Follow-up Survey for Web Clients

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Follow-up Survey for Web Clients

Public reporting burden of this collection of information is estimated to average 15 minutes 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: OMB 0920-XXXX

Section A. Consent

See Appendix 7 for the informed consent language for both the telephone and web-based versions of the survey for the Web-based program clients.

A1. IS RESPONDENT CONTINUING WITH THE INTERVIEW? Telephone Based Survey: Yes 1 No -- Assign disposition code

Web Based Survey: Yes NO

Section B. Current Tobacco Use

B1. Since you first registered for the website on (Date of first contact), seven months ago, did you stop using tobacco for 24 hours or longer because you were trying to quit?

Telephone Based Survey: Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: Yes NO

GO TO B2 IF B1==“YES” TO MAKING A QUIT ATTEMPT ABOV, ELSE GO TO B4 IF PARTICIPANT RESPONDED “NO” TO DID YOU STOP USING TOBACCO FOR 24 HOURS OR LONGER.

B2. Have you smoked any cigarettes or used other tobacco, even a puff or pinch, in the last 7 days?

Telephone Based Survey: Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: Yes NO

GO TO B3 IF PARTICIPANT RESPONDED “NO” TO USING TOBACCO IN THE PAST 7 DAYS, ELSE GO TO B4.

B3. Have you smoked any cigarettes or used other tobacco, even a puff or pinch, in the last 30 days?

Telephone Based Survey: Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: Yes NO

GO TO B4 IF PARTICIPANT RESPONDED “YES” TO USING TOBACCO IN THE PAST 30 DAYS, ELSE GO TO SECTION D.

B4. What types of tobacco have you used in the past 30 days?

Telephone Based Survey: B4a. CIGARETTES B4b. CIGARS, CIGARILLOS, OR LITTLE CIGARS B4c. PIPE [NOTE: THIS IS A TRADITIONAL PIPE, NOT A WATER PIPE OR “HOOKAH”] B4d. CHEWING TOBACCO, SNUFF, OR DIP B4e. OTHER [Read each type of tobacco from B4a – B4e and record answer using the codes below] Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: (Check all that apply) CIGARETTES CIGARS, CIGARILLOS, OR LITTLE CIGARS PIPE [NOTE: THIS IS A TRADITIONAL PIPE, NOT A WATER PIPE OR “HOOKAH”] CHEWING TOBACCO, SNUFF, OR DIP OTHER

GO TO B5a IF PARTICIPANT RESPONDED “YES” TO CIGARETTES (B4a); ELSE GO TO B6a.

B5a. Do you currently smoke CIGARETTES every day, some days, or not at all?

Telephone Based Survey: (do not read) Everyday 1 Somedays 2 Not at all 3 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Everyday Somedays Not at all

GO TO B5b IF PARTICIPANT RESPONDED “SOMEDAYS” TO B5a; ELSE GO TO B5c.

B5b. How many days did you smoke in the last 30 days?

Telephone Based Survey: _____Days [NUMBER; RANGE 1-30] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____Days [pull down menu; or limit text box to numeric responses with max response=30]

B5c. How many cigarettes do you smoke per day on the days that you smoke?

Telephone Based Survey: _____ Cigarettes per day [NUMBER SOFT RANGE 1-60; HARD RANGE 1-120] (If caller says over 100, confirm. 20 cigarettes = 1 pack in the U.S.;100 cpd ≅ 5 packs per day) If caller cannot identify a specific number, probe: “Give me your best guess – it is OK if it is not perfect REFUSED -7 DON’T KNOW -8

Web Based Survey: _____Cigarettes per day [pull down menu with max 40+ cigs or limit text box to numeric responses] Optional error messaging: If response is over 100, confirm. 20 cigarettes = 1 pack in the U.S.; 100 cpd ≅ 5 packs per day);

GO TO B6a IF PARTICIPANT RESPONDED “YES” TO CIGARS, CIGARILLOS, OR LITTLE CIGARS IN B4b; ELSE GO TO B7a.

B6a. Do you currently smoke CIGARS, CIGARILLOS, OR LITTLE CIGARS every day, some days, or not at all?

Telephone Based Survey: (do not read) Everyday 1 Somedays 2 Not at all 3 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Everyday Somedays Not at all

GO TO B6b IF PARTICIPANT RESPONDED “SOMEDAYS” TO B6a; ELSE GO TO B6c.

B6b. How many days did you smoke a CIGAR, CIGARILLO, OR LITTLE CIGAR in the last 30 days?

Telephone Based Survey: _____Days [NUMBER; RANGE 1-30] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____Days [pull down menu; or limit text box to numeric responses with max response=30]

B6c. How many CIGARS, CIGARILLOS, OR LITTLE CIGARS do you smoke per week during the weeks that you smoke?

Telephone Based Survey: _____ cigars, cigarillos, or little cigars per week [NUMBER SOFT RANGE 1-60; HARD RANGE 1-120] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____ cigars, cigarillos, or little cigars per week [pull down menu with max 40+ cigars or limit text box to numeric responses]

GO TO B7a IF PARTICIPANT RESPONDED “YES” TO PIPES (B4c); ELSE GO TO B8a.

B7a. Do you currently smoke PIPES every day, some days, or not at all?

Telephone Based Survey: (do not read) Everyday 1 Somedays 2 Not at all 3 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Everyday Somedays Not at all

GO TO B7b IF PARTICIPANT RESPONDED “SOMEDAYS” TO B7a; ELSE GO TO B7c.

B7b. How many days did you smoke a pipe in the last 30 days?

Telephone Based Survey: _____Days [NUMBER; RANGE 1-30] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____Days [pull down menu; or limit text box to numeric responses with max response=30]

B7c. How many pipes do you smoke per week during the weeks that you smoke?

(pipes per week) ________

Telephone Based Survey: _____ pipes per week [NUMBER SOFT RANGE 1-60; HARD RANGE 1-120] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____ pipes per week [pull down menu with max 40+ pipes or limit text box to numeric responses]

GO TO B8a IF PARTICIPANT RESPONDED “YES” TO PIPES (B4d); ELSE GO TO B9a.

B8a. Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or not at all?

Telephone Based Survey: (do not read) Everyday 1 Somedays 2 Not at all 3 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Everyday Somedays Not at all

GO TO B8b IF PARTICIPANT RESPONDED “SOMEDAYS” TO B8a; ELSE GO TO B8c.

B8b. How many days did you use chewing tobacco, snuff or dip in the last 30 days?

Telephone Based Survey: _____Days [NUMBER; RANGE 1-30] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____Days [pull down menu; or limit text box to numeric responses with max response=30]

B8c. How many POUCHES OR TINS do you use per week during the weeks that you use chewing tobacco or snuff?

Telephone Based Survey: _____ pouches/tins per week [NUMBER SOFT RANGE 1-60; HARD RANGE 1-120] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____ pouches/tins per week [pull down menu with max 40+ pipes or limit text box to numeric responses]

GO TO B9a IF PARTICIPANT RESPONDED “YES” TO PIPES (B4e); ELSE GO TO B10.

B9a. Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all?

Telephone Based Survey: (do not read) Everyday 1 Somedays 2 Not at all 3 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Everyday Somedays Not at all

GO TO B9b IF PARTICIPANT RESPONDED “SOMEDAYS” TO B9a; ELSE GO TO B9c.

B9b. How many days did you use other types of tobacco in the last 30 days?

Telephone Based Survey: _____Days [NUMBER; RANGE 1-30] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____Days [pull down menu; or limit text box to numeric responses with max response=30]

B9c. How much [how many] [OTHER TOBACCO NAME] do you use per week during the weeks that you use other tobacco?

Telephone Based Survey: _____ (other tobacco name) per week [NUMBER SOFT RANGE 1-60; HARD RANGE 1-120] REFUSED -7 DON’T KNOW -8

Web Based Survey: _____ (other tobacco name) per week [pull down menu with max 40+ pipes or limit text box to numeric responses]

B10. About how old were you when you first started smoking cigarettes fairly regularly?

Telephone Based Survey: _____ Number of years REFUSED -7 DON’T KNOW -8

Web Based Survey: _____ Number of years [pull down menu or limit text box to numeric responses]

Section C. Intentions to quit

ASK C1 ONLY IF PARTICIPANT REPLIED THEY HAVE USED CIGARETTES IN THE PAST 30 DAYS (B4a=”YES”); ELSE GO TO D1.

C1. Do you intend to quit using cigarettes within the next 30 days?

Telephone Based Survey: Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: Yes NO

Section D. Quitting Behaviors

Now we want to ask you about your use of different strategies people use to quit smoking.

ASK OF ALL RESPONDENTS

D1. Since you first registered for assistance on the website, seven months ago, have you used any of the following products or medications to help you quit?

Telephone Based Survey: D1a. Nicotine patches D1b. Nicotine gum D1c. Nicotine lozenges D1d. Nicotine spray D1e. Nicotine inhaler D1f. Zyban (also called Wellbutrin or bupropion) D1g. Chantix (also called varenicline) D1h. Other medications to help you quit (if yes, please specify_____) [Read each type of medication from D1a – D1h and record answer using the codes below] Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: (Check all that apply) Nicotine patches Nicotine gum Nicotine lozenges Nicotine spray Nicotine inhaler Zyban (also called Wellbutrin or bupropion) Chantix (also called varenicline) Other medications to help you quit (if yes, please specify_____)

D2. Other than the website or medications, did you use any other kinds of assistance to help you quit over the past seven months?

Telephone Based Survey: D2a. Advice from a health professional D2b. (Insert name of State specific Web Intervention Website) Website D2c. Other Website (Please Specify) D2c. Telephone program (Please Specify) D2d. Counselling program D2e. Self-help materials D2f. Other (please specify) [Read each type of assistance from D2a – D2f and record answer using the codes below] Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: (CHECK ALL THAT APPLY) Advice from a health professional (Insert name of State specific Web Intervention Website) Website Other Website (Please Specify) Telephone program (Please Specify) Counselling program Self-help materials Other (Please Specify)

Section E. User Satisfaction

Next we want to ask you about your experience with the web-based quit smoking program.

All Respondents

F1. Overall, how satisfied were you with the service you received from the website?

Telephone based survey: (READ ALL, CHECK ONE ONLY)  Very satisfied  Mostly satisfied  Somewhat satisfied  Not at all satisfied DO NOT READ REFUSED -7 DON’T KNOW -8

Web based survey (CHECK ONE ONLY)  Very satisfied  Mostly satisfied  Somewhat satisfied  Not at all satisfied

F2. To what extent has the website met your quitting needs?

Telephone based survey: (READ ALL, CHECK ONE ONLY) Almost all of my needs have been met Most of my needs have been met Only a few of my needs have been met None of my needs have been met If no, why not? _____________ DO NOT READ REFUSED -7 DON’T KNOW -8

Web based survey (CHECK ONE ONLY) Almost all of my needs have been met Most of my needs have been met Only a few of my needs have been met None of my needs have been met If no, why not? _____________

F3. If you were to seek help again, would you contact the quitline?

Telephone based survey: (READ ALL, CHECK ONE ONLY) Yes, definitely Yes, I think so No, I don’t think so No, definitely not If no, why not? _____________ DO NOT READ REFUSED -7 DON’T KNOW -8

Web based survey (CHECK ONE ONLY) Yes, definitely Yes, I think so No, I don’t think so No, definitely not If no, why not? _____________

F4. If a friend were in need of similar help, would you recommend the website to him/her?

Telephone based survey: (READ ALL, CHECK ONE ONLY) Yes, definitely Yes, I think so No, I don’t think so No, definitely not If no, why not? ______________ DO NOT READ REFUSED -7 DON’T KNOW -8

Web based survey (CHECK ONE ONLY) Yes, definitely Yes, I think so No, I don’t think so No, definitely not If no, why not? ______________

Section G. Use of Technology

Now we would like to learn more about your use of the internet and other technology.

G2. When you use the Internet, how do you access it?

Telephone Based Survey: G2a. A home computer G2b. A work computer G2c. A shared computer at a school, public library, or a community center G2d. Wireless device (i.e. mobile phone, iPad) [Read each location from G2a – G2d and record answer using the codes below] Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: (check all that apply) A home computer A work computer A shared computer at a school, public library, or a community center Wireless device (i.e. mobile phone, iPad)

G3. How often do you access the internet, including checking your e-mail?

Telephone based survey: (READ ALL, CODE ONE ONLY) Several times a day 5 About once a day 4 Every few days 3 Once a week 2 Less often 1 DO NOT READ REFUSED -7 DON’T KNOW -8

Web based survey (CHECK ONE ONLY) several times a day about once a day every few days once a week less often

G4. We’re also interested in the kinds of telephone services people have. Please tell me whether you have any of the following. Do you have a…

web survey: check boxes (directions: check all that apply)

telephone survey: Read each activity from G4a – G4c and record answer using the codes below

	Yes =1	No =2	Refused = -7	Don’t Know = -8
Landline or home telephone?
Mobile telephone?
(If yes to b, then ask c) A mobile phone with internet access?

G5. Thinking about all the different ways you socialize or communicate with friends, about how often do you...

web survey: table of activities and response categories

telephone survey: Read each activity/response category from G5a – G5e and record answer using the codes below

	Everyday =5	Several times a week =4	At least once a week =3	Less than once a week =2	Never =1	RE-FUSED = -7	DON’T KNOW = -8
(ask G5a if G4a=1) Talk to friends on a landline or home telephone?
(ask G5b if G4b=2) talk to friends on your mobile phone?
(ask G5c if G4b=2) send text messages to each other on your mobile phone?
(All respondents) send instant messages to each other through a service such as Yahoo messenger or G-chat, etc?
(All respondents) send messages through social networking sites like Facebook or Myspace via wall posts, private messages, or chat?

G6. Do you have an account or profile on the following social network sites?:

	Yes =1	No =2	Refused = -7	Don’t Know = -8
Facebook?
Twitter?
Myspace?
Google+?

G7. How often do you access your account/profile on _____?

	Everyday =5	Several times a week =4	At least once a week =3	Less than once a week =2	Never =1	RE-FUSED = -7	DON’T KNOW = -8
(ask G7a if G6a=1) Facebook?
(ask G7b if G6b=1) Twitter?
(ask G7c if G6c=1) Myspace
(ask G7d if G6d=1) Google+

G8. We're interested in the kinds of things you have done when you used the Internet to learn more about quitting smoking. Not everyone has done these things. Please just tell me whether you ever do each one, or not. Have you ever...

web survey: check boxes (directions: check all that apply)

telephone survey: Read each activity from G5a – G5d and record answer using the codes below

	Yes =1	No =2	Refused = -7	Don’t Know = -8
started or joined a quit smoking-related group on a social networking site like Facebook of Myspace?
read an online article about quitting smoking on a website such as CNN or WebMD?
Used a search engine (e.g. Google, Bing, Yahoo!) to find information about quitting smoking?

H. ENVIRONMENTAL SMOKE

//Ask of all respondents//

H1. Other than yourself, does anyone who lives in your household smoke cigarettes now?

Telephone Based Survey: Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: Yes NO

H2. Which statement best describes the rules about smoking in your home:

Telephone Based Survey: No one is allowed to smoke anywhere 1 Smoking is allowed in some places or at some times 2 Smoking is permitted anywhere 3 REFUSED -7 DON’T KNOW -8

Web Based Survey: No one is allowed to smoking anywhere Smoking is allowed in some places or at some times Smoking is permitted anywhere

H3. What is your current occupational status?

Telephone Based Survey: Employed 1 Unemployed 2 Homemaker 3 Student 4 Retired 5 Disabled 6 Other (please specify) 7 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Employed Unemployed Homemaker Student Retired Disabled Other/ Please specify below

Go to H4 if employed (H3=1); Else go to Closing Demographics.

H4. Are you currently employed outside the home?

Telephone Based Survey: Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: Yes NO

Go to H5 if employed outside of the home (H4=1); Else go to Closing Demographics.

H5. Which of these best describes your place of work’s smoking policy for work areas:

Telephone Based Survey: Not allowed in any areas 1 Allowed in some area 2 Allowed in all areas 3 REFUSED -7 DON’T KNOW -8

Web Based Survey: Not allowed in any areas Allowed in some area Allowed in all areas

Section I. Closing Demographics

(Ask only respondents who did not complete these items during intake)

I1. What is your marital status?

Telephone Based Survey: Married 1 Living as married 2 Divorced 3 Widowed 4 Separated 5 Single, never been married 6 Other (please specify) 7 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Married Living as married Divorced Widowed Separated Single, never been married

I2. What is the highest level of education you have completed?

Telephone Based Survey: Less than grade 9 1 Grade 9 to 11, no degree 2 GED 3 High school degree 4 Some college or university (includes some technical or trade school) 5 College or university degree (includes AA, BA, Masters, Ph.D.) xxxxxxxx 6 Other (please specify) 7 REFUSED -7 DON’T KNOW -8

Web Based Survey: (please check one) Less than grade 9 Grade 9 to 11, no degree GED High school degree Some college or university (includes some technical or trade school) College or university degree (includes AA, BA, Masters, Ph.D.)

I3. Are you of Hispanic or Latino origin?

Telephone Based Survey: Yes 1 No 2 REFUSED -7 DON’T KNOW -8

Web Based Survey: Yes NO

I4. What is your race? Which one or more of these

groups would you say best describes you?

Telephone Based Survey: (select one or more) White 1 Black or African American 2 Asian 3 Native Hawaiian/Pacific Islander 4 American Indian/Alaska Native 5 REFUSED -7 DON’T KNOW -8

Web Based Survey: (CHECK ALL THAT APPLY) White Black or African American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native

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