Screener

Form Approved

OMB No. 0920-0910

Exp. Date 01/31/2015

National Tobacco Prevention and Control Public Education Campaign:

Rough Cut Testing of Television, Print/Digital Print and Radio Ads

Screener for Smokers (18-54 years old),

Female smokers between the ages of 18-44,
and Non-Smokers (ages 18-54 years old),
Smokers with HIV, or

Smokers who are Lesbian, Gay, Bi-Sexual, or Transgender (LGBT)

Public reporting burden of this collection of information is estimated to average 3 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

On behalf of the Centers for Disease Control and Prevention (CDC), we're conducting a study about different health and smoking-specific advertising that you see in the media. Your opinions are very important to us! Please be assured that the purpose of this survey is to gather feedback regarding specific health-related advertising. We do not plan to report your answers individually. We plan to report results from this survey for the group as a whole. Thank you for taking the time to help us!

Your participation in this survey is voluntary.

Section: Screening Items

Demographic Information

DAGE1: What is your current age?

1. Under 18 years of age {TERMINATE}

2. 18-24 years of age

3. 25-34 years of age

4. 35-44 years of age

5. 45-54 years of age

6. 55-64 years of age {TERMINATE}

7. 65-74 years of age {TERMINATE}

8. 75 years of age or older {TERMINATE}

9. Refuse to answer {TERMINATE}

DEMO5: What state do you live in?

1. Alabama

2. Alaska

3. Arizona

4. Arkansas

5. California

6. Colorado

7. Connecticut

8. Delaware

9. Florida

10. Georgia

11. Hawaii

12. Idaho

13. Illinois

14. Indiana

15. Iowa

16. Kansas

17. Kentucky

18. Louisiana

19. Maine

20. Maryland

21. Massachusetts

22. Michigan

23. Minnesota

24. Mississippi

25. Missouri

26. Montana

27. Nebraska

28. Nevada

29. New Hampshire

30. New Jersey

31. New Mexico

32. New York

33. North Carolina

34. North Dakota

35. Ohio

36. Oklahoma

37. Oregon

38. Pennsylvania

39. Rhode Island

40. South Carolina

41. South Dakota

42. Tennessee

43. Texas

44. Utah

45. Vermont

46. Virginia

47. Washington

48. West Virginia

49. Wisconsin

50. Wyoming

51. District of Columbia

52. Other please specify

{Base = if DAGE1 = 02 & (AL (DEMO5.01) or NE (DEMO5.27))}

DAGE2. What is the year of your birth?

{Open-end, Mask for YYYY}

{Terminate respondent if respondent is from AL (DEMO5.01) or NE (DEMO5.27) & is 18 or 19 years old}

Gender1. What is your gender?

1. Male

2. Female

DEMO8. Do you consider yourself to be (Select all that apply):

01 Heterosexual / Straight

02 Lesbian

03 Gay (male)

04 Bisexual

05 Transgender

06 Something else – please specify ______________

07 Prefer not to answer

Health1. Have you been diagnosed with HIV or AIDs by a physician or other qualified medical professional?

1. Yes

2. No

3. Don’t know/not sure

4. Refused
   
   

Smoking Behavior – Core

{Base = All respondents}

TS1. Have you smoked at least 100 cigarettes in your entire life?

5. Yes

6. No

7. Don’t know/not sure

8. Refused
   
   

{Base = All respondents}

TS2. Do you now smoke cigarettes 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

{Base = All respondents}

TS3: On how many of the past 30 days did you smoke cigarettes?

Enter number: _______

Programmer Instructions:

Segments	Definition	Criteria
Smokers	Smokers	Answers TS1_1 to TS1 AND (TS2_1 or TS2_2 to TS2) AND Answers TS3 > 0
Non-Smokers	Non-Smokers	Answers TS1_2 to TS1 AND (TS2_3 to TS2) AND Answers TS3 = 0
Non-Smokers	Former Smokers	Answers TS1_1 to TS1 AND (TS2_3 to TS2) AND Answers TS3 = 0
HIVSmokers	Smokers who have HIV	Health1 = 1 & Answers TS1_1 to TS1 AND (TS2_1 or TS2_2 to TS2) AND Answers TS3 > 0
LGBTSmokers	Smokers who are Lesbian, Gay, Bi-Sexual, or Transgender (LGBT)	DEMO8 = 2, 3, 4, 5 & Answers TS1_1 to TS1 AND (TS2_1 or TS2_2 to TS2) AND Answers TS3 > 0
TargetFemaleSmokers	Smokers who are female and between the ages of 18-44	Answers 02, 03, 04 to DAGE1 and 02 to GENDER1 and Answers TS1_1 to TS1 AND (TS2_1 or TS2_2 to TS2) AND Answers TS3 > 0

{GENERAL SCREEN OUT MESSAGE}

Thank you for your participation in this study. Unfortunately, your responses indicate that you do not fit the specific criteria needed for this particular study, or that we have already reached our required quota of responses from participants similar to you. We appreciate your enthusiasm for our study and hope you will join us on future surveys!

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