Form 3 1 Week Post Quit Date Questionnaire

SFTXT – Attachment 14: 1 Week Post Quit Date Survey & Screenshots

Word Questions Pages 2 to 7

Screenshots Pages 8 to 26

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 15 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.

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INTRODUCTION:

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 15 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. Have you smoked cigarettes at all, even a puff, in the last 7 days?

a. Yes [Ask 2 & 3, then skip to #6]

b. No [SKIP TO Q4]

2. On how many days of the past 7 days did you smoke cigarettes, even a puff? If you’re not sure, give your best guess.

Type in number of days:

3. In the past 7 days, about how many cigarettes did you smoke on the days you smoked? If you’re not sure, give your best guess.

Type in number of cigarettes:

4. Since your quit date of ____, 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

5. Have you ever texted back the message “STOP” to stop the QuitTXT program?

a. Yes

b. No

c. Not sure

If respondent says yes to opting out (above), go to next two questions. If respondent says no or not sure, skip next two question. UPDATE THESE INSTRUCTIONS FOR EACH FOLLOW UP SURVEY USING QUESTION NUMBERS AND VARIABLE LABELS.

6. In your own words, please explain why you decided to stop the program.

[verbatim text, allow 100 characters]

7. On average, about how many text messages would you say you received from QuitTXT in the past 3 weeks?

1. 0-4

2. 5-9

3. 10-14

4. 15-20

5. 20 or more

8. Of those text messages you received, about how many did you read each week?

1. All

2. Most

3. Some

4. A few

5. None

9. How do you feel about the number of texts you received so far? Was it (choose one):

1. Too many

2. Too few

3. Just right

	Not at all	A little bit	Some	A good deal	A lot
So far, how much did QuitTXT messages help you:
stay smokefree	0	1	2	3	4
overcome my cravings	0	1	2	3	4
manage my moods	0	1	2	3	4
feel supported in my quit attempt	0	1	2	3	4
feel confident about my quit attempt	0	1	2	3	4
stay motivated to quit	0	1	2	3	4

16. Can you recall a specific message that you received from the program? Yes/No

17. If yes, what was it? Please type the message you recall below.

	Yes	No
Have you received any of the following types of messages?
18a. Quit date reminders (e.g. 1 week until quit day!)
19a. Mood assessments (e.g. How are you feeling today?)
20a. Craving assessments (e.g. Any cravings today?)
21a. Smokefree status (e.g. Are you still quit?)
22a. Motivational messaging (e.g. Keep on keeping on. Don’t look back now.)
23a. Smokefree Tips (e.g. Try grapes, carrots, or gum if you need something in your mouth.)
24a. Smokefree Facts (e.g. Quitting smoking improves your night vision.)
25a. Keywords (e.g. Crave, Mood, Slip)

For the next set of questions, ask only if respondent says YES to the corresponding questions 18a-25a. If #18a=No, skip #18; #19a=No, skip #19; #20a=No, skip #20; #21a=No, skip #21; #22a=No, skip #22; #23a=No, skip #23; #24a=No, skip #24; #25a=No, skip #25

	Not at all useful				Extremely useful
How useful were the following types of messages in helping you stay smokefree? 0 (Not at all useful) – 4 (extremely useful)
Quit date reminders (e.g. 1 week until quit day!)	0	1	2	3	4
Mood assessments (e.g. How are you feeling today?)	0	1	2	3	4
Craving assessments (e.g. Any cravings today?)	0	1	2	3	4
Smokefree status (e.g. Are you still quit?)	0	1	2	3	4
Motivational messaging (e.g. Keep on keeping on. Don’t look back now.)	0	1	2	3	4
Smokefree Tips (e.g. Try grapes, carrots, or gum if you need something in your mouth.)	0	1	2	3	4
Smokefree Facts (e.g. Quitting smoking improves your night vision.)	0	1	2	3	4
Keywords (e.g. Crave, Mood, Slip)	0	1	2	3	4

	0 Not at all useful	1	2	3	4 Extremely useful
Overall, how useful did you find the QuitTXT program as a quit smoking aid so far?	0	1	2	3	4

	Not at all likely				Extremely likely
Based on your experience with QuitTxt so far, how likely would you be to recommend the QuitTXT program to a friend or family member?	0	1	2	3	4

Please answer the following questions based on how you have felt or what you have noticed over the PAST 24 HOURS. Answer based on how you have felt in general during this time.	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
I have felt impatient.	1	2	3	4	5
I have been bothered by negative moods such as anger, frustration and irritability.
I have been bothered by a desire to smoke
I have been irritable, and easily angered
It has been difficult to think clearly
I have felt hungry.
I have had urges to smoke

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.

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

[approximate # of weeks until End of Tx] weeks later asking you to complete another survey about your experiences with cessation and the QuitTXT program. Thank you!

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