Non-Smoker Follow-up Survey (Waves 2-4) Screenshots

NONSMOKER FOLLOW-UP SURVEY (WAVES 2-4) SCREENSHOTS
Form Approved
OMB No. 0920-0923
Exp. Date 03/31/2017
Evaluation of the National Tobacco Prevention and Control Public Education Campaign
Nonsmoker 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).

[ASK NA4_x IF RESPONDENT HAS SMOKED 100 OR MORE CIGARETTES LIFETIME
(ALL_4C = “Yes”) BUT CURRENTLY DOES NOT SMOKE AT ALL (ALL_S5 = “not at all”)]
NA4_x.

Was the last time you smoked a cigarette, even one or two puffs…?
1. Within the past 24 hours
2. Within the past 7 days
3. Within the past 30 days
4. Within the past 3 months
5. Within the past 6 months
6. Within the past 1 year
7. Within the past 5 years
8. Within the past 10 years
9. Within the past 15 years
10. More than 15 years ago

NA4.

Have you smoked cigarettes at all, even one puff, in the past 12 months?
1. Yes
2. No

NA5.

Have you quit smoking cigarettes completely in the past 6 months?
1. Yes
2. No

1

NB2.

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

NB1.

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

NC1a.

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

NC1b.

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

NC1c.

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

NC1d_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

NC1d_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

NC1e.

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

NB3.

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

NB4.

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?
1. Yes 2. No
NB4_1. Give up cigarettes all at once
NB4_2. Gradually cut back on cigarettes
NB4_3. Switch completely to electronic cigarettes or e-cigarettes
such as Blu or NJOY
NB4_4. Substitute some of your regular cigarettes with electronic
cigarettes or e-cigarettes
NB4_5. Switch to mild or some other brand of cigarettes
NB4_6. Use nicotine replacements like the nicotine patch or nicotine
gum
NB4_7. Use medications like Zyban or Chantix
NB4_8. Get help from a telephone quit line
NB4_9. Get help from a website such as Smokefree.gov
NB4_10. Get help from a doctor or other health professional

NB5.

When you last tried to quit smoking, did any of the following motivate you to try to
quit?
1. Yes 2. No
NB5_1. A family member or friend encouraged me to try to quit
NB5_2. Television commercials, radio ads, or other types of
advertisements that focus on the health consequences of
smoking
NB5_3. My doctor or other health professional advised me to quit
smoking
NB5_4. Workplace restrictions on smoking
NB5_5. Other, specify___________

9

NB6.

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

NB6_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

NB7.

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

The next questions are about electronic vapor products. These are devices that usually contain
a nicotine-based liquid that is vaporized and inhaled. You may also know them as e-cigarettes,
vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars),
electronic pipes (e-pipes), or e-vaporizers. Some brand examples are Blu, NJOY, Vuse,
MarkTen, and Starbuzz.

NB8.

Have you ever used electronic vapor products, even one time?
1. Yes
2. No

NB9.

Do you now use electronic vapor products…
1. Every day
2. Some days
3. Not at all

10

NB9_date. How long ago did you first try an electronic vapor product?
1.
2.
3.
4.
5.
6.

NB9a.

1 to 2 weeks ago
2 to 4 weeks ago
1 to 3 months ago
3 to 6 months ago
6 to 12 months ago
More than 1 year ago

Do you usually use disposable electronic vapor products, an electronic vapor
product that uses cartridges, or an electronic vapor product that uses tanks?
Please indicate the type of electronic vapor product that you use the most.
1. Disposable electronic vapor product
2. Electronic vapor product that uses cartridges
3. Electronic vapor product that uses tanks

NB9b.

On average, about how many disposable electronic vapor products, electronic
vapor cartridges, or electronic vapor tanks do you now use each week?
________________ [ENTER NUMBER]

11

NB10.

Are any of the following a reason why you first tried/currently us electronic vapor
products?
Yes

No

NB10_1. They cost less than other forms of tobacco.
NB10_2. They can be used in places where smoking cigarettes isn’t
allowed.
NB10_3. They might be less harmful to me than regular cigarettes.
NB10_4. They might be less harmful to people around me than
regular cigarettes.
NB10_5. Electronic vapor products come in flavors I like.
NB10_6. Electronic vapor products can help me quit smoking regular
cigarettes.
NB10_7. Electronic vapor products can help me reduce the number
of regular cigarettes I smoke.
NB10_8. Electronic vapor products don’t smell.
NB10_9. Using an electronic cigarette/e-cigarette feels like smoking
a regular cigarette.
NB10_10. Electronic vapor products don’t bother people who don’t
use tobacco.
NB10_11. The advertising for electronic vapor products appeals to
me.
NB10_12. They help me deal with cravings to smoke.
NB10_13. I have a friend or family member who suggested I use
electronic vapor products as a way to quit smoking.
NB10_14. I was curious about electronic vapor products.
NB10_15. Other, specify ________________________

NB11.

NB11a.

Which of those is the main reason you first tried/currently use electronic vapor
products?

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

12

NB12.

Do you use electronic vapor products in places where smoking regular cigarettes
is not allowed?
1. Yes
2. No

NB12a.

Do you use electronic vapor products in any of the following places?
1. Yes 2. No
NB12a_1.
NB12a_2.
NB12a_3.
NB12a_4.
NB12a_5.
NB12a_6.
NB12a_7.

NB13.

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 are electronic vapor products less harmful than
regular cigarettes, more harmful than regular cigarettes, or are they equally
harmful to health?
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 regular cigarettes)
2
3 (the same as regular cigarettes)
4
5 (much more harmful than regular cigarettes)

NE9.

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 smokers?
1. Yes
2. No

13

NE9a.

In the past 3 months, that is since December 17, 2013, have you recommended
any family members or friends that smoke to call a telephone quitline?
1. Yes
2. No

NE10.

Have you heard of 1-800-QUIT-NOW?
1. Yes
2. No

NE10a.

In the past 3 months, that is since December 17, 2013, have you recommended
any family members or friends that smoke to call 1-800-QUIT-NOW?
1. Yes
2. No

14

The next few questions will ask about your opinions related to smoking and tobacco use.

NC1.

Do you believe cigarette smoking is related to
Yes
NC1_1. Lung cancer
NC1_2. Cancer of the mouth or throat
NC1_3. Heart disease
NC1_4. Diabetes
NC1_5. Emphysema
NC1_6. Stroke
NC1_7. Hole in throat (stoma or tracheotomy)
NC1_8. Buerger’s disease
NC1_9. Amputations (removal of limbs)
NC1_10. Asthma
NC1_11. Gallstones
NC1_12. COPD or chronic bronchitis
NC1_13. Periodontal or gum disease
NC1_14. Premature birth
NC1_15. Colorectal cancer

NC2.

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

NC4b.

Extremely Likely
Very Likely
Somewhat Likely
Very Unlikely
Extremely Unlikely

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.

Extremely Likely
Very Likely
Somewhat Likely
Very Unlikely
Extremely Unlikely

15

No

The next few questions ask your opinion about smoke from other people’s cigarettes.

NC3.

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

NC4.

How likely do you think it is that regularly breathing secondhand smoke from
cigarettes would cause children to have asthma or breathing problems?
1.
2.
3.
4.
5.

NC4a.

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.

ND1.

Extremely Likely
Very Likely
Somewhat Likely
Very Unlikely
Extremely Unlikely

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

ND1a.

During the past 7 days, that is, since February 28, 2013, on how many days did
you breathe vapor from someone else was using an electronic cigarette/ecigarette in an indoor or outdoor place?
_______________ [# OF DAYS]

ND4.

During the past 3 months, that is since December 17, 2013 have you talked to any
family members or friends about the dangers of smoking?
1. Yes
2. No

16

ND5a.

During the past 3 months, that is since December 17, 2013, did you encourage a
friend or family member to quit smoking?
1. Yes
2. No

ND6.

Among close friends, do…
1.
2.
3.
4.

ND7.

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

NE1.

All of them smoke?
Most of them smoke?
Most of them NOT smoke?
None of them smoke?

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

NE2.

All of them smoke?
Most of them smoke?
Most of them NOT smoke?
None of them smoke?

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 listen to the radio?
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

17

NE3.

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

NE4.

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

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

NE14.

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

NE14a.

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

NE14c.

In the past 3 months, that is since December 17, 2013, have you recommended
any family members or friends that smoke to visit www.cdc.gov/Tips?
1. Yes
2. No

18

NE14d.

In the past 3 months, that is since [FILL DATE], have you seen or heard
advertisements for medications or products to help people quit smoking such as
Chantix, nicotine patches, or nicotine gums?
1.
2.
3.
4.
5.

NE18.

Never
Rarely
Sometimes
Often
Always

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
NE18_1. TIPS FROM A FORMER SMOKER
NE18_2. TRUTH
NE18_3. BECOME AN EX
NE18_4. EVERY CIGARETTE IS DOING YOU DAMAGE
NE18_5. TOBACCO FREE LIVING

NE19.

Where have you seen or heard about the TIPS Campaign?
1. Yes 2. No
NE19_1. On TV
NE19_2. On the radio
NE19_3. In newspapers or magazines
NE19_4. On the Internet
NE19_5. Billboards or other outdoor ads

NE20.

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

19

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.

NF21_x.

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

NF23_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.

NF24_x.

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

NF24a_x_
TV.

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

NF24a_x_
COMPUTER.

Never
Rarely
Sometimes
Often
Very Often

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

Never
Rarely
Sometimes
Often
Very Often

20

NF24a_x_
MOBILE.

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

NF24d_x.

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
NF24d_x_1. Notice the ad on a Website that you were
visiting?
NF24d_x_2. Search for the ad on YouTube, Google, or
other Internet search engine?

NF25_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

NF25a_x.
NF25b_x.
NF25c_x.
NF25d_x.
NF25e_x.
NF25f_x.
NF25g_x.
NF25h_x.
NF25i_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.

21

NF26_x.

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
Not at all
NF26a_x.
NF26b_x.
NF26c_x.
NF26d_x.
NF26e_x.
NF26f_x.
NF26g_x.
NF26h_x.
NE26i_x.

F27_x.

2

3

4

5
Very

Sad
Afraid
Irritated
Ashamed
Discouraged
Hopeful
Motivated
Understood
Angry

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

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

NF29.

Did seeing these ads on television make you want to encourage someone you
care about to quit smoking?
1. Yes
2. No

NF30.

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

22

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 [FILL # TOTAL
RADIO ADS] 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.
[PLAY RADIO AD CHOSEN]
F32_x.

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

[IF F32_x=2, GO TO F34]
[ASK F34_x IF F32_x=2]
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.

[DISPLAY SCRIPT FOR RADIO AD]
F35_x.

Have you heard this ad on the radio in the past [FILL # MONTHS SINCE
CAMPAIGN LAUNCH] months, since [CAMPAIGN LAUNCH DATE]?
1. Yes
2. No

[IF F35_x=1, ASK F35a_x]
F35a_x.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how
frequently have you heard this ad on the radio?
1.
2.
3.
4.

Rarely
Sometimes
Often
Very Often

23

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.

NE36.

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

NE37.

Where did you see these advertisements?
1. Yes 2. No
NE37_1. Magazines or print publications
NE37_2. Websites online
NE37_3. Public places such as bus shelters, bus interiors,
outdoor bulletins, etc.

NF38_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.

NF38_x.

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

NF38a_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

24

NF38a_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.

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

NF41_x.

Never
Rarely
Sometimes
Often
Very Often

Never
Rarely
Sometimes
Often
Very Often

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

NF41a_x.
NF41b_x.
NF41c_x.
NF41d_x.
NF41e_x.
NF41f_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.

25

NF42_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

NF42a_x. This ad makes me want to try an electronic vapor
product.
[ASK N42b_x IF FORMER SMOKER]
N42b_x.

I want a cigarette right now.

SECTION G: CLOSING QUESTIONS
NG1.

How many children aged 17 or younger live in your household 6 months or more
of the year?
_________ Number of Children

NG5.

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

26

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).

NG6.

Was your total HOUSEHOLD income in the past 12 months…
1. Below $35,000
2. $35,000 or more
3. Don’t know

NG6a.

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.

NG6b.

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

27

NG7.

Are you now married, widowed, divorced, separated, never married, or living with a
partner?
1.
2.
3.
4.
5.
6.

NG8.

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

NG9.

Married
Widowed
Divorced
Separated
Never married
Living with a partner

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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NG15.

Have you been diagnosed by a physician or other qualified medical professional
with any of the following medical conditions?
1. Yes 2. No
NG15_1.
NG15_2.
NG15_3.
NG15_4.
NG15_5.
NG15_6.
NG15_7.
NG15_8.
NG15_9.
NG15_10.
NG15_11.
NG15_12.
NG15_13.
NG15_14.
NG15_15.
NG15_16.
NG15_17.
NG15_18.
NG15_19.
NG15_20.
NG15_21.
NG15_22.
NG15_23.
NG15_24.

NG20.

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

NG21.

Do you live in a metro or non-metro area?
1. Non-metro (rural)
2. Suburban
3. Urban

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NG22.

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

Strongly agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Strongly disagree

NG22a. I usually try new products before other people do.
NG22b. I often try new brands because I like variety and get
bored with the same old thing.
NG22c. When I shop I look for what is new.
NG22d. I like to be the first among my friends and family to try
something new.
NG22e. 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 : ______________

30