Att C-2b. Smoker Survey_Screenshots Rev Dec28 v2

Form
Form Approved
Approved
OMB
OMB No.
No. 0920-0923
0920-0923
Exp.
Exp. Date:
Date: 2/28/2013
2/28/2013
Evaluation of the National Tobacco Prevention and Control
Public Education Campaign
Smoker Phase 2 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 (0920-0923).

A3.
Do you now smoke every day, some days, or not at all?
1.
2.
3.

I smoke every day
I smoke on some days
I do not smoke at all

B1.

B2.

1

B3.
Within the past 30 days, what is the main color of the cigarettes that you have smoked,
not including the filter?
Rationale: Identify cigar smokers who mistakenly self-identify as cigarettes smokers.
Source: Developed from consultation with subject matter experts.
1.
2.
3.
4.

White Cigarettes (show picture with arrow to the body of the cigarette)
Brown Cigarettes (show picture with arrow to body of brown little cigar)
Both White Cigarettes and Brown Cigarettes
Other specify

B4.
Within the last 30 days, have you smoked a cigarette with the following flavors (select
all that apply)
Rationale: Flavored tobacco products appeal to youth and young adults.
Source: Adapted from New York Tobacco Survey (added menthol).
1.
2.
3.
4.
5.
6.
7.

B5.

Original, plain, OR regular
Menthol
Fruit (such as grape, strawberry, peach, apple)
Alcohol (such as wine, cognac, rum, Irish cream)
Candy (such as chocolate, vanilla)
Mint, other than menthol (such as wintergreen, frost, spearmint, peppermint)
Other specify

Since (FILL DATE OF CAMPAIGN LAUNCH), on how many days did you smoke
cigars, cigarillos or very small cigars that look like cigarettes?
Rationale: Provides an indicator of cigar use.
Source: National Adult Tobacco Survey
______Number of days (0 – 30)
(If B5>0, Ask B6)

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