Smoker Follow-up Survey Wave 3 - Screenshots

SMOKER FOLLOW-UP SURVEY (WAVES 2-5) SCREENSHOTS
Form Approved
OMB No. 0920-0923
Exp. Date XX/XX/20XX
Evaluation of the National Tobacco Prevention and Control Public Education Campaign
Smoker Questionnaire
Public reporting burden of 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0923).

A5.

During the past 30 days, that is since November 17, 2013, on how many days did
you smoke cigarettes?
_________ Number of Days

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.
2.
3.
4.

Within 5 minutes
6-30 minutes
From more than 30 minutes to 1 hour
After more than 1 hour

1

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

C2.

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

C1.

During the past 12 months, that is, since March 17, 2013, 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

2

C1a.

During the past 4 months, on which days did you try to quit smoking? Using your
cursor, click on each day that you did not smoke cigarettes because you were
trying to quit smoking. Your best guess is fine.
Please click on each date you did not smoke due to quitting. If you did not try to
quit smoking on any day in the past four months, select the 'Did not' response
below.

3

C1b.

In the past 4 months, during any of the weeks listed below did you quit smoking
entirely for at least one day because you were trying to quit smoking?
Please click on each week that you did not smoke due to quitting for at least one
day. If you did not try to quit smoking for at least one day during the following
weeks in the past four months, select the 'Did not' response below.

4

C1c.

On which days did you try to quit smoking during these weeks over the past 4
months? Using your cursor, click on each day that you did not smoke cigarettes
because you were trying to quit smoking. Your best guess is fine.
If you did not try to quit smoking on any day during the following weeks in the
past four months, select the 'Did not' response below.

5

C1d_1.

Did you use electronic cigarettes/e-cigarettes on at least one day during any of the
following weeks in the past 4 months?
If you did not use e-cigarettes during any of the following weeks, select the 'Did
not' response below.

6

C1d_2.

Did you use any tobacco product other than cigarettes or electronic cigarettes/ecigarettes on at least one day during any of the following weeks in the past 4
months?
If you did not use any tobacco product other than cigarettes or electronic
cigarettes/e-cigarettes during any of the following weeks, select the 'Did not'
response below.

7

C1e.

For each week listed below, we have 3 questions:
1) did you quit smoking during the week for at least one day because you
were trying to quit smoking?
2) did you use an electronic cigarette/e-cigarette on at least one day during
the week?
3) did you use any tobacco product other than cigarettes or electronic
cigarettes/e-cigarettes (such as cigar, hookahs or smokeless tobacco
products) on at least one day during the week?
Select all weeks that apply within each column. If you did NOT do a particular
behavior for all the weeks, select the appropriate 'Did not' response at the
bottom.

8

C3.

How long has it been since you last smoked a cigarette?
_____________[ENTER NUMBER]
1.
2.
3.
4.

C4.

Hours (0 – 24)
Days (0 – 10)
Weeks (0 – 26)
Months (0 – 6)

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

No

C4_1.
C4_2.
C4_3.

Give up cigarettes all at once
Gradually cut back on cigarettes
Switch completely to electronic cigarettes or e-cigarettes
such as Blu or NJOY
C4_4.
Substitute some of your regular cigarettes with electronic
cigarettes or e-cigarettes
C4_5.
Switch to mild or some other brand of cigarettes
C4_6.
Use nicotine replacements like the nicotine patch or nicotine
gum
C4_7.
Use medications like Zyban or Chantix
C4_8.
Get help from a telephone quit line
C4_9.
Get help from a website such as Smokefree.gov
C4_10. Get help from a doctor or other health professional

C5.

When you last tried to quit smoking, did any of the following motivate you to try to
quit?
Yes
C5_1.
C5_2.

C5_3.
C5_4.
C5_5.

A family member or friend encouraged me to try to quit
Television commercials, radio ads, or other types of
advertisements that focus on the health consequences of
smoking
My doctor or other health professional advised me to quit
smoking
Workplace restrictions on smoking
Other, specify___________

9

No

C6.

Since November 17, 2013 between November 17 and December 17, did you see
or talk to any type of dental care provider (dentist, dental hygienist, orthodontist,
oral surgeon, any other dental specialist) for dental care or a dental check-up?
1. Yes
2. No

C6_1.

During the past 3 months, that is since December 17, 2013, have you talked with
your dental care provider (dentist, dental hygienist, orthodontist, oral surgeon, any
other dental specialist) about your smoking or about quitting smoking?
1. Yes
2. No

C7.

During the past 3 months, that is since December 17, 2013, has a dental care
provider (dentist, dental hygienist, orthodontist, oral surgeon, any other dental
specialist) advised you to quit smoking?
1. Yes
2. No

C6a.

Do you want to quit smoking cigarettes for good?
1. Yes
2. No

C7b.

How much do you want to quit smoking? Would you say you want to quit…
1.
2.
3.
4.

C9.

Not at all
A little
Somewhat
A lot

Do you plan to quit smoking for good….
1.
2.
3.
4.
5.
6.

In the next 7 days,
In the next 30 days,
In the next 6 months,
In the next 1 year, or
More than 1 year from now?
Not sure/Uncertain

10

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.
2.
3.
4.
5.

C11.

How much do you think your health would improve if you were to quit smoking?
1.
2.
3.
4.

C12.

Not at all worried
A little worried
Somewhat worried
Very worried

Among close friends, do
1.
2.
3.
4.

C15.

Not at all
A little
Somewhat
A lot

How worried are you that smoking will damage your health in the future?
1.
2.
3.
4.

C14.

Extremely likely
Very likely
Somewhat likely
Very unlikely
Extremely unlikely

All of them smoke?
Most of them smoke?
Most of them not smoke?
None of them smoke?

Among close relatives, do
1.
2.
3.
4.

All of them smoke?
Most of them smoke?
Most of them not smoke?
None of them smoke?

11

The next questions are about electronic cigarettes, often called e-cigarettes. An e-cigarette
looks like a regular cigarette, but it runs on a battery and produces vapor instead of smoke.
There are many types of e-cigarettes.

B8.

Have you ever used electronic cigarettes or e-cigarettes, such as Smoking
Everywhere, NJOY, Blu or Vapor King, even one time?
1. Yes
2. No

B9.

Do you now use electronic cigarettes or e-cigarettes…
1. Every day
2. Some days
3. Not at all

B9a.

Do you usually use disposable electronic cigarettes/e-cigarettes an electronic
cigarette/e-cigarette that uses cartridges, or an electronic cigarette/e-cigarette that
uses tanks?
Please indicate the type of e-cigarette that you use the most.
1. Disposable electronic cigarettes/e-cigarettes
2. Electronic cigarette/e-cigarette that uses cartridges
3. Electronic cigarette/e-cigarette that uses tanks

B9b.

On average, about how many disposable e-cigarettes/e-cigarette cartridges/ecigarette tanks do you now use each week?
________________ [ENTER NUMBER]

12

B10.

Are any of the following a reason why you first tried/currently us electronic
cigarettes/e-cigarettes?
Yes
B10_1. They cost less than other forms of tobacco.
B10_2. They can be used in places where smoking cigarettes isn’t
allowed.
B10_3. They might be less harmful to me than regular cigarettes.
B10_4. They might be less harmful to people around me than
regular cigarettes.
B10_5. Electronic cigarettes/e-cigarettes come in flavors I like.
B10_6. Electronic cigarettes/e-cigarettes can help me quit smoking
regular cigarettes.
B10_7. Electronic cigarettes/e-cigarettes can help me reduce the
number of regular cigarettes I smoke.
B10_8. Electronic cigarettes/e-cigarettes don’t smell.
B10_9. Using an electronic cigarette/e-cigarette feels like smoking a
regular cigarette.
B10_10. Electronic cigarettes/e-cigarettes don’t bother people who
don’t use tobacco.
B10_11. The advertising for electronic cigarettes/e-cigarettes appeals
to me.
B10_12. They help me deal with cravings to smoke.
B10_13. I have a friend or family member who suggested I use
electronic cigarettes/e-cigarettes as a way to quit smoking.
B10_14. I was curious about electronic cigarettes/e-cigarettes.
B10_15. Other, specify ________________________

B11.

B11a.

Which of those is the main reason you first tried/currently use electronic
cigarettes/e-cigarettes?

You indicated previously that you have tried electronic cigarettes/e-cigarettes
before but do not currently use them. Using the text box below, tell us in a few
words why you do not use electronic cigarettes/e-cigarettes now.
TEXT BOX

13

No

B11b.

You indicated previously that you currently smoke cigarettes and also currently
use electronic cigarettes/e-cigarettes. Using the text box below, tell us in a few
words why your reasons for not switching completely from regular cigarettes to
electronic cigarettes/e-cigarettes.
TEXT BOX

B12.

Do you use electronic cigarettes/e-cigarettes in places where smoking regular
cigarettes is not allowed?
1. Yes
2. No

B12a.

Do you use electronic/e-cigarettes in any of the following places?
1. Yes 2. No
B12a_1.
B12a_2.
B12a_3.
B12a_4.
B12a_5.
B12a_6.
B12a_7.

B13.

Restaurants or bars
Stores or shopping malls
Airplanes
Beaches, parks, or other outdoor places
In your car or other type of vehicle
In your home
Somewhere else, specify _______________

As far as you know or believe is the use of electronic cigarettes/e-cigarettes in
combination with regular cigarettes less harmful than smoking only regular
cigarettes, more harmful than smoking only regular cigarettes, or equally as
harmful as smoking only regular cigarettes?
Please indicate your answer on a scale of 1 to 5, where one is much less harmful,
3 is the same as regular cigarettes, and 5 is much more harmful.
1 (much less harmful than smoking only regular cigarettes)
2
3 (equally as harmful as smoking only regular cigarettes)
4
5 (much more harmful than smoking only regular cigarettes)

14

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

C20a.

Have you called 1-800-QUIT-NOW or any other telephone quit line in the past 3
months since December 17, 2013?
1. Yes
2. No

The next few questions will ask about your opinions related to smoking, tobacco use, and
cessation.
Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following
statements.
Strongly
disagree
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.

15

Disagree

Agree

Strongly
agree

Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following
statement.
Strongly
disagree

Disagree

Agree

Strongly
agree

D8. I am eager for a life without
smoking.
Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following
statement.
Strongly
disagree

Disagree

Agree

Strongly
agree

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.
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
2.
3.
4.
5. Highest

16

Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following
statement.
D18.

Smoking can cause immediate damage to your body.
1.
2.
3.
4.

D20.

How likely do you think you are to develop a smoking-related disease as a result
of smoking?
1.
2.
3.
4.
5.

D21.

Strongly Agree
Agree
Disagree
Strongly Disagree

Extremely Likely
Very Likely
Somewhat Likely
Very Unlikely
Extremely Unlikely

Do you believe cigarette smoking is related to
Yes
D21_1.
D21_2.
D21_3.
D21_4.
D21_5.
D21_6.
D21_7.
D21_8.
D21_9.
D21_10.
D21_11.
D21_12.
D21_13.
D21_14.
D21_15.

Lung Cancer
Cancer of the mouth or throat
Heart Disease
Diabetes
Emphysema
Stroke
Hole in throat (stoma or tracheotomy)
Buerger’s Disease
Amputations (removal of limbs)
Asthma
Gallstones
COPD or Chronic bronchitis
Periodontal or Gum Disease
Premature birth
Colorectal Cancer

17

No

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
worse?
1.
2.
3.
4.
5.

E1.

Extremely Likely
Very Likely
Somewhat Likely
Very Unlikely
Extremely Unlikely

Other than yourself, does anyone who lives in your home smoke cigarettes now?
1. Yes
2. No

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

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.
2.
3.
4.
5.

E8b.

Extremely Likely
Very Likely
Somewhat Likely
Very Unlikely
Extremely Unlikely

Not counting decks, porches, or garages, inside your home, is smoking…
1. Always allowed
2. Allowed only at some times or in some places
3. Never allowed

18

E9.

Are you seriously considering increasing restrictions on smoking in your
household?
1.
2.
3.
4.

F1.

On an average day, how much television do you watch?
1.
2.
3.
4.
5.
6.
7.

F2.

None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more

On an average day, how many hours do you listen to the radio?
1.
2.
3.
4.
5.
6.
7.

F3.

Definitely Yes
Probably Yes
Probably Not
Definitely Not

None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more

On an average day, how many hours do you use the Internet for personal
reasons?
1.
2.
3.
4.
5.
6.
7.

None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more

19

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

F13.

Have you heard of the Website www.cdc.gov/Tips?
1. Yes
2. No

F13a.

Have you visited www.cdc.gov/Tips in the past 3 months, since December 17,
2013?
1. Yes
2. No

F17.

In the past 3 months, that is since December 17, 2013, have you seen or heard of
any ads on television or radio with the following themes or slogans?
1. Yes 2. 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

F18.

Where have you seen or heard about the TIPS Campaign?
1. Yes 2. No
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

20

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 advertisements that have been shown on television
and online in the U.S. Please make sure your computer’s volume is set to an appropriate level.
You may be prompted by your computer to download a program enabling video playback. If the
videos do not work, you’ll still be able to see images and descriptions of the advertisements.
When you are ready, please click on the link below to view the first advertisement. There is a
total of 7 ads to view. After you view each ad, there will be a few questions that ask about your
opinions of the ad.

F21_x.

Were you able to view this video?
1. Yes
2. No

F23_x.

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.

F24_x.

Have you seen this ad on television or online in the past 3 months, since
December 17?
1. Yes
2. No

F24a_x_
TV.

In the past 3 months, how frequently have you seen this ad on television?
1.
2.
3.
4.
5.

Never
Rarely
Sometimes
Often
Very Often

21

F24a_x_
COMPUTER.

In the past 3 months, how frequently have you seen this ad on a laptop or
desktop computer?
1.
2.
3.
4.
5.

F24a_x_
MOBILE.

In the past 3 months, how frequently have you seen this ad on a tablet or
smartphone?
1.
2.
3.
4.
5.

F24d_x.

Never
Rarely
Sometimes
Often
Very Often

Never
Rarely
Sometimes
Often
Very Often

You previously indicated that you have seen this ad on either a laptop or
desktop computer. When you saw this ad on your computer, did you…
1. Yes 2. No
F24d_x_1. Notice the ad on a Website that you were
visiting?
F24d_x_2. Search for the ad on YouTube, Google, or other
Internet search engine?

22

F25_x.

Please tell us if you strongly agree, agree, neither agree nor disagree,
disagree, or strongly disagree with the following statements.
1.
2.
3.
4.
5.

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

F25a_x.
F25b_x.
F25c_x.
F25d_x.
F25e_x.
F25f_x.
F25g_x.
F25h_x.
F25i_x.

F26_x.

This ad is worth remembering.
This ad grabbed my attention.
This ad is powerful.
This ad is informative.
This ad is meaningful to me.
This ad is convincing.
This ad is ridiculous.
This ad is terrible.
This ad was difficult to watch.

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
Not at all
F26a_x.
F26b_x.
F26c_x.
F26d_x.
F26e_x.
F26f_x.
F26g_x.
F26h_x.
F26i_x.

F28_x.

Sad
Afraid
Irritated
Ashamed
Discouraged
Hopeful
Motivated
Understood
Angry

Would this ad make you want to quit smoking?
1. Yes
2. No

23

3

4

5
Very

For the next few questions, think about all of the advertisements you just viewed and recalled
seeing in the past 3 months.

F28a.

In the past 3 months, since December 17, 2013, have these ads stopped you
from having a cigarette when you were about to smoke one? Would you say…
1.
2.
3.
4.

F30.

Never
Once
A few times
Many times

Did you talk to anyone about any of these ads?
1. Yes
2. No

F31.

When you talked about the ads, did the person talking to you about the ads
encourage you to stop smoking?
1. Yes
2. No

EXPOSURE TO RADIO ADS
Now, we would like you to listen to a radio advertisement that has aired in the U.S. Please make
sure your computer’s volume is set to an appropriate level. You may be prompted by your
computer to download a program enabling audio playback. If you cannot hear the audio, you’ll
still be able to read a description of the advertisement. There is a total of 2 radio ads to listen to.
When you are ready, please click on the link below to listen to the ad. After you listen to the ad,
there will be a few questions that ask about your recent recall of the ad.

F32_x.

Were you able to listen to this ad?
1. Yes
2. No

F34_x.

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.

24

F35_x.

Have you heard this ad on the radio in the past 3 months, since December
17?
1. Yes
2. No

F35a_x.

In the past 3 months, how frequently have you heard this ad on the radio?
1.
2.
3.
4.

Rarely
Sometimes
Often
Very Often

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, billboards 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.”
Please click “Next” to view the next set of images.

F36.

In the past 3 months, since December 17, 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.
F37_2.
F37_3.

Magazines or print publications
Websites online
Public places such as bus shelters, bus interiors,
outdoor bulletins, etc.

25

AWARENESS OF E-CIGARETTE ADS
F38_x.

Now we would like to show you a series of screen shots from 2 television
advertisements that have 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.

F38_x.

Have you seen this ad on television or online in the past 3 months, since
December 17, 2013?
1. Yes
2. No

F38a_x_
TV.

In the past 3 months, how frequently have you seen this ad on television?
1.
2.
3.
4.
5.

F38a_x_
COMPUTER.

In the past 3 months, how frequently have you seen this ad on a laptop or
desktop computer?
1.
2.
3.
4.
5.

F38a_x_
MOBILE.

Never
Rarely
Sometimes
Often
Very Often

Never
Rarely
Sometimes
Often
Very Often

In the past 3 months, how frequently have you seen this ad on a tablet or
smartphone?
1.
2.
3.
4.
5.

Never
Rarely
Sometimes
Often
Very Often

26

F41_x.

Please tell us if you strongly agree, agree, neither agree nor disagree,
disagree, or strongly disagree with the following statements.
1.
2.
3.
4.
5.

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

F41a_x.
F41b_x.
F41c_x.
F41d_x.
F41e_x.
F41f_x.

F42_x.

This ad is worth remembering.
This ad grabbed my attention.
This ad is powerful.
This ad is informative.
This ad is meaningful to me.
This ad is convincing.

Please tell us if you strongly agree, agree, neither agree nor disagree,
disagree, or strongly disagree with the following statements.
1.
2.
3.
4.
5.

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

F42a_x. This ad makes me want to try an e-cigarette.
F42b_x. This ad makes me want to switch to e-cigarettes
completely and quit smoking regular cigarettes.
F42c_x. This ad makes me want to use e-cigarettes as a way to
cut back on smoking regular cigarettes.
F42d_x. This ad makes me want to use e-cigarettes in places
where you normally cannot smoke regular cigarettes.

27

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

G5.

What is the highest level of school you have completed?
1. No formal education
2. 1st, 2nd, 3rd, or 4th grade
3. 5th or 6th grade
4. 7th grade or 8th 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

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G6a.

We would like to get a better estimate of your total HOUSEHOLD income in the
past 12 months before taxes. Was it…
1.
2.
3.
4.
5.
6.
7.
8.
9.

G6b.

Less than $5,000
$5,000 to $7,499
$7,500 to $9,999
$10,000 to $12,499
$12,500 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999

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 $74,999
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.
2.
3.
4.
5.
6.

Married
Widowed
Divorced
Separated
Never married
Living with a partner

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G8.

Which statement best describes your current employment status?
1.
2.
3.
4.
5.
6.
7.

G9.

Working – as a paid employee
Working – self-employed
Not working – on temporary layoff from a job
Not working – looking for work
Not working – retired
Not working – disabled
Not working – other

How many smoking or tobacco related web surveys like this have you completed
during the past year?
1.
2.
3.
4.
5.
6.

None
1 survey
2 surveys
3 surveys
4 surveys
5 or more surveys

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G15.

Have you been diagnosed by a physician or other qualified medical professional
with any of the following medical conditions?
1. Yes 2. No
G15_1.
G15_2.
G15_3.
G15_4.
G15_5.
G15_6.
G15_7.
G15_8.
G15_9.
G15_10.
G15_11.
G15_12.
G15_13.
G15_14.
G15_15.
G15_16.
G15_17.
G15_18.
G15_19.
G15_20.
G15_21.
G15_22.
G15_23.
G15_24.

G20.

Acid reflux disease
ADHD or ADD
Anxiety disorder
Asthma, chronic bronchitis, or COPD
Cancer (any type except skin cancer)
Chronic pain (such as low back pain, neck pain, or
Fibromyalgia)
Depression
Diabetes
Heart attack
Heart disease
High blood pressure
High cholesterol
HIV/AIDS
Kidney disease
Mental health condition
Multiple sclerosis
Osteoarthritis, joint pain or inflammation
Osteoporosis or osteopenia
Rheumatoid arthritis
Seasonal allergies
Skin cancer
Sleep disorders such as sleep apnea or insomnia
Stroke
Something else

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

31

G22.

Using the scale below, please tell us how much you agree or disagree with the
following statements.
1.
2.
3.
4.
5.
G22a.
G22b.
G22c.
G22d.
G22e.

Strongly agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Strongly disagree
I usually try new products before other people do.
I often try new brands because I like variety and get
bored with the same old thing.
When I shop I look for what is new.
I like to be the first among my friends and family to try
something new.
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 [AMOUNT] bonus points credited to your KnowledgePanel account for
completing the survey. A follow-up survey will be sent to you in about 3 months and you will be
awarded [AMOUNT] bonus points for completing that survey.
ADD1.

Those are all of our questions. Thanks so much for your participation in our
survey. As a token of our appreciation, we would like to send you [AMOUNT].
Would you please provide your name and mailing address so that we can put
the check in the mail. This information will not be connected with your survey
responses in any way.
After you have entered your information, please make sure to click “Next”.

Name (First/Last): ______________
Street Address (If applicable, include unit number): ____________
City: ________________
State: ________________
Zip Code : ______________

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