OMB Control No. 0910-0497 Expiration Date: 06/30/2014
Paperwork Reduction Act Statement
The public reporting burden for this collection of information has been estimated to average 1.1 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
RTI/FDA
Tobacco Focus Groups
Screening Questionnaire
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Hello, this is _____________ from [FACILITY NAME], a local market research firm. May I please speak to_____________?
(Hello, this is _____________ from [FACILITY NAME], a local market research firm.) We are working with RTI International, a nonprofit research organization, and the Food and Drug Administration (FDA) on a research study about tobacco products and would like to include your opinions. I want to assure you that we are not from a tobacco company or a company that sells quit-smoking aids.
We are holding a group discussion on [DATE] with approximately 7 other people like yourself. The discussion group starts at [TIME] and will last about 60 minutes. For study purposes, the group discussion will be audio recorded, and FDA project team members may observe the discussion. If you participate, you will receive $50 for your time and opinions. First, however, I need to ask you a few questions to see if you qualify for the study.
Record Gender—Do not ask:
Male
Female
Which of the following categories best describes your age? (Read list. Recruit a mix to show for groups with Chippers and Quit Interest.)
18–24 Recruit for poly-users
25–29 Recruit for poly-users
30–34 Recruit for current, heavy and poly-users
35–39 Recruit for current, heavy and poly-users
40–45 Recruit for current, heavy and poly-users
46–49 Recruit for current and heavy
50–59 Recruit for current and heavy
60–65 Recruit for current and heavy
Over 65 Thank the respondent and terminate
Have you smoked at least 100 cigarettes in your lifetime?
Yes Continue.
No Continue if recruiting 18–24 for Chippers Groups; otherwise, thank the respondent and terminate.
3. Do you currently smoke cigarettes …? (Read list.)
Every day Continue.
Some days Go to Question 5.
Not at all Thank the respondent and terminate.
4. [Every day only.] On average, how many cigarettes do you smoke a day? Would you say…? (Read list.)
Fewer than 10 (CHIPPERS) Go to Question 7.
10 or more but less than 30 (CURRENT) Go to Question 7.
30 or more (HEAVY) Go to Question 7.
[Some days only.] On how many of the past 30 days did you smoke a cigarette? Would you say…? (Read list.)
Fewer than 20 (LIGHT) Continue.
20 to 30 (CURRENT) (HEAVY) Continue.
6. [Some days only.] On average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day? Would you say…? (Read list.)
Fewer than 10 (CHIPPERS) Continue.
10 or more but less than 30 (CURRENT) Continue.
30 or more (HEAVY) Continue.
On a scale from 1 to 5 with 1 being “not at all” and 5 being the “a lot,” how much do you want to quit smoking?
1 - Not at all Go to Question 10.
2 Continue.
3 Continue.
4 Continue.
5 - A lot Continue.
Are you seriously considering stopping smoking within the next 6 months?
Yes Continue.
No Continue.
Are you planning to stop smoking within the next 60 days?
Yes Recruit for Quit Interest Group.
No Continue.
Do you currently use chewing tobacco, snuff, snus, or dip, such as Copenhagen, Skoal, Grizzly, or Redman?
Yes Recruit for Poly-User Group.
No Continue.
In the past 5 years, have you or any member of your household worked for any of the following? (Read list. If yes to any, thank the respondent and terminate.)
A tobacco or cigarette company
A public health or community organization involved in communicating the dangers of smoking or the benefits of quitting
A marketing, advertising, or public relations agency or department
The Federal Government (Read list. If yes to any, thank the respondent and terminate.)
The U.S. Food and Drug Administration (FDA)
The National Institutes of Health (NIH)
The Centers for Disease Control and Prevention (CDC)
The Substance Abuse and Mental Health Services Administration (SAMHSA)
The Centers for Medicare & Medicaid Services (CMS)
12. Have you or any member of your household ever lobbied on behalf of the tobacco industry?
Yes Thank the respondent and terminate.
No Continue.
13. Have you or any member of your household personally represented or worked on behalf of a tobacco company in connection with a tobacco lawsuit?
Yes Thank the respondent and terminate.
No Continue.
14. Have you participated in any paid market research in the past 6 months?
Yes Thank the respondent and terminate.
No Continue.
15. For study purposes, if you participate, the discussion group will be recorded. The interviewer will not ask any sensitive questions. Are your okay with us recording your group discussion?
Yes Continue.
No Thank the respondent and terminate.
16. What is the highest level of education that you have completed? (Read list. Recruit a mix to show per group. No more than two postgraduates per group.)
Less than high school Continue.
High school graduate or GED Continue.
Some college or 2-year degree Continue.
College degree Continue.
Postgraduate degree Continue.
17. Are you of Hispanic or Latino origin?
Yes
18. What is your race? (Read list. Recruit a mix to show per group.)
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
[DON’T READ] Hispanic
[DON’T READ] Other
19. Finally, during the focus group discussion, you will be asked to review written materials and offer your opinions; therefore, I need to ask whether you have a medical or nonmedical condition that hinders your ability to read and/or understand written materials in English?
Yes Thank the respondent and terminate.
No Continue.
Great! You qualify for our study. The discussion group will be held on [DATE] at [TIME] and will last about 60 minutes. For your time and opinions, you will receive $50 cash at the end of the session.
20. Would you like to participate in the group discussion at [TIME] on [DATE]?
Yes Continue.
No Thank the respondent and terminate.
Great! May I please have your mailing and/or e-mail address to send you a confirmation letter with directions? [Verify address and phone number.]
Thank you. That’s all the questions I have today. Please try to arrive at least 15 minutes prior to the group. If you have any questions or find that you are unable to attend, please call [facility’s phone number] as soon as possible. Thank you again for your time. We look forward to seeing you at [TIME] on [DATE].
Read if necessary:
If you have any questions about the study, you may contact Katherine Kosa of RTI at 1‑800‑334‑8571, extension 23901. If you have concerns about how participants are being treated in the study, you may contact RTI’s Office of Research Protection toll-free at 1-866-214-2043.
| File Type | application/msword |
| File Title | Information Collection Request |
| Author | OPPDE/FSIS |
| Last Modified By | Colburn, Christopher |
| File Modified | 2013-04-04 |
| File Created | 2013-02-14 |