Point-of-Sale Creative Concept Testing – Focus Groups with Current Adult Smokers

OMB# 0910-0796

Exp. 6/30/2018

Point-of-Sale Creative Concept Testing – Focus Groups with Current Adult Smokers

Quit Journey Worksheet

^Group

^{Participant ID}

^Group

^{Participant ID}

_{In your whole life, how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes?}

^{(YOUR BEST GUESS IS FINE)}

^{_______ Number of Times}

• None

• Prefer Not to Answer

_{In your whole life, how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes?}

^{(YOUR BEST GUESS IS FINE)}

^{_______ Number of Times}

• None

• Prefer Not to Answer

_{When was the last time you tried to quit smoking cigarettes for one day or longer?}

^{(CHECK ONLY ONE RESPONSE)}

• I am currently in a quit attempt

• Within the last 30 days

• Within the last 6 months

• Within the last year

• Longer than a year ago

• I have never tried to quit smoking

_{When was the last time you tried to quit smoking cigarettes for one day or longer?}

^{(CHECK ONLY ONE RESPONSE)}

• I am currently in a quit attempt

• Within the last 30 days

• Within the last 6 months

• Within the last year

• Longer than a year ago

• I have never tried to quit smoking

_{When do you plan to make your next attempt to quit smoking?}

^{(CHECK ONLY ONE RESPONSE)}

• Within the next 30 days

• Within the next 6 months

• Within the next year

• Longer than a year from now

• I have no plans at this time

_{When do you plan to make your next attempt to quit smoking?}

^{(CHECK ONLY ONE RESPONSE)}

• Within the next 30 days

• Within the next 6 months

• Within the next year

• Longer than a year from now

• I have no plans at this time

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 1 minute per response to complete the Quit Journey Worksheet (the time estimated to read, review, and complete). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to [email protected].