Form 0920-xxxx Smoker Followup

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

CDC National Media Campaign

- Smoker Follow-up Questionnaire -

Public reporting burden of this collection of information is estimated to average 25 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

SUBJECTS FOR QUESTIONNAIRE

SECTION A: INTRODUCTORY QUESTIONS

SECTION B: TOBACCO USE QUESTIONS

SECTION C: SMOKING CESSATION

SECTION D: ATTITUDES AND BELIEFS RELATED TO CESSATION

SECTION E: SECONDHAND SMOKE

SECTION F: MEDIA USE AND AWARENESS

SECTION G: CLOSING QUESTIONS

SECTION A: INTRODUCTORY QUESTIONS

A3. Do you now smoke every day, some days, or not at all?

1. I smoke every day

2. I smoke on some days

3. I do not smoke at all

SECTION B: TOBACCO USE QUESTIONS

The next few questions are about tobacco use and smoking cessation.

B1. On the average, about how many cigarettes a day do you now smoke?

Rationale: Key Outcome Indicator 2.08.2; NATS Q9

__________number of cigarettes

I smoke less than 1 cigarette a day

B2. On the days that you smoke, how soon after you wake up do you usually have your first cigarette? Would you say…

Rationale: Provides an indicator of addiction; NATS Q19

1. Within 5 minutes

2. 6-30 minutes

3. From more than 30 minutes to 1 hour

4. After more than 1 hour

SECTION C: SMOKING CESSATION

C2. During the past 3 months, that is, since [FILL DATE OF BASELINE], how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?

Rationale: Key Outcome Indicator 3.11.1; Revised from NATS Q49 with “3 months” instead of “12 months.”

_____ Number of times

C4. During the past 3 months, that is, since [FILL DATE OF BASELINE], how many times have you tried to quit smoking cigarettes for good, but stopped for less than a day?

Rationale: Key Outcome Indicator 3.11.1; Revised from NATS Q49 with “3 months” instead of “12 months.”

_____ Number of times

C6. Do you want to quit smoking cigarettes for good?

Rationale: Key Outcome Indicator 3.08.3; NATS Q54

1. Yes

2. No

C7. How much do you want to quit smoking? Would you say…

Rationale: Key Outcome Indicator 3.08.3.

1. Not at all

2. A little

3. Somewhat

4. A lot

C8. Do you have a time frame in mind for quitting?

Rationale: Key Outcome Indicator 3.08.3; NATS Q55

1. Yes

2. No

C9. Do you plan to quit smoking for good….

Rationale: Key Outcome Indicator 3.08.3; NATS Q56.

1. In the next 7 days,

2. In the next 30 days,

3. In the next 6 months,

4. In the next 1 year, or

5. More than 1 year from now?

C10. If you decided to give up smoking altogether in the next 12 months, how likely do you think you would be to succeed? Would you say…

Rationale: Increased Awareness, Knowledge, and Intention to Quit;

Change in Beliefs about Perceived Ability to Quit Smoking. Source: NY ATS; FL Online Adult Longitudinal Media Survey

1. Extremely Likely

2. Very Likely

3. Somewhat Likely

4. Very Unlikely

5. Extremely Unlikely

C11. How much do you think your health would improve if you were to quit smoking?

Rationale: Increased Awareness Knowledge and Intention to Quit and Increased belief that smoking is harmful to health. Source: FL Online Adult Longitudinal Media Survey

1. Not at all

2. A little

3. Somewhat

4. A lot

C12. How worried are you that smoking will damage your health in the future?

Rationale: Increased Awareness Knowledge and Intention to Quit;Increased belief that smoking is harmful to health. Source: FL Online Adult Longitudinal Media Survey

1. Not at all worried

2. A little worried

3. Somewhat worried

4. Very worried

C13. How do you think most people who are important to you would feel about you quitting tobacco use during the next 12 months? Would they…

Rationale: Increased Awareness Knowledge and Intention to Quit; Change in beliefs about referent’s attitudes about smoking. Source: FL Online Adult Longitudinal Media Survey

1. Strongly disapprove

2. Disapprove

3. Neither disapprove nor approve

4. Approve

5. Strongly approve

C14. Among close friends, do

Rationale: Normative behaviors about smoking and smoking cessation

1. All of them smoke?

2. Most of them smoke?

3. Most of them not smoke?

4. None of them smoke?

C15. Among close relatives, do

Rationale: Normative behaviors about smoking and smoking cessation

1. All of them smoke?

2. Most of them smoke?

3. Most of them not smoke?

4. None of them smoke?

C16. How many of your family members have quit smoking or are currently quitting smoking?

Rationale: Normative behaviors about smoking and smoking cessation

5. None

6. Only a few

7. Some

8. Most

9. All

C17. How many of your friends have quit smoking or are currently quitting smoking?

Rationale: Normative behaviors about smoking and smoking cessation

1. None

2. Only a few

3. Some

4. Most

5. All

QUITLINE USE AND AWARENESS

C18. A telephone quitline is a free telephone-based service that connects people who smoke cigarettes with someone who can help them quit. Are you aware of any telephone quitline services that are available to help you quit smoking?

Rationale: Key Outcome Indicator 3.08.6; NATS Q44

1. Yes

2. No

C19. If you decided to quit smoking in the future, would gather information or support for quitting from…

1. Yes 2. No

C19_1. A telephone quitline

C19_2. An Internet website

C19_3. Class, program, or one-on-one counseling from a healthcare provider

C19_4. Your doctor or other health care professional

C20. Have you heard of 1-800-QUIT-NOW?

Rationale: Awareness of quit line as smoking cessation resource

1. Yes

2. No

[IF C20=1, ASK C22]

C22. Have you called 1-800 QUIT-NOW or any other telephone quitline in the past 3 months?

Rationale: Awareness of quit line as smoking cessation resource

1. Yes

2. No

SECTION D: ATTITUDES AND BELIEFS RELATED TO CESSATION

The next few questions will ask about your opinions related to smoking, tobacco use, and cessation.

Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.

1 2 3 4

Strongly Strongly

disagree Disagree Agree agree

Rationale: Helps assess attitudes about smoking cigarettes. Source:

Adolescent Decisional Balance Scale from Velicer et al.l J. Pers. Soc.Psych., 48(5); 1279-89.

[RANDOMIZE ORDER]

D1. Smoking cigarettes is pleasurable.

D2. Smoking cigarettes relieves tension.

D3. Smoking helps me concentrate and do better work.

D4. I would be more energetic right now if I didn’t smoke.

D5. I’m embarrassed that I have to smoke.

D6. Smoking is hazardous to my health.

Thoughts About Quitting

Rationale: helps assess intentions to quit smoking. Source: Legacy surveys, FL Online Adult Longitudinal Media Survey

[RANDOMIZE ORDER]

D7. I have been thinking a lot about quitting smoking recently.

D8. I am eager for a life without smoking.

D9. I am not prepared to make changes in my life in order to quit smoking.

Worries About Health

Rationale: Assesses attitudes about smoking and D14 addresses belief about harm from smoking. Source: FL Online Adult Longitudinal Media Survey

[RANDOMIZE ORDER]

D10. I get upset when I think about my smoking.

D11. I am disappointed in myself because I smoke.

D12. I get upset when I hear or read about illnesses caused by smoking.

D13. Warnings about the health risks of smoking upset me.

D14. Smoking will severely lower my quality of life in the future.

D15. I will not become a burden to others in the future because of my smoking.

General Attitudes Related to Smoking and Cessation

Rationale: intention to quit smoking and beliefs about harmful effects of smoking. Source: FL Online Adult Longitudinal Media Survey (and for D18 American Legacy surveys).

[RANDOMIZE ORDER]

D16. Smokers should take warnings about cigarette smoking and lung cancer seriously.

D17. On a scale from 1 to 5 with 1 being the “lowest” and 5 being the “highest,” how would you rate quitting smoking as a priority in your life?

1. Lowest

5. Highest

Risk Perception

D18. Smoking can cause immediate damage to your body.

1. Strongly Agree

2. Agree

3. Disagree

4. Strongly Disagree

D19. How likely do you think a smoker is to develop a smoking-related disease as a result of smoking?

Rationale: beliefs about cigarette smoking and harm to health. Source: FL Online Adult Longitudinal Media Survey.

1. Extremely Likely

2. Very Likely

3. Somewhat Likely

4. Very Unlikely

5. Extremely Unlikely

D20. How likely do you think you are to develop a smoking-related disease as a result of smoking?

1. Extremely Likely

2. Very Likely

3. Somewhat Likely

4. Very Unlikely

5. Extremely Unlikely

D21. Do you believe cigarette smoking is related to:

Rationale: Beliefs about cigarette smoking and health effects related to smoking. Source: NHIS.

[RANDOMIZE ORDER] 1 2

Yes No

D21_1. Lung Cancer

D21_2. Cancer of the mouth or throat

D21_3. Heart Disease

D21_4. Diabetes

D21_5. Emphysema

D21_6. Stroke

D21_7. Hole in throat (stoma or tracheotomy)

D21_8. Buerger’s Disease

D21_9. Amputations (removal of limbs);

D21_10. Asthma

D21_11. Gallstones

Social Norms of Smoking and SHS

D22. Thinking about all the health problems in your community, how important is addressing the problem of tobacco use? Would you say it is…

Rationale: norms about tobacco use.

1. Among the most important health problems

2. Equally as important as other health problems

3. Among the least important health problems

D23. In general, how do the adults you spend time with feel about cigarette smoking by adults?  Do they feel it is…

Rationale: norms about tobacco use.

1. Totally acceptable

2. Somewhat acceptable

3. Neither acceptable nor unacceptable

4. Somewhat unacceptable

5. Totally unacceptable

 

D24. How do the adults you spend time with feel about someone smoking if children are present?  Do they feel it is…

Rationale: norms about tobacco use.

1. Totally acceptable

2. Somewhat acceptable

3. Neither acceptable nor unacceptable

4. Somewhat unacceptable

5. Totally unacceptable

SECTION E: SECONDHAND SMOKE

E1. Other than yourself, does anyone who lives in your home smoke cigarettes now?

Rationale: Perceived social norms about smoking. Source: NY ATS; FL Online Adult Longitudinal Media Survey.

1. Yes

2. No

E2. About how often do you smoke when you are in the company of children?

Rationale: Perceived social norms about smoking. Source: FL Online Adult Longitudinal Media Survey.

1. Always

2. Sometimes

3. Rarely

4. Never

E3. Not counting decks, porches, or garages, during the past 7 days, that is, since last [today’s day of week], on how many days did someone other than you smoke tobacco inside your home while you were at home?

Rationale: Perceived social norms about smoking. Source: NATS.

Number of days____________

E4. Not counting decks, porches, or garages, inside your home, is smoking …?

Rationale: Key Outcome Indicator 2.04.4; NATS Q74

1. Always allowed

2. Allowed only at some times or in some places

3. Never allowed

E5. Not counting motorcycles, in the vehicles that you and your family members who live with you own or lease, is smoking …

Rationale: Key Outcome Indicator 2.04.4; NATS Q88

1. Always allowed in all vehicles

2. Sometimes allowed in at least one vehicle

3. Never allowed in any vehicle

4. My family does not own or lease a vehicle

The next few questions will ask about your opinions related to smoking, tobacco use, and cessation.

E6. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.

Rationale: belief that cigarette smoking and secondhand smoke are harmful to health. Source: Cantor, O’Hare, and O’Connor, 2006.

1 2 3 4

Strongly Strongly

disagree Disagree Agree agree

E6_1. Cigarette smoking has no serious effects on non-smokers.

E6_2. Parents who live with their children should not be allowed to smoke in their homes.

E6_3. Adults should not smoke around other people in their home.

E6_4. I protect all other household members from any harm related to smoking.

E7. Do you think that breathing smoke from other people’s cigarettes or from other tobacco products is …?

Rationale: Key Outcome Indicator 2.03.5; NATS Q95

1. Not at all harmful to one’s health

2. Somewhat harmful to one’s health

3. Very harmful to one’s health

E8. How likely do you think it is that regularly breathing secondhand smoke from cigarettes would cause children to have asthma or breathing problems?

Rationale: Increased belief that cigarette smoking and secondhand smoke are harmful to health.

1. Extremely Likely

2. Very Likely

3. Somewhat Likely

4. Very Unlikely

5. Extremely Unlikely

E9. Are you seriously considering increasing restrictions on smoking in your household?

1. Definitely Yes

2. Probably Yes

3. Probably Not

4. Definitely Not

SECTION F: MEDIA USE AND AWARENESS

F5. In the past 3 months, about how often have you seen ads against smoking on television?

Rationale: exposure to tv ads. Source: MTS (replaced “anti smoking” with “ads against smoking”).

1. Never

2. Rarely

3. Sometimes

4. Often

5. Always

F6. In the past 3 months, how often have you heard ads against smoking on the radio?

Rationale: exposure to radio ads. Source: FL Online Adult Longitudinal Media Survey (replaced “anti smoking” with “ads against smoking”).

1. Never

2. Rarely

3. Sometimes

4. Often

5. Always

F7. In the past 3 months, how often have you seen ads against smoking in newspapers or magazines?

Rationale: exposure to print ads.

1. Never

2. Rarely

3. Sometimes

4. Often

5. Always

F8. In the past 3 months, how often have you seen ads against smoking in videos, or websites online?

Rationale: exposure to web ads and/or videos. Source: MTS (replaced “anti smoking” with “ads against smoking”).

1. Almost every time I was online

2. Frequently when I was online

3. Occasionally when I am online

4. Never/Not that I remember

5. I rarely or never go online or use the internet

F9. Have you ever heard of any quit smoking websites online?

Rationale: awareness of internet smoking cessation resources.

1. Yes

2. No

[IF F9 = 1, ASK F10A]

F10A. Have you visited any quit smoking websites online in the past 3 months?

Rationale: use of internet smoking cessation resources.

1. Yes

2. No

F11. Have you heard of the Website www.smokefree.gov?

Rationale: awareness of smoking cessation resources.

1. Yes

2. No

[IF F11 = 1, ASK F12A]

F12A. Have you visited www.smokefree.gov in the past 3 months?

Rationale: use of internet smoking cessation resources.

1. Yes

2. No

F13. In the past 3 months, have you seen or heard advertisements for products to help people quit smoking, such as nicotine patches or gums?

Rationale: awareness of smoking cessation resources.

1. Never

2. Rarely

3. Sometimes

4. Often

5. Always

F17. In the past 3 months, have you seen or heard of any ads on television or radio with the following themes or slogans?

Rationale: Ad awareness. Source: FL Online Adult Longitudinal Media Survey.

[RANDOMIZE ORDER] 1 2

Yes No

F17_1. TIPS FROM A FORMER SMOKER

F17_2. TRUTH

F17_3. BECOME AN EX

F17_4. EVERY CIGARETTE IS DOING YOU DAMAGE

F17_5. TOBACCO FREE LIVING

[IF F17_1 = YES, ASK F18]

F18. Where have you seen or heard about the TIPS Campaign?

Rationale: Ad awareness. Source: FL Online Adult Longitudinal Media Survey.

1 2

Yes No

F18_1. On TV

F18_2. On the radio

F18_3. In newspapers or magazines

F18_4. On the Internet

F18a. Have you heard of the Website www.cdc.gov/tobacco/campaign/tips?

1. Yes

2. No

F18b. Have you visited www.cdc.gov/tobacco/campaign/tips in the past 3 months?

1. Yes

2. No

F20. The TIPS campaign is on social networking sites including Facebook, MySpace, and Twitter. Have you ever seen the TIPS campaign on these sites?

Rationale: Ad awareness. Source: FL Online Adult Longitudinal Media Survey.

1. Yes

2. No

EXPOSURE AND REACTION TO TV ADS

Now, we would like you to view a series of television advertisements that have been shown in the U.S. When you are ready, please click on the link below to view the first advertisement. There are a total of XX ads to view. After you view each ad, there will be a few questions that ask about your opinions of the ad.

[randomize order of ads]

[record order]

SHOW AD #1

F21. Were you able to view this video?

Rationale: exposure to ad. Source: FL Online Adult Longitudinal Media Survey.

1. Yes

2. No

[if F21=no, skip to f23]

F22. As you viewed this ad, how was it in terms of viewing and sound quality? In answering, think about such issues as whether the images were jerky or unclear or whether the sound was clear and smooth.

Rationale: clear exposure to ad. Source: NY Media Tracking Survey Online.

1. Not at all clear and smooth

2. Somewhat clear and smooth

3. Clear and smooth

4. Very clear and smooth

5. Extremely clear and smooth

F23. Now we would like to show you some screen shots from a television advertisement that has been shown in the U.S. Once you have viewed the images displayed below, please click on the forward arrow below to continue with the survey.

[display images for ad #1]

F24. Have you seen this ad on television in the past 3 months?

Rationale: exposure to ad.

1. Yes

2. No

[if f24=1, ask f24A]

F24A. In the past 3 months, how frequently have you seen this ad on television?

Rationale: exposure to ad.

1. Rarely

2. Sometimes

3. Often

4. Very Often

F25. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.

Rationale: resonance of ad. Source: FL Online Adult Longitudinal Media Survey.

1. Strongly Disagree

2. Disagree

3. Neither agree nor disagree

4. Agree

5. Strongly Agree

[RANDOMIZE ORDER]

F25_1. This ad is worth remembering.

F25_2. This ad grabbed my attention.

F25_3. This ad is powerful.

F25_4. This ad is informative.

F25_5. This ad is meaningful to me.

F25_6. This ad is convincing.

F25_7. This ad is ridiculous.

F25_8. This ad is terrible.

F25_9. This ad was difficult to watch.

F26. On scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel…

1 2 3 4 5

[RANDOMIZE ORDER] Not at all Very

F26_1. Sad

F26_2. Afraid

F26_3. Irritated

F26_4. Ashamed

F26_5. Discouraged

F26_6. Hopeful

F26_7. Motivated

F26_8. Understood

E26_9. Angry

F27. Would this ad make you want to encourage someone you care about to quit smoking? Rationale: ad impact. Source: CDC Health Message Testing System.

1. Yes

2. No

F28. Would this ad make you want to quit smoking?

Rationale: ad impact. Source: Adapted from the CDC Health Message Testing System.

1. Yes

2. No

[REPEAT ABOVE SEQUENCE OF QUESTIONS FOR EACH TV AD SHOWN]

For the next few questions, think about all of the advertisements you just viewed and recalled seeing in the past three months.

F29. Did seeing these ads on television make you want to encourage someone you care about to quit smoking?

Rationale: ad impact. Source: CDC Health Message Testing System.

F30. Did you talk to anyone about any of these ads?

Rationale: resonance of ad. Source: FL Online Adult Longitudinal Media Survey.

1. Yes

2. No

[IF F30=1, ASK F31]

F31. When you talked about the ads, did you talk about any of the following topics? Please select all that apply.

Rationale: ad impact. Source: FL Online Adult Longitudinal Media Survey.

1 2

Yes No

F31_1. These ads were effective

F31_2. These ads were NOT effective

F31_3. I should stop smoking

F31_4. The person I was talking to or someone else I know should stop smoking

F31_5. Other, specify________________________

EXPOSURE TO RADIO ADS

Now, we would like you to listen to a series of radio advertisements that have aired in the U.S. When you are ready, please click on the link below to listen to the first advertisement. There are a total of XX ads to listen to. After you listen to each ad, there will be a few questions that ask about your recent recall of the ad.

[randomize order of ads]

[record order]

PLAY RADIO AD #1

F32. Were you able to listen to this ad?

Rationale: exposure to ad. Source: FL Online Adult Longitudinal Media Survey.

1. Yes

2. No

[if F32=no, skip to f34]

F33. As you listened to this ad, how was it in terms of sound quality?

Rationale: clear exposure to ad. Source: NY Media Tracking Survey Online.

1. Not at all clear and smooth

2. Somewhat clear and smooth

3. Clear and smooth

4. Very clear and smooth

5. Extremely clear and smooth

F34. Now we would like to show you a script from a radio advertisement that has been shown in the U.S. Once you have read the script displayed below, please click on the forward arrow below to continue with the survey.

[display SCRIPT for ad #1]

F35. Have you heard this ad on the radio in the past 3 months?

Rationale: exposure to ad.

1. Yes

2. No

[if f35=1, ask f35a]

F35A. In the past 3 months, how frequently have you heard this ad on the radio?

Rationale: exposure to ad.

1. Rarely

2. Sometimes

3. Often

4. Very Often

Next, you will see some advertisements that have recently appeared in magazines, on websites, and on signs in areas such as bus shelters, bus interiors, and other public places. There are 3 sets of images to view, followed by a few questions about whether you have seen these ads before. When you are ready to view them, please click “Next.”

SHOW IMAGE #1

Please click “Next” to view the next set of images.

SHOW IMAGE #2

Please click “Next” to view the next set of images.

SHOW IMAGE #3

F36. In the past 3 months, have you seen any of these ads in magazines, on Websites, or in public places outside your home?

1. Yes

2. No

F37. Where did you see these advertisements?

1. Yes 2. No

F37_1. Magazines or print publications

F37_2. Websites online

F37_3. Public places such as bus shelters, bus interiors, outdoor bulletins, etc.

Thank you for completing today’s survey. Your input will greatly help researchers assess the impact of television ads about quitting smoking.

You will be awarded 15,000 KN points for completing the survey.