Form 2 Baseline

SSA SFTXT– Attachment 10: Baseline Questionnaire & Screenshots

Word Questions Pages 2 to 14

Screenshots Pages 15 to 69

INTRODUCTION:

OMB No.: 0925-XXXX

Expiration Date:  xx/xx/20xx

Collection of this information is authorized by The Public Health Service Act, Section 410 (285) and Section 412 (285a-1). 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 to the extent provided by law.  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.  In order to provide feedback on its tobacco cessation services, the National Cancer Institute has asked you to complete this voluntary survey.

Public reporting burden for this collection of information is estimated to average 30 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-XXXX). Do not return the completed form to this address.

[on next webpage]

Thank you for taking time from your busy schedule to take part in this research. Your answers will be kept private to the extent provided by law – that is, your personal responses will not be traced to your name.

Make sure you are comfortable and can read the screen from where you sit.

The survey will take about 30 minutes to complete. We ask you to complete the survey in one sitting (without taking any breaks) in order to avoid distractions.

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1. How old were you when you smoked a whole cigarette for the first time? If you’re not sure, give your best guess.

1. I have never smoked a whole cigarette

2. ____ years old

If respondent says “have never smoked a whole cigarette,” POINT OUT INCONSISTENCY WITH SCREENER & ASK RESPONDENT AGAIN. IF RESPONSE IS REPEATED, TERMINATE.

2. Have you smoked at least 100 cigarettes in your life?

1. Yes

2. No

3. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?

1. Yes

2. No

4. During the past 30 days, on how many days did you smoke cigarettes? =If you’re not sure, give your best guess.

Type in total number of days:

If respondent says “0,” POINT OUT INCONSISTENCY WITH SCREENER & ASK RESPONDENT AGAIN. IF RESPONSE IS REPEATED, TERMINATE.

5. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day? If you’re not sure, give your best guess.

Type in number of cigarettes per day:

6. What is the total number of years you have smoked? Do not include any time you stopped smoking for at least 6 months or longer. If you’re not sure, give your best guess.

a. < 1 year

b. 1-2 years

c. 3-4 years

d. 5 or more years

7. How many times during the past 12 months have you stopped smoking for one day or longer because you were trying to quit smoking?

1. I have not smoked in the past 12 months

2. I have not tried to quit

3. 1 time

4. 2 times

5. 3 to 5 times

6. 6 to 9 times

7. 10 or more times

If respondent says “have not smoked in past 12 months,” POINT OUT INCONSISTENCY WITH SCREENER & ASK RESPONDENT AGAIN. IF RESPONSE IS REPEATED, TERMINATE.

8. When you last tried to quit, how long did you stay off cigarettes?

1. I have never tried to quit [SKIP NEXT ITEM]

2. Less than a day

3. 1-2 days

4. 3- 7 days

5. More than 7 days but less than 30 days

6. 30 days or more but less than 6 months

7. 6 months or more but less than a year

8. 1 year or more

9. During the past 30 days, have you: (SELECT ALL THAT APPLY)

1. Used dissolvable smokeless tobacco, e.g., sticks, strips, or orbs?

2. Smoked bidis, kreteks, or tobacco in a pipe?

3. Smoked flavored cigarettes?

4. Smoked menthol cigarettes?

5. Smoked flavored cigars?

6. Smoked tobacco out of a water pipe - (also called a "hookah")?

7. Used snus?

8. Used an electronic cigarette?

9. None of the above

10. Are the cigarettes you usually smoke menthol cigarettes?

1. Yes

2. No

3. I don’t have a usual type

11. In the past 12 months, did you do any of the following to help you stop smoking? (SELECT ALL YOU HAVE TRIED)

1. I did not try to quit in the past 12 months

2. Attended a program (i.e., in my community or school)

3. Called a help line or quit line

4. Used nicotine gum

5. Used nicotine patch

6. Used some other medicine to help quit

7. Visited an internet quit site

8. Used a text message service

9. Downloaded a Smartphone application focused on helping people quit smoking

10. Got help from family or friends

11. I tried to quit but did not do any of these things

12. How soon after you wake up do you smoke your first cigarette?

1. Within 5 minutes

2. 6-30 minutes

3. 31-60 minutes

4. After 60 minutes

13. Do you find it difficult to refrain from smoking in places where it is forbidden (e.g. in church, at the library, cinema, etc.)? (Check one)

a. Yes

b. No

14. Which cigarette would you hate most to give up? (check one)

a. The first one in the morning

b. All others

15. Do you smoke more frequently during the first hours after waking than during the rest of the day?

a. Yes

b. No

16. Do you smoke if you are so ill you are in the bed most of the day?

a. Yes

b. No

17. Do you think it is safe to smoke for only a year or two, as long as you quit after that?

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

18. Do you think people can get addicted to smoking just like they can get addicted to cocaine or heroin?

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

19. Do you think smoking is harmful to you, even if you don’t smoke every day?

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

20. Does anyone who lives with you now smoke cigarettes (do not count yourself)?

1. Yes

2. No

21. Which statement best describes the rules about smoking inside your home?

1. No one is allowed to smoke anywhere inside my home

2. Smoking is allowed in some places or at some times inside my home

3. Smoking is allowed anywhere in my home

22. Does everyone you live with approve of your smoking?

1. Yes

2. No

23. On a scale from 1 to 10 with 10 being extremely motivated and 1 being not at all motivated, how motivated are you to continue working on quitting smoking right now? (check one)

1	2	3	4	5	6	7	8	9	10
Not at all motivated									Extremely motivated

24. Please choose the statement that best describes your level of motivation:

1. I don't want to stop smoking

2. I think I should stop smoking but don't really want to

3. I want to stop smoking but haven't thought about when

4. I really want to stop smoking but I don’t know when I will

5. I want to stop smoking and hope to soon

6. I really want to stop smoking and intend to in the next 3 months

7. I really want to stop smoking and intend to in the next month

25. Do you think that you will be smoking cigarettes one year from now?

a. Definitely yes

b. Probably yes

c. Probably not

d. Definitely not

26. If you try to quit smoking within the next 30 days, how hard will it be to stay smoke-free? (check one)

1	2	3	4	5	6	7
Not hard at all						Extremely hard

27. How long would you be willing to put up with strong urges to smoke and really bad moods in order to stay smoke-free? (check one)

a. Less than 1 day

b. 1 day

c. 2 – 3 days

d. 4 – 7 days

e. 1 – 2 weeks

f. 2 – 4 weeks

g. More than a month

If you were to try to quit smoking, how confident are you that will be able to stay off cigarettes for good?

0 Not at all confident

1

2

3

4 Extremely confident

In spite of good intentions, some people who try to quit may not succeed at first. Imagine that after you quit smoking, you have started up again. How confident are you that you could quit again…
Even if I slip up and smoke one or more cigarettes, I am confident that I can quit again.	0 Not at all confident	1	2	3	4 Extremely confident

The next set of questions asks for your opinions about smoking.

	1 Strongly Disagree	2	3 Neither disagree nor agree	4	5 Strongly Agree
Smoking cigarettes helps people relieve stress	1	2	3	4	5
Cigarettes are good for dealing with boredom	1	2	3	4	5
Smoking picks a person up if they are feeling down	1	2	3	4	5
When a person is angry, cigarettes can help them calm down	1	2	3	4	5

If you are trying or have tried to quit smoking, to what extent do you agree/disagree with the following 8 statements for you?

	Strongly Disagree	Disagree	Neither disagree nor agree	Agree	Strongly Agree
There are people or resources I can count on for emotional support.	1	2	3	4	5
I am pretty much on my own.	1	2	3	4	5
There are people or resources who can help me find out the answers to my questions.	1	2	3	4	5
I have been overwhelmed by the amount of information on quitting smoking.	1	2	3	4	5
The information I get on quitting smoking is easy to understand.	1	2	3	4	5
I have found it easy to get the information on quitting smoking that I need.	1	2	3	4	5
I have the skills and knowledge needed to quit smoking successfully.	1	2	3	4	5
The resources (things I can read, people I can talk with) that I have had for quitting smoking have been helpful to me.	1	2	3	4	5

42. What is your sex?

1. Male

2. Female

43. Are you:

1. Hispanic or Latino

2. Not Hispanic or Latino

44. What is your race? One or more categories may be selected

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or other Pacific Islander

45. What is your current employment status? (Fill in all that apply)

1. Employed part time

2. Employed full time

3. Not currently employed

46. What is your total annual household income before taxes?

1. Less than $35,000

2. Between $35,000 and $70,000

3. Over $70,000

4. Prefer not to answer

47. When you estimated household income for the previous question, did you consider your parents’ or guardians’ income or only that of you and any significant other person living with you?

1. I included my parents’ income.

2. I included only my own or my own and that of a significant other.

48. What is the highest level of education your father has completed?

1. Less than High School

2. High School/GED

3. Some College

4. 2-Year College Degree (Associates)

5. 4-Year College Degree (BA, BS)

6. Master’s Degree

7. Doctoral Degree

8. Professional Degree (MD, JD)

49. What is the highest level of education your mother has completed?

1. Less than High School

2. High School/GED

3. Some College

4. 2-Year College Degree (Associates)

5. 4-Year College Degree (BA, BS)

6. Master’s Degree

7. Doctoral Degree

8. Professional Degree (MD, JD)

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

1. Less than High School

2. High School/GED

3. Some College

4. 2-Year College Degree (Associates)

5. 4-Year College Degree (BA, BS)

6. Master’s Degree

7. Doctoral Degree

8. Professional Degree (MD, JD)

51. Have you ever been diagnosed with or treated for any of the following by a medical or psychological professional? (Check all that apply)

a. Depression

b. Bipolar Disorder

c. Schizophrenia

d. Anxiety Disorder

e. Panic Disorder

f. Post-traumatic Stress Disorder

g. Attention Deficit Disorder

h. Alcohol abuse

i. Drug abuse

j. None

52. About how tall are you without shoes? ___ Feet ___ Inches

53. About how much do you weigh without shoes? ___ pounds

54. How would you describe your weight over the past month?

I have been losing weight

I have been gaining weight

I have stayed the same

55. Right now do you feel you are…

Overweight

Slightly overweight

Underweight

Slightly underweight

Just about the right weight for you

56. During the past 30 days, how many days did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor? (Input number 0-30)

______days

57. During the past 30 days, on how many days did you use any kind of illegal drugs or take prescription drugs for non-medical reasons? (input number 0-30)

_____days

58. During the past 12 months did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some of your usual activities?

1. Yes

2. No

	Strongly Disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
When I am upset, I believe that...
I can usually find a way to cheer myself up	1	2	3	4	5
Telling myself “it will pass” will calm me down	1	2	3	4	5
I can forget about what’s upsetting me pretty easily	1	2	3	4	5

In the last 30 days, how often have you felt	Never	Almost Never	Sometimes	Fairly Often	Very Often
….that you were unable to control the important things in your life?	0	1	2	3	4
…confident in your ability to handle your personal problems?	0	1	2	3	4
…that things were going your way?	0	1	2	3	4
…that difficulties were piling up so high that you could not overcome them?	0	1	2	3	4

66. Overall, how often do you go online?

1. Several times a day

2. About once a day

3. 3-5 times a week

4. 1-2 days a week

5. Every few weeks

6. Less often

67. Do you, personally, have any of the following? (check all that apply)

1. A Blackberry, iPhone or other device that is also a cell phone

2. A desktop or laptop computer

3. An iPod or other MP3 player

4. A tablet like an iPad

68. On an average day, would you say you send or receive …

1. No text messages on your cell phone

2. 1 to 10 text messages

3. 11 to 20

4. 21 to 50

5. 51 to 100

6. 101 to 200

7. More than 200 text messages a day

8. Don’t know

69. Who pays for your phone service?

1. I pay for my own phone service.

2. My parent or parents pay for my phone service.

3. Someone else pays for my phone service.

70. Finally, we would like you to select a quit date that is between [insert date two weeks from today] and [insert date that is 3 weeks from today].In order for you to be eligible to participate in this study and receive an incentive, you must select a quit date.

On this day, you will make a strong personal commitment to quit smoking.

[Note to programmer: Display as calendar and gray out dates that cannot be selected. If this cannot be done, show them a calendar and bold dates they can select in text above.]

Which date would you like to choose as your quit date? ___________________

(click on the calendar above to select the date)

IF RESPONDENT DOES NOT SELECT A QUIT DATE, DISPLAY THIS TEXT:

In order for you to be eligible to participate in this study and receive an incentive, you must select a quit date. Please select a quit date that is between [insert date two weeks from today] and [insert date that is 3 weeks from today].

It seems you have skipped the following questions:

DISPLAY SKIPPED QUESTIONS HERE. INCLUDE “SKIP” AS A RESPONSE OPTION

If you skipped these questions by mistake, please click on the question to complete it now.

If you meant to skip the question, please select “I prefer not to answer” next to the question.

Thank you!

This is the end of the survey. To retrieve your gift card for this survey click here [insert link to claim gift card]. We also will send you an email that will contain the link to the gift card if you would like to claim it at a later time. We will send you an email 7 days after your quit date asking you to complete a very short survey about the program.

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