The purpose of this study was to identify the effects of question type, order, and inclusion of product images on tobacco use estimates in a national sample of young adults.Participants aged 18-34 (n = 4,100) in the Truth Initiative Young Adult Cohort Study (2016) were randomized to one of five question types assessing ever and past 30-day use of tobacco products: 1) “select all that apply” list (checklist, CL); 2) breakout items for each product (B); 3) breakout + images (B+I); 4) CL and B; and, 5) CL and B+I. Order of question type was randomly assigned in Groups 4 and 5. Bivariate analyses estimated product-specific prevalence by question type/order.Ever cigarette and cigar use prevalence was higher and ever e-cigarette use was lower in B and B+I compared to CL. Ever hookah use was higher in B+I vs. CL. Past 30-day e-cigarette use was 8.3% higher and past 30-day smokeless use was 13.0% higher in B+I compared to CL. In Groups 4 and 5, higher prevalence of ever cigarette, cigar, hookah, and past 30-day smokeless use were observed when B was presented first.Question type, order, and inclusion of images impact prevalence estimates of tobacco use.
This study identifies the effects of question type, order, and inclusion of product images on tobacco use estimates in a national sample of young adults. Ever use and past 30-day use prevalence estimates of specific products were impacted by respondents answering breakout items or breakout items with images compared to respondents answering a checklist of items in the survey. Current surveys that include a “select all that apply” list format may be underestimating ever and past 30-day prevalence estimates of tobacco products.