Form 2 Baseline Survey

OMB No.: 0925-0945

Expiration Date: 12/31/2014

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being asked to complete this survey so that we can gather information about the study participants and their opinions about Snus.

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0645). Do not return the completed form to this address.

Attachment B - Baseline Participant Survey #1

(this survey is completed as part of the Moderator’s Guide)

1. How old were you when you smoked a whole cigarette for the first time?

____ years old

2. How old were you when you first started smoking cigarettes every day?

____ In years:

3. On average, how many cigarettes do you now smoke a day?

____ Number of cigarettes:

4. How soon after you awake in the morning do you usually smoke your first cigarette?

____ Number of minute(s):

and/or

____ Number of hour(s):

5. Have you EVER stopped smoking for one day or longer because you were trying to quit smoking? ____ Yes

____ No (Go to question 11)

6. During the PAST 12 MONTHS, have you stopped smoking for one day or longer because you were trying to quit smoking?

____ Yes

____ No

Each rung on this ladder represents where various smokers are in their thinking about quitting.

Taking action to quit (e.g., cutting down, enrolling in a program).

Starting to think about how to change my smoking patterns.

Think I should quit but not quite ready.

Think I need to consider quitting someday.

No thought of quitting.

7. Indicate the number where you are now.

10

9

8

7

6

5

4

3

2

1

8. During the past 30 days, what brand (and type) of cigarettes did you smoke most often? Be as specific as you can.

______________________________________________________________

9. Do you usually smoke menthol or non-menthol cigarettes?

____ Menthol ____Non-Menthol

In the following questions, we will be asking you about a tobacco product called Snus (or Swedish Snuff). This is a new tobacco product that is available in the United States that comes in different variations. Snus is used in a similar way as dipping tobacco, but there is no need to spit. Snus comes in a small white pouch (like a small teabag), which is placed in the cheek or between the teeth and gums, without chewing, for extended periods of time. A package of Snus usually contains 15 pouches.

10. Before this survey, had you ever heard of a tobacco product called Snus?

____ Yes

____ No

11. Have you EVER used Snus?

____ No, I have never used it

____ I used it once

____ I have used it multiple times

____ I currently use it some days

____ I currently use it every day

12. If offered a free package of Snus today, what would be the likelihood that you would use Snus in the next 7 days?

1. Extremely unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Extremely likely

13. What is the likelihood that you would use Snus instead of cigarettes in situations where you are not allowed to smoke (for instance, on an airplane or another public place where smoking was not allowed)?

1. Extremely unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Extremely likely

14. What is the likelihood that you would switch to Snus completely and give up cigarettes?

1. Extremely unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Extremely likely

To what extent do you disagree or agree with the following statement:

15. “Snus is harmful to one’s health.”

1. Strongly disagree

2. Disagree

3. Agree

4. Strongly agree

16. Do you believe that Snus is less or more harmful to one’s health than ordinary cigarettes?

1. Much less harmful

2. Less harmful

3. About the same

4. More harmful

5. Much more harmful

17. To what extent do you disagree or agree with the following statement:

“Snus is addictive.”

1. Strongly disagree

2. Disagree

3. Agree

4. Strongly agree

18. Do you believe that Snus is less or more addictive than ordinary cigarettes?

1. Much less addictive

2. Less addictive

3. About the same

4. More addictive

5. Much more addictive

19. What is your marital status?

____ Married

____ Living as married

____ Divorced

____ Widowed

____ Separated

____ Single, never been married

20. What is your current occupational status (choose one)?

____ Employed

____ Unemployed

____ Homemaker

____ Student

____ Retired

____ Disabled

____ Other (please specify) _____________________________________________

21. What is the highest grade or level of schooling you completed?

____ Less than 8 years

____ 8 through 11 years

____ 12 years or completed high school

____ Post high school training other than college (vocational or technical)

____ Some college

____ College graduate

____ Postgraduate

Thank you for completing Part I of this survey. Please let the survey administrator know that you are finished.

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