Screener

Experimental Study of Graphic Cigarette Warning Labels

graphic warning labels questionnaire

Screener

OMB: 0910-0668

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0910-0668 can be found here:

2012-12-05 - Reinstatement without change of a previously approved collection

Document [pdf]

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Appendix – Survey Introduction and Questionnaires

Introduction to Survey

This study is funded by the U.S. Food and Drug Administration’s (FDA’s) Center
for Tobacco Products (CTP) and conducted by RTI International. For this study,
we would like you to complete two surveys – one now and another in a week or
two. Each survey asks about your attitudes about smoking and your reactions to
specific images on smoking. Your participation in this research study is
completely voluntary, and you may skip any questions you do not want to
answer. Your participation involves no risk. All of your answers will be kept
confidential. Each survey will take about 10 minutes to complete.
If you have any questions about the study, you may call Katherine Kosa of RTI at
1-800-334-8571, extension 23901. If you have any questions about your rights as
a study participant, you may call RTI’s Office of Research Protection at 1-866214-2043.

ADULT SMOKERS AGED 25 AND OLDER
1
S. Screening Questions
S1.

What is your age?
_________ years
NOT AGE 25+ - NOT ELIGIBLE - terminate
99 I do not wish to answer

[IF S1=99 NOT ELIGIBLE; ELSE GO TO S2]
S 2.

Do you now smoke every day, some days, or not at all?
1 I smoke every day
2 I smoke on some days
3 I do not smoke at all

[If S2=1 or S2=2 THEN ELIGIBLE TO CONTINUE; ELSE NOT ELIGIBLE]

WARM UP

A1.

What is your gender?
1 Male
2 Female
99 I do not wish to answer

A1a. Are you Hispanic or Latino? (Select one.)
1.Yes

2.No
99
A2.

I do not wish to answer

What is your race? Please select one or more..
1
2
3
5
6

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

I do not wish to answer

[IF MORE THAN ONE RESPONSE GIVEN IN A3, ASK A4; ELSE GO TO A5]
A3.
Which one of these races best describes you? (Select one.)[ALLOW ONE RESPONSE
ONLY]
1
American Indian or Alaska Native
2
Asian
3
Black or African American
4
Native Hawaiian or Other Pacific Islander
5
White
99

I do not wish to answer

ADULT SMOKERS AGED 25 AND OLDER
2
A4.

City and State or Zip Code
________________________ [ALLOW 60 CHARACTERS]
99 I do not wish to answer

SMOKING BEHAVIOR

Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
99 I do not wish to answer

EXPOSURE TO IMAGE/LABEL OCCURS HERE

Next, you will view an image of a pack of regular full flavor cigarettes. . This pack of
cigarettes is not real but has been made up for the purpose of this study. After viewing the pack,
you will be asked to answer some questions.
ALLOW RESPONDENT AS MUCH TIME AS DESIRED TO VIEW IMAGE(S)
REMOVE LABEL IMAGE AND DO NOT ALLOW RESPONDENT TO RETURN TO THE
IMAGE FOR THE REMAINDER OF THE STUDY

WARNING LABELS

D1.

Please indicate how much the image of the pack of cigarettes made you feel…
RESPONSE OPTIONS:
1 “Not at all” 2 “A little” 3 “Some” 4 “A lot” 5 “Completely” -1 “I do not wish to
answer”
[RANDOMIZE THE FOLLOWING]
a. Depressed
b. Afraid
c. Irritated
d. Ashamed
e. Discouraged
f. Hopeful
g. Motivated
h. Amused
i. Understood
j. Disgusted
k. Sad
l. Scared
m. Angry
n. Happy
o. Encouraged
p. Uncomfortable

ADULT SMOKERS AGED 25 AND OLDER
3
q. Uneasy
r. Anxious
D2.

Please tell us how much you agree or disagree with the following statements.
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” -1 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. This label is worth remembering
b. This label grabbed my attention
c. This label is powerful
d. This label is informative
e. This label is meaningful to me
f. This label is convincing
g. This label is ridiculous
h. This label is terrible
i. This label is frightening
j. This label is worrisome
k. This label is believable
l. This label was difficult to look at
m. This label is cool

D3.

How likely do you think it is that a regular smoker would…?
RESPONSE OPTIONS:
1 “Not at all Likely” 2 “Somewhat Likely” 3 “Moderately Likely” 4 “Very Likely” 5
“Extremely Likely” -1 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. get cancer
b. have fatal lung disease
c. have heart disease
d. have a stroke
e. become addicted

D4.

How likely do you think it is that breathing second-hand smoke from cigarettes would
cause…?
RESPONSE OPTIONS:
1 “Not at all Likely” 2 “Somewhat Likely” 3 “Moderately Likely” 4 “Very Likely” 5
“Extremely Likely” -1 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. nonsmokers to get cancer
b. nonsmokers to have fatal lung disease
c. nonsmokers to get heart disease
d. children to have respiratory problems

ATTITUDES & BELIEFS

E1.
Now, think about your own smoking. Do you think your smoking has affected your
health?
1 Yes

ADULT SMOKERS AGED 25 AND OLDER
4
2
9

No
I do not wish to answer

E2.

How concerned are you that your smoking has affected your health?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E3.

Do you think that your smoking has affected the health of someone else (e.g. spouse,
partner, child, grandchild)?
1 Yes
2 No
3
99 I do not wish to answer

E4.

How concerned are you that your smoking is harming the health of those who live with
you?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E5.

Please tell us how much you agree or disagree with the following statements…
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” -1 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. If I have smoked a pack of cigarettes a day for more than 20 years, there is little
health benefit to me quitting smoking.
b. Many people who smoke live to a ripe old age, so smoking is not all that bad for
me.
c. If a woman smokes when pregnant, it will harm her baby.
d. It is extremely hard for a smoker to quit smoking and stay quit.
e. I do not need help from anyone to quit smoking.
f. I am confident I won’t be smoking a year from now.
g. I should take warnings about cigarette smoking and lung cancer seriously.

CESSATION and INTENTIONS TO QUIT

F1.

During the past 12 months, have you stopped smoking for one day or longer because
you were trying to quit smoking?
1 Yes
2 No
99 I do not wish to answer

F2.

How much do you want to quit smoking?
1 Not at all
2 A little

ADULT SMOKERS AGED 25 AND OLDER
5
3
4
5
99

Somewhat
A lot
No opinion
I do not wish to answer

F3.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 I do not wish to answer

F4.

If you decided to give up smoking altogether in the next 12 months, how likely do you
think you would be to succeed?
1 Very unlikely
2 Somewhat unlikely
3 Somewhat likely
4 Very likely
5 No opinion
99 I do not wish to answer

RECALL Questions

H1a.

Do you recall the warning statement on the pack of cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 I do not wish to answer

[IF H1A=1 GO TO H2A; ELSE GO TO H1B]

ADULT SMOKERS AGED 25 AND OLDER
6
H2a.

Which one of the following warning statements, do you recall seeing on the pack of
cigarettes you viewed earlier in the survey?
[INCLUDE ACTUAL WARNING STATEMENT (without image) VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING STATEMENTS
FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall

H1b.

Do you recall seeing a picture on the pack of cigarettes you viewed earlier in the survey?
1 Yes
2 No
99 I do not wish to answer

[IF H1B=1 GO TO H2B; ELSE GO TO I1]
H2b.

Which one of the following pictures, do you recall seeing on the pack of cigarettes you
viewed earlier in the survey?
[INCLUDE ACTUAL IMAGE (2-D view without warning statement) VIEWED FOR
THAT RESPONDENT ALONG WITH 3RANDOMLY SELECTED IMAGES FROM
THOSE NOT VIEWED BY THAT RESPONDENT]
8
There was no image on the pack I viewed
9
Do not recall

I.
I1.

CLOSING QUESTIONS & DEMOGRAPHICS
What type of Internet connection do you have for your home computer or other primary
computer?
1. Highspeed, Broadband, DSL, or Cable
2. Dial up
3. Other
4. Not sure
99 I do not wish to answer

[IF I1=1 GO TO I3; ELSE GO TO I4]

I3.

What is the highest level of school you completed or the highest degree you received?

[ALLOW ONE RESPONSE ONLY]
1
2
3
4
5
6
7
99

Never attended school
Grades K through 8 (Elementary or grade school)
Grades 9 through 12 (Some high school)
Grade 12 (High school graduate) or GED
Some college
College graduate
Postgraduate/masters/doctorate/law/MD
I do not wish to answer

ADULT SMOKERS AGED 25 AND OLDER
7
I5.

What was your annual household income from all sources in 2009? Was it…?
1. Less than $25,000
2. Between $25,000 and $49,999
3. Between $50,000 and $74,999
4. More than $75,000
99. I do not wish to answer
END OF SURVEY
The survey is now complete. Thank you!

YOUNG ADULT SMOKERS AGED 18-24
1
S. Screening Questions
S1.

What is your age?
_________ years
99 NOT AGE 18-24 NOT ELIGIBLE - terminate
99 Choose not to answer

[IF S1=99 NOT ELIGIBLE; ELSE GO TO S2]
S 2.

Do you now smoke every day, some days, or not at all?
1 I smoke every day
2 I smoke on some days
3 I do not smoke at all

[If S2=1 or S2=2 THEN ELIGIBLE TO CONTINUE; ELSE NOT ELIGIBLE]

WARM UP

A1.

What is your gender?
1 Male
2 Female
99 Choose not to answer

A1a. Are you Hispanic or Latino? (Select one.)
1.Yes

2. No
99
A2.

I do not wish to answer

What is your race? Please select one or more..
1
2
3
5
6

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

I do not wish to answer

YOUNG ADULT SMOKERS AGED 18-24
2
A4.

City and State or Zip Code
________________________ [ALLOW 60 CHARACTERS]
99 Choose not to answer

SMOKING BEHAVIOR

Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
99 Choose not to answer

EXPOSURE TO IMAGE/LABEL OCCURS HERE

Next you will view a pack of a hypothetical cigarette brand. This pack contains regular
full flavor cigarettes. After viewing the pack you will be asked to answer some questions.
ALLOW RESPONDENT AS MUCH TIME AS DESIRED TO VIEW IMAGE(S)
REMOVE LABEL IMAGE AND DO NOT RESPONDENT TO RETURN TO THE IMAGE FOR
THE REMAINDER OF THE STUDY

WARNING LABELS

D1.

Please indicate how much the label made you feel…
RESPONSE OPTIONS:
1 “Not at all” 2 “A little” 3 “Some” 4 “A lot” 5 “Completely” 99 “Choose not to
answer”
[RANDOMIZE THE FOLLOWING]
a. Depressed
b. Afraid
c. Irritated
d. Ashamed
e. Discouraged
f. Hopeful
g. Motivated
h. Amused
i. Understood
j. Disgusted
k. Sad
l. Scared
m. Angry
n. Happy
o. Encouraged
p. Uncomfortable

YOUNG ADULT SMOKERS AGED 18-24
3
q. Uneasy
r. anxious

D2.

Please tell us how much you agree or disagree with the following statements.
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. This label is worth remembering
b. This label grabbed my attention
c. This label is powerful
d. This label is informative
e. This label is meaningful to me
f. This label is convincing
g. This label is ridiculous
h. This label is terrible
i. This label is frightening
j. This label is worrisome
k. This label is believable
l. This label was difficult to look at
m. This label is cool

D3.

How likely do you think it is that a regular smoker would:
RESPONSE OPTIONS:
1 “Not at all Likely” 2 “Somewhat Likely” 3 “Moderately Likely” 4 “Very Likely” 5
“Extremely Likely” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. Get cancer?
b. have fatal lung disease?
c. have heart disease?
d. Have a stroke?
e. Become addicted?

D4.

How likely do you think it is that breathing smoke from cigarettes would cause:
RESPONSE OPTIONS:
1 “Not at all Likely” 2 “Somewhat Likely” 3 “Moderately Likely” 4 “Very Likely” 5
“Extremely Likely” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. Nonsmokers to get cancer?
b. Nonsmokers to have fatal lung disease?
c. Nonsmokers to get heart disease?
d. Children to have respiratory problems?

ATTITUDES & BELIEFS

E1.

Do you think that your smoking has already affected your health?
1 Not at all
2 A little

YOUNG ADULT SMOKERS AGED 18-24
4
3
4
5
9

Somewhat
A lot
No opinion
Choose not to answer

E2.

Now think about your own smoking, how concerned are you concerned about the
possible effects of cigarette smoking on your health?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
5 Choose not to answer

E3.

How concerned are you about the possible effects of tobacco smoke from your smoking
on someone else’s health (e.g. spouse, partner, children, grandchildren)?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
9 Choose not to answer

E4.

How concerned are you that your smoking is harming the health of those who live with
you?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
9 Choose not to answer

E5.

Please tell us how much you agree or disagree with the following statements…
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. If I have smoked a pack of cigarettes a day for more than 20 years, there is little
health benefit to me quitting smoking.
b. Many people who smoke live to a ripe old age, so smoking is not all that bad for
me.
c. Smoking by pregnant women may harm the baby.
d. If a woman smokes when pregnant, it will harm the health of her baby.
e. It is extremely hard for a smoker to quit smoking and stay quit.
f. I do not need help from anyone to quit smoking.
g. I am confident I won’t be smoking a year from now.
h. I should take warnings about cigarette smoking and lung cancer seriously.

E6.

Cigarette smoking is…
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]

YOUNG ADULT SMOKERS AGED 18-24
5
a.
b.
c.
d.
e.

Glamorous
Rebellious
Cool
Disgusting
Foolish

CESSATION and INTENTIONS TO QUIT

F1.

During the past 12 months, have you stopped smoking for one day or longer because
you were trying to quit smoking?
1 Yes
2 No
99 Choose not to answer

F2.

How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
99 Choose not to answer

F3.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 Choose not to answer

F4.

RECALL Questions

H1a.

Do you recall the warning statement on the pack of cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 Choose not to answer

[IF H1A=1 GO TO H2A; ELSE GO TO H1B]
H2a.

Which of the following warning statements, if any, do you recall seeing on the pack of
cigarettes you viewed earlier in the survey?

YOUNG ADULT SMOKERS AGED 18-24
6
[INCLUDE ACTUAL WARNING STATEMENT (without image) VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING STATEMENTS
FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall
H1b.

Do you recall the image, if any, on the pack of cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 Choose not to answer

[IF H1B=1 GO TO H2B; ELSE GO TO I1]
H2b.

Which of the following images, if any, do you recall seeing on the pack of cigarettes you
viewed earlier in the survey?
[INCLUDE ACTUAL IMAGE VIEWED (2-D version without warning statement) FOR
THAT RESPONDENT ALONG WITH 4 RANDOMLY SELECTED IMAGES FROM
THOSE NOT VIEWED BY THAT RESPONDENT]
8
There was no image on the pack I viewed
9
Do not recall

I.
I1.

I2.

What is the highest level of school you completed or the highest degree you received?

[ALLOW ONE RESPONSE ONLY]
1
2
3
4
5
6
7
8
9
10
11
12
99

Never attended school or only attended kindergarten
Grades 1 through 8 (Elementary)
Grades 9 through 12 (Some high school)
Grade 12 (High school graduate)
G.E.D
Some technical or vocational school
Some college, no degree
AA; technical or vocational school
AA; academic`
BA, BS (College graduate)
At least some graduate or professional school
Graduate or professional degree
Choose not to answer

YOUNG ADULT SMOKERS AGED 18-24
7
I3.

What was your annual household income from all sources during 2009? Was it –
1
2
3
4

less than $25,000
between $25,000 and $49,999
between $50,000 and $74,999
$75,000 or more

Choose not to answer

END OF SURVEY
The survey is now complete. Thank you!

YOUTH AGED 13-17 SMOKERS OR SUSCEPTIBLE TO INITIATION
1
S. Screening Questions
S1.

What is your age?
_________ years
99 NOT AGE 13-17 – not eligible - terminate
99 Choose not to answer

[IF S1=99 NOT ELIGIBLE; ELSE GO TO S2]
S2. During the past 30 days, on how many days did you smoke cigarettes, even 1 or 2 puffs?
1.
0 days
2.
1 or 2 days
3.
3 to 5 days
4.
6 to 9 days
5.
10 to 19 days
6.
20 to 29 days
7.
All 30 days
[If S2 DOES NOT EQUAL 1 (CURRENT SMOKER=YES) THEN GO TO A1; ELSE GO TO S3]
S3.

Do you think you will smoke a cigarette anytime during the next year?
1 Definitely yes
2 Probably yes
3 Probably not
4 Definitely not
99 Choose not to answer

S4.

Do you think you will try a cigarette soon?
1 Definitely yes
2 Probably yes
3 Probably not
4 Definitely not
99 Choose not to answer

S5.

If one of your best friends offered you a cigarette, would you smoke it?
1 Definitely yes
2 Probably yes
3 Probably not
4 Definitely not
99 Choose not to answer

[IF S3=4 & S4=4 & S5=4 THEN NOT ELIGIBLE (CLOSED TO SMOKING); ELSE GO TO A1]
A.

WARM UP

YOUTH AGED 13-17 SMOKERS OR SUSCEPTIBLE TO INITIATION
2
A1.

What is your gender?
1 Male
2 Female
99 Choose not to answer

A1a. Are you Hispanic or Latino? (Select one.)
1.Yes

2. No
99
A2.

I do not wish to answer

What is your race? Please select one or more.
1
2
3
5
6

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

I do not wish to answer

A3.
Which one of these races best describes you? (Select one.)[ALLOW ONE RESPONSE
ONLY]
1
American Indian or Alaska Native
2
Asian
3
Black or African American
4
Native Hawaiian or Other Pacific Islander
5
White
99

I do not wish to answer

A4.

City and State or Zip Code
________________________ [ALLOW 60 CHARACTERS]
99 Choose not to answer

SMOKING BEHAVIOR/SUSCEPTIBILITY TO SMOKING

B1.

Have you smoked at least 100 cigarettes in your entire life?
1
Yes
2
No
99
Choose not to answer

EXPOSURE TO IMAGE/LABEL OCCURS HERE

YOUTH AGED 13-17 SMOKERS OR SUSCEPTIBLE TO INITIATION
3
REMOVE LABEL IMAGE AND DO NOT ALLOW RESPONDENT TO RETURN TO THE
IMAGE FOR THE REMAINDER OF THE STUDY

WARNING LABELS

D1.

D2.

Please tell us how much you agree or disagree with the following statements.
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. This label is worth remembering
b. This label grabbed my attention
c. This label is powerful
d. This label is informative
e. This label is meaningful to me
f. This label is convincing
g. This label is ridiculous
h. This label is terrible
i. This label is frightening
j. This label is worrisome
k. This label is believable
l. This label was difficult to look at
m. This label is cool

YOUTH AGED 13-17 SMOKERS OR SUSCEPTIBLE TO INITIATION
4
D3.

D4.

[IF CURRENT SMOKER= YES GO TO E1 ELSE GO TO E5]

ATTITUDES & BELIEFS

E1.

Do you think that your smoking has already affected your health?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
9 Choose not to answer

E2.

E3.

How concerned are you about the possible effects of tobacco smoke from your smoking
on someone else’s health (e.g. brother/sister, friends)?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
9 Choose not to answer

YOUTH AGED 13-17 SMOKERS OR SUSCEPTIBLE TO INITIATION
5
E4.

Please tell us how much you agree or disagree with the following statements…
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. If I have smoked a pack of cigarettes a day for more than 20 years, there is little
health benefit to me quitting smoking.
b. Many people who smoke live to a ripe old age, so smoking is not all that bad for
me.
c. Smoking by pregnant women may harm the baby.
d. If a woman smokes when pregnant, it will harm the health of her baby.
e. It is extremely hard for a smoker to quit smoking and stay quit.
f. I do not need help from anyone to quit smoking.
g. I am confident I won’t be smoking a year from now.
h. I should take warnings about cigarette smoking and lung cancer seriously.

E5.

[IF CURRENT SMOKER = YES GO TO F1; ELSE GO TO G1]

CESSATION and INTENTIONS TO QUIT

F1.

During the past 12 months, have you stopped smoking for one day or longer because
you were trying to quit smoking?
1 Yes
2 No
99 Choose not to answer

F2.

How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
99 Choose not to answer

F3.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 Choose not to answer

YOUTH AGED 13-17 SMOKERS OR SUSCEPTIBLE TO INITIATION
6
F4.

RECALL Questions

H1a.

Do you recall the warning statement on the pack of cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 Choose not to answer

[IF H1A=1 GO TO H2A; ELSE GO TO H1B]
H2a.

Which of the following warning statements, if any, do you recall seeing on the pack of
cigarettes you viewed earlier in the survey?
[INCLUDE ACTUAL WARNING STATEMENT (without image) VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING STATEMENTS
FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall

H1b.

Do you recall the image, if any, on the pack of cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 Choose not to answer

[IF H1B=1 GO TO H2B; ELSE GO TO I1]
H2b.

I.
I1.

CLOSING QUESTIONS & DEMOGRAPHICS
What type of Internet connection do you have for your home computer or other primary
computer?
1. Highspeed, Broadband, DSL, or Cable
2. Dial up
3. Other

YOUTH AGED 13-17 SMOKERS OR SUSCEPTIBLE TO INITIATION
7
4. Not sure
99 I do not wish to answer

I2.

What is the highest grade or year of school you have completed?
[ALLOW ONE RESPONSE ONLY]
1
4th Grade
2
5th Grade
3
6th Grade
4
7th Grade
5
8th Grade
6
9th Grade
7
10th Grade
8
11th Grade
9
12th Grade or GED
99
Choose not to answer

END OF SURVEY
The survey is now complete. Thank you!

ADULT SMOKERS AGED 25 AND OLDER: ADVERTISEMENT
1
S. Screening Questions
S1.

What is your age?
_________ years
NOT AGE 25+ - NOT ELIGIBLE - terminate
99 Choose not to answer

[IF S1=99 NOT ELIGIBLE; ELSE GO TO S2]
S2.

Do you now smoke every day, some days, or not at all?
1 I smoke every day
2 I smoke on some days
3 I do not smoke at all

[If S2=1 or S2=2 THEN ELIGIBLE TO CONTINUE; ELSE NOT ELIGIBLE]

WARM UP

A1.

What is your gender?
1 Male
2 Female
99 Choose not to answer

A1a. Are you Hispanic or Latino? (Select one.)
1.Yes

2. No
99
A2.

I do not wish to answer

What is your race? Please select one or more..
1
2
3
5
6

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

I do not wish to answer

ADULT SMOKERS AGED 25 AND OLDER: ADVERTISEMENT
2
A4.

City and State or Zip Code
________________________ [ALLOW 60 CHARACTERS]
99 Choose not to answer

SMOKING BEHAVIOR

Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
99 Choose not to answer

EXPOSURE TO MOCK SMOKING AD OCCURS HERE

Next you will view an ad of a hypothetical cigarette brand. This ad contains regular full
flavor cigarettes. After viewing the ad you will be asked to answer some questions.
ALLOW RESPONDENT AS MUCH TIME AS DESIRED TO VIEW AD IMAGE(S)
REMOVE AD IMAGE AND DO NOT RESPONDENT TO RETURN TO THE IMAGE FOR THE
REMAINDER OF THE STUDY

MOCK SMOKING AD

D1.

Please indicate how much the ad made you feel…
RESPONSE OPTIONS:
1 “Not at all” 2 “A little” 3 “Some” 4 “A lot” 5 “Completely” 99 “Choose not to
answer”
[RANDOMIZE THE FOLLOWING]
a. Depressed
b. Afraid
c. Irritated
d. Ashamed
e. Discouraged
f. Hopeful
g. Motivated
h. Amused
i. Understood
j. Disgusted
k. Sad
l. Scared
m. Angry
n. Happy
o. Encouraged
p. Uncomfortable
q. Uneasy

ADULT SMOKERS AGED 25 AND OLDER: ADVERTISEMENT
3
r.

anxious

D2.

Please tell us how much you agree or disagree with the following statements.
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. This ad is worth remembering
b. This ad grabbed my attention
c. This ad is powerful
d. This ad is informative
e. This ad is meaningful to me
f. This ad is convincing
g. This ad is ridiculous
h. This ad is terrible
i. This ad is frightening
j. This ad is worrisome
k. This ad is believable
l. This ad was difficult to look at
m. This ad is cool

D3.

D4.

ATTITUDES & BELIEFS

E1.

Do you think that your smoking has already affected your health?
1 Not at all
2 A little
3 Somewhat

ADULT SMOKERS AGED 25 AND OLDER: ADVERTISEMENT
4
4
5
9

A lot
No opinion
Choose to not answer

E2.

E3.

E4.

How concerned are you that your smoking is harming the health of those who live with
you?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
9 Choose not to answer

E5.

Please tell us how much you agree or disagree with the following statements…
RESPONSE OPTIONS:
1 “Strongly Agree” 2 “Agree” 3 “Neither Agree nor Disagree” 4 “Disagree” 5
“Strongly Disagree” 99 “Choose not to answer”
[RANDOMIZE THE FOLLOWING]
a. If I have smoked a pack of cigarettes a day for more than 20 years, there is little
health benefit to me quitting smoking.
b. Many people who smoke live to a ripe old age, so smoking is not all that bad for
me.
c. Smoking by pregnant women may harm the baby.
d. If a woman smokes when pregnant, it will harm the health of her baby.
e. It is extremely hard for a smoker to quit smoking and stay quit.
f. I do not need help from anyone to quit smoking.
g. I am confident I won’t be smoking a year from now.
h. I should take warnings about cigarette smoking and lung cancer seriously.

CESSATION and INTENTIONS TO QUIT

F1.

During the past 12 months, have you stopped smoking for one day or longer because
you were trying to quit smoking?
1 Yes
2 No

ADULT SMOKERS AGED 25 AND OLDER: ADVERTISEMENT
5
99 Choose not to answer
F2.

How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
99 Choose not to answer

F3.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 Choose not to answer

F4.

RECALL Questions

H1. Do you recall the ad for cigarettes you viewed earlier in the survey?
1 Yes
2 No
99 Choose not to answer
H2. [create confirmed awareness question for the ad – describe features of the ad and ask if
respondent recalls those specific features]
H1a.

Do you recall the warning statement in the ad for cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 Choose not to answer

[IF H1A=1 GO TO H2A; ELSE GO TO H1B]
H2a.

Which of the following warning statements, if any, do you recall seeing in the ad for
cigarettes you viewed earlier in the survey?
[INCLUDE ACTUAL WARNING STATEMENT (without image) VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING STATEMENTS
FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall

H1b.

Do you recall the image, if any, in the ad for cigarettes you viewed earlier in the survey?

ADULT SMOKERS AGED 25 AND OLDER: ADVERTISEMENT
6
1 Yes
2 No
99 Choose not to answer
[IF H1B=1 GO TO H2B; ELSE GO TO I1]
H2b.

Which of the following images, if any, do you recall seeing in the ad for cigarettes you
viewed earlier in the survey?
[INCLUDE ACTUAL IMAGE (2-D version without warning statement) VIEWED FOR
THAT RESPONDENT ALONG WITH 4 RANDOMLY SELECTED IMAGES FROM
THOSE NOT VIEWED BY THAT RESPONDENT]
8
There was no image in the ad I viewed
9
Do not recall

I.
I1.

I2.

What is the highest level of school you completed or the highest degree you received?

[ALLOW ONE RESPONSE ONLY]
1
2
3
4
5
6
7
99

I3.

What was your annual household income from all sources during 2009? Was it –
1
2
3
4

less than $25,000
between $25,000 and $49,999
between $50,000 and $74,999
$75,000 or more

Choose not to answer

END OF SURVEY
The survey is now complete. Thank you!

ADULT SMOKERS AGED 25 AND OLDER: SAMPLE SCREEN SHOTS

Insert Graphic
Warning Here

ADULT SMOKERS AGED 25 AND OLDER: SAMPLE SCREEN SHOTS

Insert Graphic Image Here

ADULT SMOKERS AGED 25 AND OLDER: SAMPLE SCREEN SHOTS

FOLLOW-UP – 1 week follow-up of sub-set of respondents who completed
baseline in first week
A.

RECALL Questions

A1a.

Do you recall the warning statement on the pack of cigarettes you viewed during
the initial survey about 1 week ago?
1 Yes
2 No
99 Choose not to answer

[IF A1A=1 GO TO A2A; ELSE GO TO A1B]
A2a.

Which of the following warning statements, if any, do you recall seeing on the
pack of cigarettes you viewed during the initial survey about 1 weeks ago?
[INCLUDE ACTUAL WARNING STATEMENT VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING
STATEMENTS FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall

A1b.

Do you recall the image, if any, on the pack of cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 Choose not to answer

[IF A1B=1 GO TO A2B; ELSE GO TO END]
A2b.

Which of the following images, if any, do you recall seeing on the pack of
cigarettes you viewed earlier in the survey?
[INCLUDE ACTUAL IMAGE VIEWED FOR THAT RESPONDENT ALONG
WITH 4 RANDOMLY SELECTED IMAGES FROM THOSE NOT VIEWED BY
THAT RESPONDENT]
8
There was no image on the pack I viewed
9
Do not recall

File Type	application/pdf
File Modified	2010-08-24
File Created	2010-08-24