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ti Your report on the census schedule is acco'rded CONF'IDENTIAL treatment, in accordance with the provisions of the law. This inquiry is authorized by law. ~, ::'° Form CI-2 this survey. ; Budget Bureau No. 41 5449.i-_:,-._._._; Approval Expires April 19SS .. a~ ~:=s ; _, . .;:.• ~; .-„ DEPARDMENT OF COMERCE Bureau of the Census Washington 25y D. C. , ,. Several days ago we sent you a questionnaire which was part ~ ~ of a special survey we are conducting to find out about the smoking ; habits of the population. This survey is sponsored by the U. S. Public : Health~Service. The information will be used in connection with the Government's research program on the possible relationship between smoking and various types of disease. Your help is needed to complete Dear Friend: Please answer the questions on the back of this letter and return the form within the next few days to the Bureau of the Census field office, in the envelope which has been provided. Your contribution in giving this information will be of def- inite service to your country. I want you to know that we appreciate your help. Sincerely yours, IIJYititl4?, :!'iSR~ Robert W. Burgess - Director Bureau of the Census I I ~ i. d! ,Q ~ i ~ I Im - --------- - -- ,.J~1~ sn!,I ~iv~. sr*l~.I .•.0 .A f! J.Cd f:UA'U7av ;

$ECTION I CIOARETTEB" (Answer all applicable questions in this Section; then contihue with Section II) BECTION II CIGARS (Answer slll Dlicabie estions in is Section; m continue td Section III) SECTION III PIPE SMOKING (Answer all applicable questions in thia section). Yom sbould have at least ome box eAecked In Sections 1, II, lsad III. (3) 0 Between 10 and 20 cigarettes (1/2-1 pack) (4) 0 Between 21 and 40 cigarettes (1-2 packs) (5) Q Over 40 cigarettes (over 2 packs) b. Did you ever regularly smoke more then this amount each d$y? (1) ElNo (2) E1IYes:,lhat was the maxi.a number of ceash~dny'?s you regularly smoked - c. How old were you when you started smoking _ cigarettes regularly? d. How maayyears have you been smoking cigarettes? _ (1) 0 Smoke once in a while, not every dw (2) OlLess than 10 cigarettes (1/2 pack) a. How many cigarettes do you smoke a day on the average? A: Have you ever smoked an,y cigarettes? 1. [] No (Skip to Section II - Cigars) $. [] Yes (Answer puestion below) B. Do you woke any cigarettes at the present ti.e? 1. 0 Yes (Answer questions below) A. Have you ever smoked any cigars? .1. ED No (Skip to Section III - Pipe smoking) 2. D Yes (Answer question below) B. Do you smoke au,y cigars at the present time? , L 0 a. (4) 0 5 to 8 cigars a daq. (5) Q 9 or more cigars a day Yes (Answer questions below) How many cigara do you smoke a day on the average? (1) M Smoke once in a while, not every day (2) ED 1 or 2 cigars a day , (3) Q 3 or 4 cigars a day c. How old were you when you started'smoking cigars regularly? - d. How many years have you been smoking cigars? _ . Did you ever reau larly smoke more than thlq amount each day? (1) MINo(7) [3IYeb: llhat1wgaas the mazimum number osmoked eachod~7~larly - A. Have you ever smoked a pipe? 1. OINo (Do not answer any more questions) 2. 0 'Yes (Answer question below) B. Do you smoke a pipe at the presemt time? L 0 Yes (Answer questions below) a. How naqy pipefuls do you smoke a day an the average? (1) C3 Smoke once in a while, not every day. (2) LJ Less than 5 pipefuls (3) ~ Between 5 and' 9 pipefuls (4) ~ Between 10 and 19 pipefuls (5) ~ 20 or more pipefuls b. Did you ever regularly smoke more than this amount each day? (1) 0' No (2) E3 Yes: What was the maxissu number of pipefuls you regularly smoked' el c. How old were you when you started smoking s pipe regularly? d. How many years have you been smoking a pipe? - 2. :~;, ~~ ; _.......+..~,,,; ~' ['] No (Answer questions below) a. During your entire life, have you smoked as rat~7 as 5 to 10 packs of cigarettes? (1) []' Yes (2), 0 No (Skip to Section II). How old were you when you started smoking ' cigarettes regularly? c. How many years did you smoke cigarettes? d. How long ago did you stop smoking Ciga- rettes? e. What was the mazimum number of cigarettes were s~amloker? smoked each day when you (1) [] 8moked once in a while, not every day (2) E] Less than 10 cigarettes (1/2 pack). (3)l0 Between 10 and 20 cigarettes (1/2-1 pack) (4) Q Between 21 and 40 cigarettes (1-2 packs), (5) C1l0ver 40 cigarettes (over 2 packs) 2. 0 No (Answer questions below) Ia. During your entire life have you smoked as many as 50 to 75 cigars? (1) E] Yes (2) Q No (Skip to Section IPI) b. How old were you when you started'smoking cigars regularly? c. How many years did you smoke cigars? ~ d. How long ago did you stop smoking cigars? e. 4hat was the smzisum number of cigars you regularly smoked each day when you were a smoker? (1) ~ Smoked once in a while, not every day (2) ~ 1 or 2,cigars a day (3) ~ 3 or 4 cigars a day (4), [] 5 to 8 cigars a day (5) ED 9 or more cigars a day 2. C! No (Answer questions below) a. During your entire life, have you smoked as many as 3 to 5 packages of pipe tobacco? (1) [3 Yes (2) O'No (F:nd of interview) b. How old were you when you started smoking a pipe regularly? c. How many years did you smoke a pipe? d. How long ago did you stop smoking a pipe? e. What was the maxiaum number of pipefuls you regularly smoked each day when you were a smoker?' (1) EJ Smoked once in a while, not every day (2) 0 Less than 5 pipefuTs (3) [3Between 5 and 9 pipefuls (4) C3 Between 10 and 19 pipefuls (5) C3120 or more pipefuls Form oI-a(12-a1-s4) Coma-DC-44230 Control No. Line No. of person Line No. of respondent