Screener for General Pop. and AI/AN

Tips from Former Smokers Campaign

Tips 2 Formative Research

Rough Cut Testing

Screener for General Population and American Indians/Alaska Natives

November 28, 2012

Form Approved

OMB No. 0920-0910

Exp. Date 01/31/2015

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 (0920-0910).

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 might 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 100 points [note - $1.00]. Your participation in this survey is voluntary.

Screening Criteria:

Screener Section I: DEMOGRAPHICS

Are you…?

Male

Female

In which of the following categories does your age fall?

Under 18 years of age SCREEN OUT

18-24 years of age

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

In what U.S. state or territory do you currently reside?

[insert standard list]

What is your zip code?

|_|_|_|_|_|

If Alabama or Nebraska and 18-24 years of age

How old are you?

|_|_|

If 18 SCREEN OUT

Do you work for…?

A market research company

An advertising agency or public relations firm

The media (TV/radio/newspapers/magazines)

A healthcare professional (doctor, nurse, pharmacist, dietician, etc.)

None of these

IF ANY OF 1-4 SELECTED, SCREEN OUT.

Do you consider yourself…?

Hispanic or Latino

Not Hispanic or Latino

Do you consider yourself…?

White/Caucasian

Black or African-American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Asian

ASK IF IDENTIFY AS AMERIAN INDIAN OR ALASKA NATIVE

Please describe your tribal affiliation.________

_____________________________________________________________

Do you currently have or have you had in the past any of the following conditions as diagnosed by a doctor, nurse, or other health care professional? Please select all that apply.

[MULTIPLE RESPONSE]

[RANDOMIZE]

1 Asthma

2 Cancer

3 Chronic bronchitis

4 COPD (Chronic Obstructive Pulmonary Disease)

5 Diabetes

6 Emphysema

7 Heart disease

8 Stroke

97 None of these E ANCHOR

99 Decline to answer E ANCHOR

Screener Section II. SMOKING HISTORY SCREENING

Have you smoked at least 100 cigarettes in your entire life?

Yes CONTINUE

No SKIP TO MAIN QUESTIONNAIRE

Do you now smoke cigarettes every day, some days, or not at all? SINGLE RESPONSE.

Every day CONTINUE

Some days CONTINUE

Not at all SKIP NEXT FOUR QUESTIONS

On how many of the past 30 days did you smoke cigarettes?

Enter number: _______

On the average, on those (INSERT PRIOR QUESTION RESPONSE) days, how many cigarettes did you usually smoke each day?

FILL IN NUMBER ______

During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

Yes

No

Which of the following statements best describes you?

1. I am seriously thinking about quitting smoking in the next 30 days

2. I am seriously thinking about quitting smoking in the next 6 months

3. I am not thinking about quitting smoking

ASK FORMER SMOKERS ONLY

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)

IF QUALFIED, PROCEED TO THE MAIN QUESTIONNAIRE. ALL OTHERS SHOW THE MESSAGE BELOW.

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!

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