CDC National Media Campaign--Revised Smoker Questionnair

D R A F T

Form Approved

OMB No. 0920-0923

Exp. Date 04/30/2014

CDC National Media Campaign

- Revised Smoker 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).

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

A5. During the past 30 days, that is, since [DATE FILL], on how many days did you smoke cigarettes?

__________Number of Days

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?

__________number of cigarettes

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

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

The next few questions ask about your attempts to quit smoking at different times over the past year. In answering, please think specifically about the timeframe for each question.

C1. During the past 12 months, that is, since [DATE FILL], how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?

_____ Number of times

[IF C1 > 0, ASK C1a]

C1a. During the past [FILL MONTHS SINCE MARCH 4, 2013] months, that is since March 4, 2013, have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?

1. Yes

2. No

[IF C1a=1, ASK C2]

C2. Thinking about your more recent past, during the past 3 months, how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?

_____ Number of times

C3. How long has it been since you last smoked a cigarette?

B3a. _____________[ENTER NUMBER]

B3b. [DROP BOX FOR UNITS]

1. Hours (0 – 24)

2. Days (0 – 10)

3. Weeks (0 – 26)

4. Months (0 – 6)

[IF C1a > 0 ASK C4]

C4a. When you last tried to quit smoking, did you do any of the following?

[PRESENT IN RANDOM ORDER] Yes No

[ANSWER ALL]

C4a_1. Give up cigarettes all at once

C4a_2. Gradually cut back on cigarettes

C4a_3. Switch completely to electronic cigarettes or e-cigarettes such as Blu or

NJOY

C4a_4. Substituted some of your regular cigarettes with e-cigarettes

C4a_5. Switch to mild or some other brand of cigarettes

C4a_6. Use nicotine replacements like the nicotine patch or nicotine gum

C4a_7. Use medications like Zyban or Chantix

C4a_8. Get help from a telephone quit line

C4a_9. Get help from a website such as Smokefree.gov

C4a_10. Get help from a doctor or other health professional

[IF C1a > 0 ASK C4b]

C4b. When you last tried to quit smoking, did any of the following motivate you to try to quit?

[PRESENT AS GRID IN RANDOM ORDER] Yes No

[ANSWER ALL]

C4b_1. A family member or friend encouraged me to try to quit

C4b_2. Television commercials, radio ads, or other types of advertisements that

Focus on the health consequences of smoking

C4b_3. My doctor or other health professional advised me to quit smoking

C4b_4. Workplace restrictions on smoking

C4b_4. Other, specify_________________

[ASK C4c & C4d OF ALL SMOKERS]

C4c. During the past [FILL MONTHS SINCE MARCH 4, 2013] months, that is since March 4, 2013, did any doctor, nurse or health professional ask if you smoke?

1. Yes

2. No

C4c1. During the past [FILL MONTHS SINCE MARCH 4, 2013] months, that is since March 4, 2013, have you talked with your doctor or health care professional about quitting smoking?

1. Yes

2. No

C4d. During the past [FILL MONTHS SINCE MARCH 4, 2013] months, that is since March 4, 2013, has a doctor, nurse or health professional advised you to quit smoking?

1. Yes

2. No

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

1. Yes

2. No

[ASK C7 if C6=1]

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

1. Not at all

2. A little

3. Somewhat

4. A lot

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

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?

6. Not sure/Uncertain

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…

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?

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?

1. Not at all worried

2. A little worried

3. Somewhat worried

4. Very worried

C14. Among close friends, do

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

1. All of them smoke?

2. Most of them smoke?

3. Most of them not smoke?

4. None of them smoke?

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?

1. Yes

2. No

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

1. Yes

2. No

[IF C20=1, ASK C20a]

C20a. Have you called 1-800-QUIT-NOW or any other telephone quit line in the past [FILL MONTHS SINCE MARCH 4, 2013] months, since March 4, 2013?

1. Yes

2. No

[IF C20a DATE FILL = “3 MONTHS” AND C20a=1, FILL C22=1 AND GO TO D1]

[ELSE, IF C20a=1, ASK C22]

C22. Thinking about your more recent past, have you called 1-800 QUIT-NOW or any other telephone quit line 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

D21_12. COPD or Chronic bronchitis

E8b. How likely do you think it is that smoking by diabetics will make their medical complications from diabetes such as blindness, renal failure, or amputations from diabetes worse?

1. Extremely Likely

2. Very Likely

3. Somewhat Likely

4. Very Unlikely

5. Extremely Unlikely

SECTION E: SECONDHAND SMOKE

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

1. Yes

2. No

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

1. Always

2. Sometimes

3. Rarely

4. Never

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

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?

1. Extremely Likely

2. Very Likely

3. Somewhat Likely

4. Very Unlikely

5. Extremely Unlikely

E8a. How likely do you think it is that regularly breathing secondhand smoke from cigarettes would cause non-smokers to have asthma, infections, or lung damage?

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

F1. On an average day, how much television do you watch?

1. None

2. Less than one hour

3. About 1 hour

4. About 2 hours

5. About 3 hours

6. About 4 hours

7. 5 hours or more

F2. On an average day, how many hours do you listen to the radio?

1. None

2. Less than one hour

3. About 1 hour

4. About 2 hours

5. About 3 hours

6. About 4 hours

7. 5 hours or more

F3. On an average day, how many hours do you use the Internet for personal reasons?

1. None

2. Less than one hour

3. About 1 hour

4. About 2 hours

5. About 3 hours

6. About 4 hours

7. 5 hours or more

F4. What type of Internet connection do you have for your home computer or other primary computer?

1. Cable/DSL/Broadband/High-Speed

2. Dial-Up

3. Not sure

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

1. Yes

2. No

[IF F9 = 1, ASK F10A]

F10. Have you visited any quit smoking websites online in the past [FILL MONTHS SINCE MARCH 4, 2013] months, since March 4, 2013?

1. Yes

2. No

[IF F10 DATE FILL = “3 MONTHS, FILL F10a=1 AND GO TO F13a]

[ELSE, IF F10=1, ASK F10a]

F10a. Thinking about your more recent past, have you visited any quit smoking websites online in the past 3 months?

[IF F10 DATE FILL = “3 MONTHS” AND F10a=1, FILL F10a=1 AND GO TO F13a]

1. Yes

2. No

F13a. Have you heard of the Website www.cdc.gov/Tips?

1. Yes

2. No

[IF F13a=1 ASK F13b]

F13b. Have you visited www.cdc.gov/Tips in the past [FILL MONTHS SINCE MARCH 4, 2013] months, since March 4, 2013?

1. Yes

2. No

[IF F13b DATE FILL = “3 MONTHS” AND F13b=1, FILL F13c=1 AND GO TO F14a]

[IF F13b=1, ASK F13c]

F13c. Thinking about your more recent past, have you visited www.cdc.gov/Tips in the past 3 months?

1. Yes

2. No

F17. In the past [FILL MONTHS SINCE MARCH 4, 2013], that is since March 4, 2013, have you seen or heard of any ads on television or radio with the following themes or slogans?

[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?

1 2

Yes No

[RANDOMIZE]

F18_1. On TV

F18_2. On the radio

F18_3. In newspapers or magazines

F18_4. On the Internet

F18_5. Billboards or other outdoor ads

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

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 [FILL MONTHS], since March 4, 2013?

Rationale: exposure to ad.

1. Yes

2. No

[if f24=1, ask f24A]

F24A. In the past [FILL MONTHS SINCE March 4, 2013], how frequently have you seen this ad on television?

Rationale: exposure to ad.

1. Rarely

2. Sometimes

3. Often

4. Very Often

F24b. Have you seen this ad online in the past [FILL MONTHS], since March 4, 2013?

1. Yes

2. No

F24c. In the past [FILL MONTHS SINCE March 4, 2013], how frequently have you seen this ad online?

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.

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?

1. Yes

2. No

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

1. Yes

2. No

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

To view the next ad, please click the “Next” arrow below.

For the next few questions, think about all of the advertisements you just viewed and recalled seeing in the past [FILL MONTHS SINCE MARCH 4, 2013].

[ASK F28c IF ANY F24=1]

F28c. In the past [FILL MONTHS] months, since March 4, 2013, have these ads stopped you from having a cigarette when you were about to smoke one? Would you say….

1. Never

2. Once

3. A few times

4. Many times

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

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

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.

1 2

Yes No

[RANDOMIZE]

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?

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?

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 [FILL MONTHS], since March 4, 2013?

1. Yes

2. No

[if f35=1, ask f35a]

F35A. In the past [FILL MONTHS SINCE March 4, 2013] months, how frequently have you heard this ad on the radio?

1. Rarely

2. Sometimes

3. Often

4. Very Often

To hear the next radio ad, please click the “Next” arrow to the right.

[REPEAT ABOVE SEQUENCE OF QUESTIONS FOR EACH RADIO AD]

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 [FILL MONTHS], since March 4, 2013, 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.

SECTION G: CLOSING QUESTIONS

G1. How many children aged 17 or younger live in your household 6 months or more of the year?

__ Number of Children

[ASK G2 – G11 OF ALL RESPONDENTS]

G2. What is your gender?

1. Male

2. Female

G3. This question is about Hispanic ethnicity. Are you of Spanish, Hispanic, or Latino descent?

1. No, I am not.

2. Yes, Mexican American, Chicano/a

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, Central American

6. Yes, South American

7. Yes, Caribbean

8. Yes, Other Spanish/Hispanic/Latino

G4. Please indicate what you consider your racial background to be. We greatly appreciate your effort to describe your background using the standard categories provided. These race categories may not fully describe you, but they do match those used by the Census Bureau. It helps us compare our survey respondents to the U.S. population.

Please check one or more categories below that indicate what race(s) you consider yourself to be.

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian/Pacific Islander

G5. What is the highest level of school you have completed?

1. No formal education

2. 1^st, 2^nd, 3^rd, or 4^th grade

3. 5^th or 6th grade

4. 7th grade or 8^th grade

5. 9th grade

6. 10th grade

7. 11th grade

8. 12th grade, no diploma

9. High school graduate – high school Diploma or the equivalent (GED)

10. Some college, no degree

11. Associate degree

12. Bachelor’s degree

13. Master’s degree

14. Professional or Doctorate degree

The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS. Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).

G6. Was your total HOUSEHOLD income in the past 12 months…

1. Below $35,000

2. $35,000 or more

3. Don’t Know

[IF G6=1, ASK G6a]

G6a. We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

1. $5,000 to $7,499

2. $7,500 to $9,999

3. $10,000 to $12,499

4. $12,500 to $14,999

5. $15,000 to $19,999

6. $20,000 to $24,999

7. $25,000 to $29,999

8. $30,000 to $34,999

[IF G6=2, ASK G6b]

G6b. We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

1. $35,000 to $39,999

2. $40,000 to $49,999

3. $50,000 to $59,999

4. $60,000 to $75,999

5. $75,000 to $84,999

6. $85,000 to $99,999

7. $100,000 to $124,999

8. $125,000 to $149,999

9. $150,000 to $174,999

10. $175,000 or more

G7. Are you now married, widowed, divorced, separated, never married, or living with a partner?

1. Married

2. Widowed

3. Divorced

4. Separated

5. Never married

6. Living with a partner

G8. Which statement best describes your current employment status?

1. Working as a paid employee

2. Working, self-employed

3. Not working, on temporary layoff from a job

4. Not working, looking for work

5. Not working, retired

6. Not working, disabled

7. Not working, other

G9. How many smoking or tobacco related web surveys like this have you completed during the past year?

1. None

2. 1 survey

3. 2 surveys

4. 3 surveys

5. 4 surveys

6. 5 or more surveys

[IF G9 > 1, ASK G10]

G10. Did you view or listen to any videos or other advertisements about quitting smoking in any of these surveys?

1. Yes

2. No

[ASK G11 OF ALL RESPONDENTS]

G11. Do you currently participate in any other online web panels besides Knowledge Networks?

1. Yes

2. No

[ASK G15 OF ALL RESPONDENTS]

G15. Have you been diagnosed by a physician or other qualified medical professional with any of the following medical conditions?

1 2

Yes No

[RANDOMIZE]

G15_1. Acid reflux disease

G15_2. ADHD or ADD

G15_3. Anxiety disorder

G15_4. Asthma, chronic bronchitis, or COPD

G15_5. Cancer (any type except skin cancer)

G15_6. Chronic pain (such as low back pain, neck pain, or Fibromyalgia)

G15_7. Depression

G15_8. Diabetes

G15_9. Heart attack

G15_10. Heart disease

G15_11. High blood pressure

G15_12. High cholesterol

G15_13. HIV/AIDS

G15_14. Kidney disease

G15_15. Mental health condition

G15_16. Multiple sclerosis

G15_17. Osteoarthritis, joint pain or inflammation

G15_18. Osteoporosis or osteopenia

G15_19. Rheumatoid arthritis

G15_20. Seasonal allergies

G15_21. Skin cancer

G15_22. Sleep disorders such as sleep apnea or insomnia

G15_23. Stroke

G15_24. Something else

[ASK G16-G22 IF SSI OR NEW ABS]

G16. Would you say you can carry on a conversation in Spanish, both understanding and speaking – very well, pretty well, just a little, or not at all?

1. Very well

2. Pretty well

3. Just a little

4. Not at all

G17. Would you say you can read a newspaper or book in Spanish – very well, pretty well, just a little, or not at all?

1. Very well

2. Pretty well

3. Just a little

4. Not at all

G18. Would you say you can carry on a conversation in English, both understanding and speaking – very well, pretty well, just a little, or not at all?

1. Very well

2. Pretty well

3. Just a little

4. Not at all

G19. Would you say you can read a newspaper or book in English – very well, pretty well, just a little, or not at all?

1. Very well

2. Pretty well

3. Just a little

4. Not at all

G20. Do you or anyone in this household connect to the Internet from home?

1. Yes

2. No

G21. Do you live in a metro or non-metro area?

1. Non-Metro (Rural)

2. Suburban

3. Urban

G22. Using the scale below, please tell us how much you agree or disagree with the following statements.

1 2 3 4 5

Strongly Somewhat Neither Somewhat Strongly

Agree Agree Agree nor Disagree Disagree

Disagree

G20A. I usually try new products before other people do.

G20B. I often try new brands because I like variety and get bored with the same

old thing.

G20C. When I shop I look for what is new.

G20D. I like to be the first among my friends and family to try something new.

G20E. I like to tell others about new brands or technology.

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.

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