Attachment 4 Illustrative Example of Screener and Questionnaire

Form Approved
OMB No. 0920-0572
Exp. Date 11/30/2011

Counter-Marketing Youth Tobacco Prevention
Campaign and Health Reform Tobacco Media Initiative,
on behalf of the Centers for Disease Control and Prevention
OSH Media Campaign: Phase 1 - HHS Region 6 Advertising Effectiveness
Screener Questionnaire
All items used are from Health Message Testing System (HMTS) Question Bank

dated January 26, 2011

Public reporting burden of this collection of information is estimated to average 2 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/ATSDR Information Collection Review
Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

1

On behalf of the Centers for Disease Control and Prevention (CDC), we're conducting a study about different
health and smoking-specific advertising that you see in the media. Your opinions are very important to us! Please
be assured that the purpose of this survey is to gather feedback regarding specific health-related advertising. We
do not plan to report your answers individually. We plan to report results from this survey for the group as a
whole. Thank you for taking the time to help us!
If you decide to participate and are eligible, you will receive 400 points [note - $2.00] as compensation for your
time if you complete the online survey. Completing the survey will take approximately 21 minutes.
Screening Criteria:
PROGRAMMER NOTE: EACH QUESTION HAS AN ITALICIZED REFERENCE QUESTION AFTER IT, PLEASE DO NOT
SHOW THIS, THIS IS FOR BACKEND REFERENCE ONLY.
Screener Section I: DEMOGRAPHICS

HMTS Question 1a

HARRIS Q1-SI. Gender:
Male
Female

HMTS Question 2a

HARRIS Q2-SI. In which of the following categories does your age fall:
Under 18 years of age
SCREEN OUT
18-24 years of age
SCREEN OUT
25-34 years of age
35-44 years of age
45-54 years of age
55-64 years of age
SCREEN OUT
65-74 years of age
SCREEN OUT
75 years of age or older
SCREEN OUT

HMTS Question 1b

HARRIS Q7-SI. Do you, or does any member of your household or immediate family work for:
a market research company
an advertising agency or public relations firm
the media (TV/radio/newspapers/magazines)
as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)
IF ANY OF 1-4 SELECTED, SCREEN OUT.

HMTS Question 14a

HARRIS Q10-SI. Number of children (under age 18) living in the household:
None
1-2 children
3-4 children
5 or more children

2

HMTS Question 4a

HARRIS Q3-SI. What is the highest level of education you have completed?
Grade school
Less than high school graduate/some high school
High school graduate or completed GED
Some college or technical school
Received four-year college degree
Some post graduate studies
Received advanced degree
Other: _____________________

HMTS Question 5a

HARRIS Q4-SI. Please tell me your race or ethnic background. Do you consider yourself?
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Don’t Know/Not Sure
Refused
Race:
White/Caucasian
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
Vietnamese
Cambodian
Filipino
Japanese
Korean
Chinese
Don’t Know/Not Sure
Refused

HMTS Question 9a

HARRIS Q6-SI. In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE.

HMTS Question 10a

HARRIS Q8-SI. What is your current occupational status? Would you say…?
Employed full time
Employed part time
Unemployed
Homemaker
Student
Retired, or
Disabled
Other:_______________
Don’t Know/Not Sure
Refused

3

HMTS Question 12a

HARRIS Q9-SI. What is your marital status?
Married
Unmarried living with a partner
Divorced
Widowed
Separated, or
Single, never been married
Don’t Know/Not Sure
Refused

HMTS Question 13a

HARRIS Q11-SI. Which of the following categories best describe your total, annual household income?
Under $20,000/year
$20,001 - $30,000/year
$30,001 - $40,000/year
$40,001 - $50,000/year
$50,001 - $60,000/year
$60,001 - $80,000/year
$80,001 - $100,000/year
Over $100,000/year

4

Screener Section II. TOBACCO HISTORY SCREENING

HMTS Question 32a

HARRIS Q12-SII. Have you smoked at least 100 cigarettes in your entire life? SINGLE RESPONSE.
Yes
No

HMTS Question 33a

HARRIS Q13-SII. Do you now smoke cigarettes every day, some days, or not at all? SINGLE RESPONSE.
Every day
Some days
Not at all

HMTS Question 36a

HARRIS Q14-SII. On how many of the past 30 days did you smoke cigarettes?
Enter number: _______
IF 0, SKIP TO Section - Main Questionnaire: Message Evaluations

HMTS Question 37a

On the average, on those (INSERT QUESTION #36a RESPONSE) days, how many cigarettes did you usually smoke each day?
FILL IN NUMBER ______

HMTS Question 34a

HARRIS Q15-SII. During the past 12 months, have you stopped smoking for one day or longer because you were
trying to quit smoking? SINGLE RESPONSE.
Yes
No

HMTS Question 35a

HARRIS Q16-SII. About how long has it been since you completely quit smoking cigarettes? FILL IN NUMBER
FOR UNIT THAT APPLIES.
_____ Days (RANGE OF 0 TO 30)
_____ Weeks (RANGE OF 0 TO 5)
_____ Months (RANGE OF 0 TO 12)
_____ Years (RANGE OF 0 TO 50)
CODE, DO NOT DISPLAY.
1
2
3

Smokers
Non-smokers - former smokers
Non-smokers

QUOTA OF 515
QUOTA OF 970

5

Target States 
Arkansas 

Segments 

Arkansas 
Louisiana 

non smokers

Louisiana 
Oklahoma 

non smokers

Oklahoma 
Texas 

non smokers

Texas 
New Mexico 

non smokers

New Mexico 

non smokers

smokers

smokers

smokers

smokers

smokers

IR 
Sample Size 
18% 
3956.948 
48% 
18% 
5275.931 
48% 
18% 
5275.931 
48% 
18% 
10551.86 
48% 
18% 
2110.372 
48% 

Quota 

Parents 
75 
150
100
175
100
175
200
400
40

93 
116 
123 
266 
44 

70

6

Form Approved
OMB No. 0920-0572
Exp. Date 11/30/2011

Counter-Marketing Youth Tobacco Prevention
Campaign and Health Reform Tobacco Media Initiative,
on behalf of the Centers for Disease Control and Prevention
OSH Media Campaign: Phase 1 - HHS Region 6 Advertising Effectiveness
Main Questionnaire
All items used are from Health Message Testing System (HMTS) Question Bank

dated January 26, 2011

Public reporting burden of this collection of information is estimated to average 21 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/ATSDR Information Collection Review
Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

7

Main Questionnaire: Message Evaluations
SHOW: We would now like to show you several different video spots and then gather your reactions to those
spots. Please make sure the volume on your computer is turned up, so that you may both see and hear the
video. Please click “Next” to continue.
RANDOMLY ROTATE 4 VIDEOS at a time in two groups, HEALTH CONSEQUENCES and SECONDHAND
SMOKE. TO SHOW, RECORD ORDER/POSITION AS NOTED BELOW.
HEALTH CONSEQUENCES:

Spot
Reverse Heart
Attack

Reverse Lung
Cancer

Rick Stoddard –
46
Rick Stoddard –
Emergency
Room

MCRC Description
The announcer explains the immediate and long term cardiovascular benefits
of smoking cessation including lowered blood pressure and diminished risk of
heart attack. The viewer is then bombarded with a series of graphic, bloody,
and disturbing images of open heart surgeries, distraught families, and a final
image of a male deceased patient on a gurney. The spot ends with a caution
to stop smoking immediately, and the faint wail of an ambulance siren.
As the announcer explains that ten years after smoking cessation a person's
risk of dying from lung cancer is cut in half, the screen fills with a series of
disturbing images of lung surgery, chest x-rays, distraught patients and a
diseased lung. The announcer cautions that until a person stops smoking they
are at risk of illness and cancer.
Rick Stoddard is tearfully reminiscing about his late wife, Marie, who died of
smoking-related cancer. He talks about the fact that she died at age 46,
making her a middle-aged person at age 23.
Rick Stoddard is tearfully reminiscing about his wife, Marie, who died of
smoking-related cancer. He recalls the day he took her to the emergency room
and learned that the cancer had spread to her brain.

Record
position
shown
(1-8)
5

6

7

8

8

SECONDHAND SMOKE:

Spot
Victim Wife
Apartment CA

It’s Like
They’re
Smoking

Escape

MCRC Description
An elderly man is reminiscing about his late wife. He acknowledges that his
secondhand smoke led to his wife’s death.
A middle aged man is smoking a cigarette while relaxing on a couch next to a
vent. The camera follows the cigarette smoke as it travels throughout the
man’s apartment and into a vent before exiting into the bedroom of an
adjacent apartment where a young boy is sitting on the floor and playing with
his toys. The boy begins to rub his eyes as they become irritated by the
secondhand smoke. A voiceover reminds viewers about the toxicity of
secondhand smoke.
Young children pretend that they are smokers. Snapshots of them are shown
at several moments. Each time, the children say a line that matches up with
that activity, such as, “I smoke when I’m watching cartoons,” or “I smoke
while I am coloring” and “it seems like I’ve been smoking all of my life.” A
female voiceover reminds adult smokers that when they smoke around their
children, “it is like the children are also smoking.” She continues by warning
smokers about the negative health effects that inhaling the harmful chemicals
in cigarette smoke has on children, such as permanent lung damage.
The door opens to a diner and the cook bolts outside to get some fresh air. He
has been holding his breath for a very long time to avoid the secondhand
smoke from the patrons inside. The cook takes in several deep breaths before
returning to the diner. An announcer reminds viewers that secondhand smoke
is not safe at any levels of exposure.

Record
position
shown
(1-8)
1
2

3

4

9

Main Questionnaire SECTION 1: Questions for Each Ad, to be shown right after each ad

HMTS Question 16d

Harris Q1-M1. Is this message believable? GRID FORMAT, ROTATE LIST AS RELEVANT. (MESSAGE TO BE
INSERTED BASED ON SPOT just recently aired)
1
Yes
2
No
INSERT MESSAGE FROM AD

HMTS “Testing Media Messages” preamble

Harris Q2-M1. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you
strongly agree, please tell me the number which indicates how much you agree or disagree with this
advertisement.
Strongly
Strongly
Disagree
Agree
1
2
3
4
5

A
B
C
D

This ad was convincing
This ad grabbed my attention
This ad was easy to understand
I learned something new by viewing this ad

HMTS Question 68e
HMTS Question 71e
HMTS Question 33e
HMTS Question 30e

HMTS Question 20d
Harris Q3-M1. Do you think you will talk about any of these ads with others?
Yes
No

10

Main Questionnaire, Section IIA:
Questions after set of HEALTH CONSEQUENCES ads have been shown

HMTS Question 23d

Harris Q4-M2a. Please rank these four advertisements by placing a 1 by the ad you felt was the most effective in
motivating you or someone else to think about the dangers of smoking, a 2 by the second-most
effective in motivating you to think about the dangers of smoking, etc. RANKING QUESTION UP TO TOP 4,
FORCE EXACTLY ONE RESPONSE FOR EACH OF 1 THROUGH 4. ROTATE 1-4.
1
2
3
4

PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION

OF FIRST SPOT VIEWED
OF SECOND SPOT VIEWED
OF THIRD SPOT VIEWED
OF FOURTH SPOT VIEWED

HMTS Question 19d

Harris Q7-M2a. Please rank these four advertisements by placing a 1 by the ad you felt was the most memorable,
a 2 by your second-most memorable, etc. RANKING QUESTION UP TO TOP 4, FORCE EXACTLY ONE RESPONSE
FOR EACH OF 1 THROUGH 4. ROTATE 1-4.
1
2
3
4

PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION

OF
OF
OF
OF

FIRST SPOT VIEWED
SECOND SPOT VIEWED
THIRD SPOT VIEWED
FOURTH SPOT VIEWED

HMTS Question 30f

Harris Q8-M2a. Thinking about the next 6 months, on a scale from 1 to 10, where 1 is not at all likely and 10 is
extremely likely, how likely are you to…………?
Not
2
3
4
5
6
7
8
9
Extre DK
RF
at All
mely
88
99
Likely
Likely
1
10
1. Look for more information on [the health risks of tobacco].
2. Contact a local official about [reducing tobacco use in your community].
3. Contact a school official about [reducing youth tobacco use].

11

Main Questionnaire, Section IIB:
Questions after set of SECONDHAND SMOKE ads have been shown

HMTS Question 23d

Harris Q4-M2b. Please rank these four advertisements by placing a 1 by the ad you felt was the most effective in
motivating you or someone else to think about the dangers of secondhand smoke, a 2 by the secondmost effective in motivating you to think about the dangers of secondhand smoke, etc. RANKING
QUESTION UP TO TOP 4, FORCE EXACTLY ONE RESPONSE FOR EACH OF 1 THROUGH 4. ROTATE 1-4.
1
2
3
4

PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION

OF FIRST SPOT VIEWED
OF SECOND SPOT VIEWED
OF THIRD SPOT VIEWED
OF FOURTH SPOT VIEWED

HMTS Question 19d

Harris Q7-M2b. Please rank these four advertisements by placing a 1 by the ad you felt was the most memorable,
a 2 by your second-most memorable, etc. RANKING QUESTION UP TO TOP 4, FORCE EXACTLY ONE RESPONSE
FOR EACH OF 1 THROUGH 4. ROTATE 1-4.
1
2
3
4

PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION
PICTURE/DESCRIPTION

OF
OF
OF
OF

FIRST SPOT VIEWED
SECOND SPOT VIEWED
THIRD SPOT VIEWED
FOURTH SPOT VIEWED

HMTS Question 30f

Harris Q8-M2b. Thinking about the next 6 months, on a scale from 1 to 10, where 1 is not at all likely and 10 is
extremely likely, how likely are you to…………?
Not
2
3
4
5
6
7
8
9
Extre DK
RF
at All
mely
88
99
Likely
Likely
1
10
1. Look for more information on [the health risks of secondhand smoke].
2. Talk to a friend about ways to [avoid exposure to secondhand smoke].
3. Contact a local official about [reducing tobacco use in your community].

12

Thank you for your participation in this study. We appreciate your responses and hope you will join
us on future surveys!

13

GENERAL SCREEN OUT MESSAGE UNLESS OTHERWISE NOTED
Thank you for your participation in this study. Unfortunately, your responses indicate that you are not qualified
for this particular study, or that we have already reached our required quota of responses from participants
similar to you. We appreciate your enthusiasm for our study and hope you will join us on future surveys!

14