such as 7-11, Circle K, Wawa, etc.)
   Independent Convenience Stores (such as small neighborhood shops)
   Specialty Tobacco Stores
   Online
   From a restaurant, hookah bar, or lounge (for in-home use)
   Mass merchandisers (such as Wal-Mart, K-Mart, Sam’s Club, etc.)
   Drug Stores (such as Walgreens, Rite-Aid, etc.)
   Grocery Stores
   Other (PLEASE SPECIFY)
   Total (CALCULATED)	100%

9. Do you ever buy hookah replacements parts, like hoses and/or mouth pieces?

1. Yes [CONTINUE]

2. No [SKIP TO Q.18]

1. Thinking just about the hookah replacement parts you buy for in-home use:

For in-home use	a. How often do you purchase hookah hoses?	b. Each time you purchase hookah hoses, how many do you buy at one time?		c. How much do you spend per hose, on average? (This should be the cost per item, not the total expenditure)
Hookah hoses	_____times per year	______ hoses		$________.00
	d. How often do you purchase hookah mouth pieces or tips?	e. Each time you purchase mouth pieces or tips, how many packs do you buy?	f. How many mouth pieces or tips are in each pack?	g. How much do you spend per pack, on average? (This should be the cost per item, not the total expenditure)
Hookah mouth pieces and/or tips	_____times per year	____ packs	_____mouth pieces or tips per pack	$______.00

1. Based on the information you just provided, your total annual expenditure per year for replacement parts is $ (INSERT CALCULATED AMOUNT). Please think about where you spend this money on hookah replacement parts for in-home use, and provide the approximate percentages below, based on your normal purchasing behavior. NOTE: The percentages must equal 100%.

Purchase Outlets	Allocate Percentage of Dollars Spent on Replacement Parts
Chain Convenience Stores (such as 7-11, Circle K, Wawa, etc.)
Independent Convenience Stores (such as small neighborhood shops)
Specialty Tobacco Stores
Online
From a restaurant, hookah bar, or lounge (for in-home use)
Mass merchandisers (such as Wal-Mart, K-Mart, Sam’s Club, etc.)
Drug Stores (such as Walgreens, Rite-Aid, etc.)
Grocery Stores
Other (PLEASE SPECIFY)
Total (CALCULATED)	100%

17. The following questions are about your hookah use and purchases when you are smoking hookah in hookah lounges, bars, or restaurants – excluding your in-home use. For this series of questions, we want you to think about MONTHLY expenditures, not yearly.

Please answer the next series of questions as if you were purchasing hookah for one person to use alone with one pipe.

For use in hookah lounges, bars, or restaurants	How much do you spend on your first round, on average? (This should be the cost per one person)	If you were to purchase a second round, how much would you expect to spend on your second round, on average? (This should be the cost per one person)
For one person, everything included (pipe, shisha, and charcoal)	$________.00	$________.00 I don’t know/do not purchase a second round

17. Now, if you were going into a hookah lounge with a group of people, please record your expenditures below.

For use in hookah lounges, bars, or restaurants	How much do you spend on your first round, as a part of a group, on average? (This should be the cost per one person)	If you were to purchase a second round, how much would you expect to spend on your second round, as a part of a group, on average? (This should be the cost per one person)
For your share, everything included (pipe, shisha, and charcoal), when in a group	$________.00	$________.00 I don’t know/do not purchase a second round

17. How many times per month do you typically visit a hookah lounge to smoke hookah? (RECORD NUMBER)

___________________ times/month

17. When smoking in hookah lounges, do you normally smoke hookah tobacco or herbal (non-tobacco) shisha? (SELECT ONE)

1. Tobacco

2. Herbal (non-tobacco)

17. When smoking in hookah lounges, do you normally choose quick-light or regular charcoal? (SELECT ONE)

1. Quick-light

2. Regular

DEMOGRAPHIC QUESTIONS [DO NOT SHOW TEXT]

Now we have a few more questions so we may combine your answers with those of others participating in this study.

1. What is the last grade in school you had the opportunity to complete? (SELECT ONE)

1. Some elementary school

2. Elementary school

3. Some high school

4. High school degree (or equivalent)

5. Some technical school

6. Technical school certificate

7. Some college

8. College degree

9. Some post-graduate work

10. Graduate degree

23. What is your current employment status? (SELECT ALL THAT APPLY)

1. Employed full-time for wages

2. Employed part-time for wages

3. Self-employed

4. Out of work and looking for work

5. Out of work but not currently looking for work

6. A homemaker

7. A student

8. Military

9. Retired

10. Unable to work

23. Are you of Hispanic or Latino descent? (SELECT ONE)

1. Yes

2. No

23. Which of these categories describes you? (SELECT ALL THAT APPLY)

1. White/Caucasian

2. Black/African-American

3. Asian

4. Native American/Alaskan Native

5. Native Hawaiian or Other Pacific

23. Which of the following categories includes your total, annual household income in 2017, before taxes? (SELECT ONE)

1. Under $15,000

2. $15,000 to under $30,000

3. $30,000 to under $50,000

4. $50,000 to under $75,000

5. $75,000 to under $100,000

6. $100,000 to under $200,000

7. $200,000 or more

8. Prefer not to say

Thank you. That is all the questions we have for you today.

[In addition to these questions, up to two some computer-generated questions to verify participants are paying attention will be added. Such as:

This question is to verify you are paying attention to the questionnaire. Please select choice B.

1. B

2. F

3. D

4. A

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 20 minutes per response to complete this survey (the time estimated to read and complete). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.”

13