Adult smokers ages 25 to 54; Wave 1 Questionnaire

Evaluation of the Food and Drug Administration’s Point-of-Sale Campaign

Attachment_02a_POSITEv_Wave_1_questionnaire Clean

Adult smokers ages 25 to 54; Wave 1 Questionnaire

OMB: 0910-0851

Document [docx]
Download: docx | pdf


August 2017




Point of Sale Intervention for Tobacco Evaluation (POSITEv)




Wave 1 Questionnaire















Prepared for

Food and Drug Administration

Janine Delahanty, PhD

Health Scientist

Health Communication and Education

U.S. Food and Drug Administration

[email protected]



Prepared by

RTI International

3040 E. Cornwallis Road

Research Triangle Park, NC 27709

RTI Project Number 0213772.003.001.005

_________________________________

RTI International is a registered trademark and a trade name of Research Triangle Institute


TABLE OF CONTENTS

Section AA: Programming Notes and Instructions

Section A: Informed Consent

Section B: Demographics

Section C: Tobacco Use Behavior

Section D: Tobacco Use Intentions and Self-Efficacy

Section E: Cessation (Intention, Behavior, Motivation)

Section F: Attitudes, Beliefs, Risk Perceptions and Social Norms

Section G: Media Use and Awareness

Section H: Environment

Section AL: Locator Module

Section J: App-based portion of study


SECTION AA: PROGRAMMING NOTES



PROGRAMMING NOTES

  • All questions should appear on separate pages.

  • Participants may refuse to answer any question by clicking “next”. When participants refuse to answer a question, show “Prefer not to answer” as an additional response option and provide a prompt to check that option if they want to skip the question. “Prefer not to answer” will not be displayed unless a question is left unanswered.

  • If response boxes are used, such as in Hatteras, use radio buttons for questions where only one answer is allowed.

  • If response boxes are used, use check boxes for questions where more than one answer is allowed.

  • Prefer Not To Answer/Don’t Know/Refused/None of these are not allowed in combination with other responses.

  • If the questionnaire interface includes a banner across the top of the page, such as in Hatteras, include the variable name on the banner. In Hatteras, the banner also displays the name of the study, the progress bar, a Help button, and a Log out button. If not, do not include the variable name on the screen.

  • Except where noted, response options should not be labeled with numbers.

  • Do not display section headings.

  • Do not display question headings, or headings for question series.

  • Abbreviations used include ‘R’ for ‘respondent’ and ‘PNTA’ for ‘prefer not to answer’

  • A back button will not be offered to respondents.

  • Images displayed should be of equal size to one another.

  • Timestamp Specs

  • Overall time for respondents – NAVIGATION INSTRUCTIONS through EXIT1 OR EXIT3

  • Overall time by section

  • SECTION A – INFORMED CONSENT

  • SECTION B – B1 through B5

  • SECTION C - C1 through C18

  • SECTION D – D1 through D4

  • SECTION E – E1 through E20_

  • SECTION F – F1 through F6

  • SECTION G – G1 through G12

  • SECTION H – H1 through ENDCASI2

  • SECTION AL - AL_INT1 through AL_A2PEM

  • SECTION J - APP_CONSENT through EXIT1 OR EXIT3


All telephone numbers should only accept exactly 10 digits – all numbers and a mask should appear for formatting: XXX-YYY-ZZZZ. Area codes and prefixes should not begin with 0 or 1. The mask will allow the entry of 0 or 1 and the rest of the digits up to 10. Then when Next is pressed, the check happens and a message says that the number is invalid due to the leading 0 or 1, prefix 0 or 1 or less than 10 digits.


  • Consent

  • AL_INT2 (R willing to provide contact info?)

  • AL_INT3 (R willing to provide a contact?)

  • AL_INT4 (R willing to provide a second contact?)

  • Start recording APP_CONSENT

      • APP_INSTRUCTIONS1

      • APP_INSTRUCTIONS2

      • Stop recording at EXIT 3


NAVIGATION INSTRUCTIONS


INTERVIEWER, READ: Now I’d like you to read the questions and enter your answers into the laptop yourself. This will allow you to answer the questions in complete privacy. I will not be able to see the answers you type into the computer. You can also skip any question you don’t want to answer by clicking the next button. Let me explain how to use the laptop.


Move laptop so respondent can see the screen and point out the following:


Point to the mouse and say: Please use the mouse to select your answers to the questions.


Point out number keys and say: Please use these keys for questions that ask you to enter a specific number.


Point to “Next” button and say: When you are ready to move to the next question or page, click here. This button will store your answers. Once you have entered your responses and clicked this button, you will not be able to go back and change your answers.


Point to the “Log Out” button and say: The Log Out button will take you out of the survey. Please do not click on it unless you need to stop the survey. This button will save your answers so that you can pick up where you left off when you go back to the survey.


Say: If you have any questions or trouble with the laptop, please ask. If not, click here to begin.”


Point to “Next” button and say “Please answer all of the questions to the best of your abilities.


PROGRAMMER: PROGRAM A NEXT BUTTON AT THE END OF THIS SCREEN


PROGRAMMER: START CASI


SECTION A: INFORMED CONSENT



[INSERT INFORMED CONSENT HERE]

SECTION B: DEMOGRAPHICS



B1 INTRO: Please answer the following general questions about you and your background.


B1. Are you Hispanic, Latino/a, or of Spanish origin?

  1. Yes

  2. No

999 Prefer not to answer


ASK: All respondents



B2. What race or races do you consider yourself to be? Select all that apply.

  1. American Indian or Alaska Native

  2. Asian

  3. Black or African American

  4. Native Hawaiian or Pacific Islander

  5. White

  6. Other

999 Prefer not to answer


ASK: All respondents



B3. What is the highest level of school you have completed?

  1. 8th grade or less

  2. 9th to 12th grade but no diploma

  3. Regular high school diploma

  4. GED or alternative credential

  5. Some college (no degree)

  6. Associate’s Degree (for example: AA, AS)

  7. Bachelor’s degree (for example: BA, BS)

  8. Master’s degree (for example: MA, MS, MEng, Med, MSW, MBA)

  9. Professional degree or doctoral degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD, PhD, EdD)

999 Prefer not to answer


ASK: All respondents




B4. Are you currently…? Please select the option that best describes you.

  1. Employed for wages

  2. Self-employed

  3. Out of work for 1 year or more

  4. Out of work for less than 1 year

  5. A homemaker

  6. A student

  7. Retired

  8. Unable to work

999 Prefer not to answer


ASK: All respondents



B5 INTRO: 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, Social Security, public assistance, pensions, or retirement benefits).


B5. Was your total household income in the past 12 months.

  1. Below $35,000

  2. $35,000 or more

  3. Don’t Know

999 Prefer not to answer


ASK: All respondents




SECTION C: TOBACCO USE



INTRODUCTION: The next set of questions are about tobacco products and how often you use them.


C1. Do you consider yourself a smoker?

  1. Yes

  2. No

999 Prefer not to answer


ASK: All respondents



C2. About how long has it been since you last smoked cigarettes? If you smoked a cigarette today please enter 0 days. Please enter days or weeks.


_____ Number of days (Range: 0–7)

_____ Number of weeks (Range: 0–4)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 7 FOR DAYS. ALLOW A MINIMUM OF 0 AND A MAXIMUM OF 4 FOR WEEKS.


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN [0 AND 7/ 0 AND 4].” IN LOWERCASE LETTERS


ALLOW R TO ENTER DAYS OR WEEKS. IF DAYS AND WEEKS ARE ENTERED ERROR MESSAGE SHOULD SAY, “PLEASE ENTER A NUMBER OF DAYS OR A NUMBER OF WEEKS, BUT NOT BOTH. IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NUMBER OF DAYS OR A NUMBER OF WEEKS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: All respondents



C3. Not including today, how many cigarettes did you smoke on the most recent day you smoked? A pack usually has 20 cigarettes in it.


_____ Number of cigarettes (Range: 1–99)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99. PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX.


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN [0 AND 99.” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NUMBER OF DAYS OR A NUMBER OF WEEKS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: All respondents



C4. On the days that you smoke, how soon after you wake up do you typically smoke your first cigarette of the day? Please enter the number of minutes or hours.


_____ Minutes after waking (Range: 0–60)

_____ Hours after waking (Range: 0–24)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 60 FOR MINUTES. ALLOW A MINIMUM OF 0 AND A MAXIMUM OF 24 FOR HOURS.


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN [0 AND 60/ 0 AND 24].” IN LOWERCASE LETTERS


ALLOW R TO ENTER MINUTES OR HOURS. IF MINUTES AND HOURS ARE ENTERED ERROR MESSAGE SHOULD SAY, “PLEASE ENTER A NUMBER OF MINUTES OR A NUMBER OF HOURS, BUT NOT BOTH. IN LOWERCASE LETTERS


ASK: All respondents



TOBACCO PURCHASING BEHAVIOR


C5. Do you usually buy your own cigarettes?

  1. Yes

  2. No –> GO TO C15

999 Prefer not to answer


ASK: All respondents



C6. [IF C5=1 OR C5=999]


Do you usually buy your cigarettes by the carton, pack, or single cigarettes, or do you roll your own?

  1. Carton

  2. Pack

  3. Single cigarettes

  4. Roll your own

999 Prefer not to answer


ASK: Respondents who usually buy their own cigarettes or did not indicate whether they usually buy their own cigarettes



C7. [IF C5=1 OR C5=999]


Now think about cigarettes you purchased for your own personal use in the past 7 days. How many of the past 7 days did you purchase cigarettes?


_____ Number of days (Range: 0–7)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 7


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 7” IN LOWERCASE LETTERS


ASK: Respondents who usually buy their own cigarettes or did not indicate whether they usually buy their own cigarettes



C8. [IF C7 NE 0 OR C6=4]


In the past 7 days, how many cartons, packs, single cigarettes, and pouches of roll-your-own tobacco did you buy for your own personal use?


C8_1. _____ Cartons (Range: 0–99)

C8_2. _____ Packs (Range: 0–99)

C8_3. _____ Single cigarettes (Range: 0–99)

C8_4. _____ Pouches of roll your own tobacco (Range: 0–99)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99 FOR C8_1, C8_2, C8_3, C8_4


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 99.” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS NOT CAPTURED FOR EACH ITEM, ERROR MESSAGE SHOULD SAY “PLEASE ENTER NUMBERS FOR ALL TOBACCO PRODUCTS”. IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PRICE WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents who purchased cigarettes for their own personal use in the past 7 days



C9. [IF C8_1 > 0]


When you last got a carton of cigarettes for your own personal use, what price did you pay?


$_ _ _._ _ per carton (Range: 0–150.00)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 150.00

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 150.00.” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PRICE WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents who purchased at least one carton of cigarettes for their own personal use in the past 7 days



C10. [IF C8_2 > 0]


When you last got a pack of cigarettes for your own personal use, what price did you pay?


$_ _ _._ _ per pack (Range: 0–20.00)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 20.00


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 20.00.” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PRICE WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents who purchased at least one pack of cigarettes for their own personal use in the past 7 days



C11. [IF C8_1>0 OR C8_2>0 OR C8_3>0]


When you last got a single cigarette for your own personal use, what price did you pay?


$_ _ _._ _ per cigarette (Range: 0–15.00)


_____ I have never purchased a single cigarette


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 15.00


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 15.00.” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PRICE WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents who purchased at least one pack of cigarettes or one carton of cigarettes or one cigarette for their own personal use in the past 7 days



C12. [IF C8_4>0]


When you last got a pouch of roll-your-own-tobacco for your own personal use, what price did you pay?


$_ _ _._ _ per pouch (Range: 0–30.00)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 30.00


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 30.00.” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PRICE WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents who purchased at least one pouch of roll-your-own tobacco for their own personal use in the past 7 days



C13 INTRO [IF C7 NE 0 OR C8_4 >0]


Next, we would like to ask two questions about where you got cigarettes in the past 7 days. Please think about purchases that you made for your personal use.


C13. [IF C7 NE 0 OR C8_4 >0]


In the past 7 days, have you purchased cigarettes or roll your own tobacco from any of the following locations?




Yes

No

Prefer not to answer

C13_1.

At a convenience store or gas station

1

2

999

C13_2.

At a grocery store

1

2

999

C13_3.

At a drugstore

1

2

999

C13_4.

Mass merchandisers such as Wal-Mart, Costco, Sam’s Club

1

2

999

C13_5.

At a tobacco shop

1

2

999

C13_6.

Other

1

2

999


ASK: Respondents who purchased cigarettes for their own personal use in the past 7 days


[IF C13_1=1 OR C13_2=1 OR C13_3=1 OR C13_4=1 OR C13_5=1 OR C13_6=1, ASK C14; ELSE, GO TO C15]



C14. [IF C13_1=1 OR C13_2=1 OR C13_3=1 OR C13_4=1 OR C13_5=1 OR C13_6=1]


Please write the name of the specific store where you usually bought cigarettes or roll-your-own-tobacco in the past 7 days for your own use.


_______________________ (ALLOW 25 ALPHA OR NUMERIC CHARACTERS).


999 Prefer not to answer


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


ASK: Respondents who purchased cigarettes from a location for their own personal use in the past 7 days



CURRENT ELECTRONIC VAPOR PRODUCT USE


This question focuses on electronic vapor products, which include e-cigarettes, e-cigars, e-hookahs, e-pipes, vape pens, tanks, mods, and hookah pens.


Picture 9


C15. Do you now use an electronic vapor product . . .

  1. Every day

  2. Some days

  3. Rarely

  4. Not at all

999 Prefer not to answer


ASK: All respondents




CURRENT SMOKELESS USE


Next, we ask a question about smokeless tobacco which you put in your mouth. You chew, suck or spit some types of smokeless tobacco but not other types. For example, snus is smokeless tobacco that comes in a small pouch that you put inside your lip.


There are many kinds of smokeless tobacco, such as snus pouches, loose snus, moist snuff, dip, spit, and chewing tobacco. Common brands include Redman, Levi Garrett, Beechnut, Skoal, Grizzly, Nordic Ice and Copenhagen.


C16. Do you now use smokeless tobacco products . . .


  1. Every day

  2. Some days

  3. Rarely

  4. Not at all

999 Prefer not to answer


ASK: All respondents




CURRENT CIGAR/CIGARILLO USE


The next question is about traditional cigars, cigarillos, little cigars, and filtered cigars. These products go by lots of different names, so please use these descriptions and photos to understand what they are.


Traditional cigars contain tightly rolled tobacco that is wrapped in a tobacco leaf. Some common brands of cigars include Macanudo, Romeo y Julieta, and Arturo Fuente, but there are many others.


Cigarillos, little cigars, and filtered cigars are smaller than traditional cigars. They are usually brown. Some are the same size as cigarettes, and some come with filters or with plastic or wooden tips. Some common brands are Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, and Winchester.



C17. Do you now use traditional cigars, cigarillos, little cigars and/or filtered cigars . . .


  1. Every day

  2. Some days

  3. Rarely

  4. Not at all

999 Prefer not to answer


ASK: All respondents




CURRENT HOOKAH USE


We next ask about smoking tobacco in a hookah, which is a type of water pipe. It is sometimes also called shisha or a “narghile” pipe. From now on, we will use “hookah” to refer to a water pipe, shisha, or narghile pipe that is often used to smoke tobacco.


There are many types of hookahs. People often smoke tobacco in hookahs in groups at cafes or in hookah bars.



C18. Do you now smoke tobacco in a hookah, even one or two puffs . . .


  1. Every day

  2. Some days

  3. Rarely

  4. Not at all

999 Prefer not to answer


ASK: All respondents




SECTION D: TOBACCO USE INTENTIONS AND SELF-EFFICACY



INTRODUCTION: In the next section, we ask you some questions about quitting smoking cigarettes.


SMOKING EXPECTATIONS


D1. Three months from now, how much do you expect to be smoking cigarettes, compared to now?


  1. Not smoking cigarettes at all

  2. A lot less than now

  3. A little less than now

  4. The same amount as now

  5. A little more than now

  6. A lot more than now

999 Prefer not to answer


ASK: All respondents



SELF-EFFICACY FOR QUITTING


D2. If you did try to quit smoking cigarettes altogether in the next 3 months, how likely do you think you would be to succeed?


  1. Not at all likely

  2. A little likely

  3. Somewhat likely

  4. Very likely

999 Prefer not to answer


ASK: All respondents



D3. How much do you believe that quitting smoking completely is possible for you?


  1. Not at all possible

  2. Somewhat possible

  3. Very possible

999 Prefer not to answer


ASK: All respondents




D4 INTRO: How much do you disagree or agree with the following statement?


D4. I feel ready to take a small step toward quitting.

  1. Strongly disagree

  2. Disagree

  3. Neither disagree nor agree

  4. Agree

5 Strongly agree

999 Prefer not to answer


ASK: All respondents




SECTION E: CESSATION (INTENTION, BEHAVIOR, MOTIVATION)



QUIT BEHAVIOR


E1. Have you ever tried to quit smoking cigarettes?


  1. Yes

  2. No–> GO TO E10

999 Prefer not to answer


ASK: All respondents



E2. [IF E1=1 OR E1=999]


Of all the times you tried to quit smoking cigarettes, what was the longest period you stayed off cigarettes completely? Enter either hours, days, weeks, months or years below.


______ (NUMERIC ENTRY)


  1. hours (Range: 0-23)

  2. days (Range: 0-6)

  3. weeks (Range: 0-4)

  4. months (Range: 0-11)

  5. years (Range: 0-99)

999 Prefer not to answer


PROGRAMMER: ALLOW R TO ENTER EITHER HOURS, DAYS, WEEKS, MONTHS, OR YEARS. NUMERIC RESPONSE.


IF HOURS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 23.

IF DAYS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 6.

IF WEEKS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 4.

IF MONTHS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 11.

IF YEARS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99.

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND (HOURS: 23; DAYS: 6; WEEKS: 4; MONTHS: 11; YEARS: 99).” IN LOWERCASE LETTERS


ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking



E3 INTRO: [IF E1=1 OR E1=999]


For most of the questions in this section, we ask you about the past 3 months. For the next question, please note that we are asking you about the past 6 months.


E3. In the past 6 months, did you intentionally quit smoking cigarettes for at least 24 hours?


  1. Yes

  2. No

999 Prefer not to answer


ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.



E4 INTRO: [IF (E1=1 OR E1=999) AND E3 NE 2]


Now, we are going to ask you about your behavior in the past 3 months again.


E4. In the past 3 months, did you intentionally quit smoking cigarettes for at least 24 hours?


  1. Yes

  2. No–> GO TO E8

999 Prefer not to answer


ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.



E5. [IF E4=1 OR E4=999]


In the past 3 months, how many times have you intentionally quit smoking cigarettes for at least 24 hours?


_____ times (Range: 0–99)

999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 99” IN LOWERCASE LETTERS


ASK: Respondents who intentionally quit smoking cigarettes in the past 3 months for at least 24 hours, or Respondents who preferred not to indicate whether they had intentionally quit smoking cigarettes in the past 3 months for at least 24 hours.



E6. [IF E4=1 OR E4=999]


When you tried to quit smoking cigarettes in the past 3 months, did you avoid going to places where you used to buy cigarettes in case you might be tempted to buy them?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: Respondents who intentionally quit smoking cigarettes in the past 3 months for at least 24 hours, or Respondents who preferred not to indicate whether they had intentionally quit smoking cigarettes in the past 3 months for at least 24 hours.



E7. [IF E4=1 OR E4=999]


When you tried to quit smoking cigarettes in the past 3 months, was there a time when seeing the cigarette pack display in the store gave you an urge to buy cigarettes?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: Respondents who intentionally quit smoking cigarettes in the past 3 months for at least 24 hours, or Respondents who preferred not to indicate whether they had intentionally quit smoking cigarettes in the past 3 months for at least 24 hours.



MOTIVATION TO QUIT


E8. [IF E1=1 OR E1=999]


How much do you want to quit smoking cigarettes?


  1. Not at all

  2. A little

  3. Somewhat

  4. A lot

999 Prefer not to answer


ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.



E9. [IF E1=1 OR E1=999]


In the past 3 months, have you tried to quit smoking cigarettes by reducing or cutting back on the number of cigarettes you smoke?


  1. Yes

  2. No

999 Prefer not to answer


ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.



E10. On a scale of 1-5, where 1 is the lowest and 5 is the highest, how would you rate quitting smoking cigarettes as a priority in your life?


  1. Lowest priority

  2. Highest priority

999 Prefer not to answer


PROGRAMMER: LABEL RESPONSE OPTIONS WITH NUMBERS


ASK: All respondents



INTENTION TO QUIT


E11. Do you plan to quit smoking cigarettes for good . . .


  1. In the next 7 days,

  2. In the next 30 days,

  3. In the next 3 months,

  4. In the next 6 months,

  5. In the next year, or

  6. More than one year from now?

  7. I do not plan to quit smoking cigarettes for good

  8. Not sure/uncertain

999 Prefer not to answer


ASK: All respondents



E12. [IF E11=1 OR 2 OR 3 OR 4 OR 5 OR 6]


Have you set a firm date to quit smoking cigarettes?

  1. Yes

  2. No

999 Prefer not to answer


ASK: Respondents who plan to quit smoking cigarettes for good


CESSATION COGNITION INDEX


E13. INTRO: Please tell us how much you disagree or agree with the following statements.


PROGRAMMER: RANDOMIZE ALL





Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

E13_1.

I have been thinking a lot about quitting smoking cigarettes recently.

1

2

3

4

5

999

E13_2.

I am eager for a life without smoking cigarettes.

1

2

3

4

5

999

E13_3.

Lately, I have been thinking about which cigarettes during my day would be the hardest to give up.

1

2

3

4

5

999

E13_4.

I am not prepared to make changes in my life to quit smoking cigarettes.

1

2

3

4

5

999


ASK: All respondents



E14. During the past 3 months, how often would you say you have thought about the changes you will have to make in your life to quit smoking cigarettes?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: All respondents



MICROINDICATORS OF QUITTING


E15. Compared to three months ago, are you more or less concerned about the price of cigarettes?


  1. Less concerned

  2. Just as concerned

  3. More concerned

999 Prefer not to answer


ASK: All respondents



E16. In the past 3 months, did you practice not smoking in some situations, or for periods of time?


  1. Yes

  2. No

999 Prefer not to answer


ASK: All respondents



E17. In the past 3 months, have you stubbed out a cigarette before you finished it because you wanted to quit smoking?


  1. Yes

  2. No

999 Prefer not to answer


ASK: All respondents



E18. In the past 3 months, how often did you put off purchasing cigarettes because you wanted to quit smoking?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: All respondents



E19. In the past 3 months, how often have you stopped yourself from having a cigarette when you had the urge to smoke?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: All respondents



E20. In the past 3 months, how often did you avoid social situations where people were smoking?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: All respondents




SECTION F: ATTITUDES, BELIEFS & RISK PERCEPTIONS, SOCIAL NORMS



INTRODUCTION: Now we would like to ask you some questions about your attitudes and beliefs.


SMOKING BELIEFS


F1. How harmful do you think smoking cigarettes is to people’s health in general?


  1. Not at all harmful

  2. Slightly harmful

  3. Somewhat harmful

  4. Very harmful

  5. Extremely harmful

999 Prefer not to answer


ASK: All respondents



F2. Please tell us how much do you disagree or agree with the following statements about smoking cigarettes.


PROGRAMMER: RANDOMIZE ORDER OF QUESTIONS





Strongly Disagree



Disagree

Neither Agree or Disagree



Agree



Strongly Agree

Prefer Not to Answer

F2_1.

I would be more energetic right now if I didn’t smoke cigarettes.

1

2

3

4

5

999

F2_2.

I’m embarrassed that I smoke cigarettes.

1

2

3

4

5

999

F2_3.

Smoking cigarettes is hazardous to my health.

1

2

3

4

5

999

F2_4.

Smoking cigarettes is pleasurable.

1

2

3

4

5

999

F2_5.

Smoking cigarettes reduces stress.

1

2

3

4

5

999

F2_6.

Smoking cigarettes helps me concentrate.

1

2

3

4

5

999

F2_7.

Smoking cigarettes helps keep my weight down.

1

2

3

4

5

999


ASK: All respondents



F3. In the past 3 months, how often did you think about the harm your cigarette smoking might be doing to you?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: All respondents



F4. How likely do you think you are to develop a smoking-related disease as a result of smoking cigarettes?


  1. Extremely unlikely

  2. Very unlikely

  3. Very likely

  4. Extremely likely

999 Prefer not to answer


ASK: All respondents



F5. Please tell us how much you disagree or agree that smoking cigarettes increases your risk of . . . [randomize presentation]


PROGRAMMER: RANDOMIZE PRESENTATION





Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

F5_1.

Lung cancer?

1

2

3

4

5

999

F5_2.

Heart disease?

1

2

3

4

5

999

F5_3.

Emphysema?

1

2

3

4

5

999

F5_4.

Chronic obstructive pulmonary disorder (COPD) or chronic bronchitis?

1

2

3

4

5

999


ASK: All respondents



CESSATION BELIEFS


F6. How much do you think your health would improve if you were to stop smoking cigarettes for good?


  1. Not at all

  2. A little

  3. Somewhat

  4. A lot

999 Prefer not to answer


ASK: All respondents




SECTION G: MEDIA USE AND AWARENESS



INTRODUCTION: Next, we’d like to ask you about your use of TV and other media.


GENERAL MEDIA EXPOSURE


G1. How often do you…


PROGRAMMER: RANDOMIZE PRESENTATION


Never


Once a month or less

Every few weeks


1-3 days a week

4-6 days a week

About once a day

Several times a day

Prefer not to answer

G1_1.

Watch television, including streaming TV (Hulu, Netflix, or Amazon Prime)?

1

2

3

4

5

6

7

999

G1_2.

Watch videos on YouTube?

1

2

3

4

5

6

7

999

G1_3.

Listen to streaming radio?

1

2

3

4

5

6

7

999

G1_4.

Listen to radio over the air?

1

2

3

4

5

6

7

999


ASK: All respondents



G2. Thinking about the social networking sites you use, about how often do you visit or use the following…


PROGRAMMER: RANDOMIZE PRESENTATION


Never


Once a month or less


Every few weeks


1-3 days a week

4-6 days a week

About once a day

Several times a day

Prefer not to answer

G2_1.

Facebook

1

2

3

4

5

6

7

999

G2_2.

Instagram

1

2

3

4

5

6

7

999

G2_3.

Twitter

1

2

3

4

5

6

7

999

G2_4.

Tumblr

1

2

3

4

5

6

7

999

G2_5.

Snapchat

1

2

3

4

5

6

7

999

G2_6.

Pinterest

1

2

3

4

5

6

7

999


ASK: All respondents



ANTI-SMOKING MEDIA EXPOSURE


G3. In the past 3 months, how frequently have you seen or heard the following slogan or theme on the TV, radio, or Internet?


Tips from Former Smokers (Tips)




  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


ASK: All respondents



EVERY TRY COUNTS EXPOSURE


G4. In the past 3 months, how frequently have you seen or heard the following slogan or theme?


Every Try Counts


PROGRAMMER: RANDOMLY INSERT 1 OF THE FOLLOWING FOUR EXAMPLE ADS


Ad 1: “You didn’t fail at quitting”



Ad 2: “If at first you don’t succeed”







Ad 3: “Every time you put out a cigarette”



Ad 4: Keep Your Head Up



  1. Never–> GO TO G6

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer–> GO TO G6


ASK: All respondents



G5. [IF G4>=2 AND G4 NE 999]


You said you have seen or heard “Every Try Counts”. Where have you seen or heard it? Please check “yes” or “no” for each item.


PROGRAMMER: RANDOMIZE PRESENTATION



Yes

No

Prefer not to answer

G5_1.

Inside of a store

1

2

999

G5_2.

Outside of a store

1

2

999

G5_3.

At the gas pump

1

2

999

G5_4.

On a billboard

1

2

999

G5_5.

On television

1

2

999

G5_6.

On the internet and/or on social media

1

2

999

G5_7.

On the radio

1

2

999


ASK: Respondents who indicated they saw or hear the ‘Every Try Counts’ slogan or theme once, a few times, or a lot of times in the past 3 months.



IDENTIFICATION WITH CAMPAIGN MESSAGE


G6. Please tell us how much you disagree or agree with the following statements about smoking cigarettes?


PROGRAMMER: RANDOMIZE PRESENTATION





Strongly Disagree



Disagree

Neither Agree or Disagree



Agree



Strongly Agree

Prefer Not to Answer

G6_1.

I feel like a failure when I start smoking again after quitting.

1

2

3

4

5

999

G6_2.

Every quit attempt I make is a step towards quitting smoking cigarettes for good.

1

2

3

4

5

999

G6_3.

The more times I try to quit smoking cigarettes, the more likely I am to quit for good.

1

2

3

4

5

999

G6_4.

It may take me several quit attempts to quit smoking cigarettes for good.

1

2

3

4

5

999

G6_5.

I have a chance to learn something new with every quit attempt.

1

2

3

4

5

999

G6_6.

It’s important for me to learn not to smoke cigarettes in situations where I typically smoke.

1

2

3

4

5

999

G6_7.

With each quit attempt, I become better at quitting.

1

2

3

4

5

999

ASK: All respondents



G7 INTRO: Please tell us how much do you disagree or agree with the following statements.


G7. When I think about quitting smoking cigarettes, I feel…






Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

G7_1.

Confident

1

2

3

4

5

999

G7_2.

Hopeful

1

2

3

4

5

999

G7_3.

Discouraged

1

2

3

4

5

999

G7_4.

Stressed

1

2

3

4

5

999


ASK: All respondents



G8 INTRO: How much do you disagree or agree with the following statements?


G8. I continue to smoke cigarettes because…






Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

G8_1.

I’m addicted to smoking.

1

2

3

4

5

999

G8_2.

I enjoy smoking.

1

2

3

4

5

999

G8_3.

I don’t have enough willpower.

1

2

3

4

5

999

G8_4.

I’m stressed out.

1

2

3

4

5

999

G8_5.

I don’t have the support I need from friends and family.

1

2

3

4

5

999

G8_6.

I haven’t tried to quit enough times.

1

2

3

4

5

999


ASK: All respondents



G9 INTRO: Now we would like to show you some ads that you may have seen close to places that sell tobacco.


PROGRAMMER: RANDOMIZE PRESENTATION OF G9-G10 LOOP RANDOMIZE PRESENTATION. THE AD SELECTED FOR G4 SHOULD SKIP QG9 AND GO TO QG10 INSTEAD:


G9_1. Apart from this survey, how frequently have you seen this ad in the past 3 months?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


PROGRAMMER: DISPLAY CAMPAIGN AD FOR “YOU DIDN’T FAIL AT QUITTING…”



ASK: All respondents



G9_2. Apart from this survey, how frequently have you seen this ad in the past 3 months?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


PROGRAMMER: DISPLAY CAMPAIGN AD FOR “IF AT FIRST YOU DON’T SUCCEED…”



ASK: All respondents



G9_3. Apart from this survey, how frequently have you seen this ad in the past 3 months?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


PROGRAMMER: DISPLAY CAMPAIGN AD FOR “EVERY TIME YOU PUT OUT A CIGARETTE”



G9_4 Apart from this survey, how frequently have you seen this ad in the past 3 months?


  1. Never

  2. Once

  3. A few times

  4. Lots of times

999 Prefer not to answer


PROGRAMMER: DISPLAY CAMPAIGN AD FOR “KEEP YOUR HEAD UP”



ASK: All respondents



PERCEIVED EFFICACY OF CAMPAIGNS


G10_1. Please tell us how much you disagree or agree with the following statements about this ad.


PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “YOU DIDN’T FAIL AT QUITTING…”





Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

G10_1_1.

This ad is worth remembering.

1

2

3

4

5

999

G10_1_2.

This ad grabbed my attention.

1

2

3

4

5

999

G10_1_3.

This ad is powerful.

1

2

3

4

5

999

G10_1_4.

This ad is informative.

1

2

3

4

5

999

G10_1_5.

This ad is meaningful to me.

1

2

3

4

5

999

G10_1_6.

This ad is convincing.

1

2

3

4

5

999

G10_1_7.

This ad made me want to quit smoking cigarettes.

1

2

3

4

5

999

G10_1_8.

This ad made me feel motivated to try to quit smoking cigarettes.

1

2

3

4

5

999

G10_1_9.

This ad made me feel hopeful about quitting smoking cigarettes.

1

2

3

4

5

999

G10_1_10.

This ad made me feel understood.

1

2

3

4

5

999


ASK: All respondents



G10_2. Please tell us how much you disagree or agree with the following statements about this ad.


PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “IF AT FIRST YOU DON’T SUCCEED…”





Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

G10_2_1.

This ad is worth remembering.

1

2

3

4

5

999

G10_2_2.

This ad grabbed my attention.

1

2

3

4

5

999

G10_2_3.

This ad is powerful.

1

2

3

4

5

999

G10_2_4.

This ad is informative.

1

2

3

4

5

999

G10_2_5.

This ad is meaningful to me.

1

2

3

4

5

999

G10_2_6.

This ad is convincing.

1

2

3

4

5

999

G10_2_7.

This ad made me want to quit smoking cigarettes.

1

2

3

4

5

999

G10_2_8.

This ad made me feel motivated to try to quit smoking cigarettes.

1

2

3

4

5

999

G10_2_9.

This ad made me feel hopeful about quitting smoking cigarettes.

1

2

3

4

5

999

G10_2_10.

This ad made me feel understood.

1

2

3

4

5

999


ASK: All respondents



G10_3. Please tell us how much you disagree or agree with the following statements about this ad.


PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “EVERY TIME YOU PUT OUT A CIGARETTE”





Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

G10_3_1.

This ad is worth remembering.

1

2

3

4

5

999

G10_3_2.

This ad grabbed my attention.

1

2

3

4

5

999

G10_3_3.

This ad is powerful.

1

2

3

4

5

999

G10_3_4.

This ad is informative.

1

2

3

4

5

999

G10_3_5.

This ad is meaningful to me.

1

2

3

4

5

999

G10_3_6.

This ad is convincing.

1

2

3

4

5

999

G10_3_7.

This ad made me want to quit smoking cigarettes.

1

2

3

4

5

999

G10_3_8.

This ad made me feel motivated to try to quit smoking cigarettes.

1

2

3

4

5

999

G10_3_9.

This ad made me feel hopeful about quitting smoking cigarettes.

1

2

3

4

5

999

G10_3_10.

This ad made me feel understood.

1

2

3

4

5

999


ASK: All respondents



G10_4. Please tell us how much you disagree or agree with the following statements about this ad.


PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “KEEP YOUR HEAD UP”





Strongly Disagree



Disagree



Neither Agree or Disagree



Agree



Strongly Agree



Prefer Not to Answer

G10_4_1.

This ad is worth remembering.

1

2

3

4

5

999

G10_4_2.

This ad grabbed my attention.

1

2

3

4

5

999

G10_4_3.

This ad is powerful.

1

2

3

4

5

999

G10_4_4.

This ad is informative.

1

2

3

4

5

999

G10_4_5.

This ad is meaningful to me.

1

2

3

4

5

999

G10_4_6.

This ad is convincing.

1

2

3

4

5

999

G10_4_7.

This ad made me want to quit smoking cigarettes.

1

2

3

4

5

999

G10_4_8.

This ad made me feel motivated to try to quit smoking cigarettes.

1

2

3

4

5

999

G10_4_9.

This ad made me feel hopeful about quitting smoking cigarettes.

1

2

3

4

5

999

G10_4_10.

This ad made me feel understood.

1

2

3

4

5

999


ASK: All respondents


COMPREHENSION OF CAMPAIGN MESSAGE


G11. Please pick the answer below that you think best fits the main message of all of the ads we showed you…


  1. Quitting smoking takes practice.

  2. It may take several attempts to quit smoking for good.

  3. You learn something every time you try to quit smoking.

  4. It is important to talk to your doctor before quitting smoking.

  5. Using nicotine patches helps you quit smoking.

999 Prefer not to answer


PROGRAMMER: RANDOMIZE ORDER OR RESPONSE OPTIONS


ASK: All respondents



BRAND IDENTIFICATION


G12. In the past 3 months, did you talk to anyone, either in person or online, about the “Every Try Counts” ads?


  1. Yes

  2. No

999 Prefer not to answer


ASK: All respondents






SECTION H: ENVIRONMENT





INTRODUCTION: This section asks some additional questions about you and your environment.


BLUNT USE


H1. Do you now use a “blunt” (a cigar, cigarillo, little cigar, or filtered cigar with marijuana in it) . . .


  1. Every day

  2. Some days

  3. Rarely

  4. Not at all

999 Prefer not to answer


ASK: All respondents





TOBACCO ENVIRONMENT IN HOME


H2. The next question asks about rules of using tobacco inside your home. Please think about everyone who might be in your home including children, adults, visitors, guests, or workers. For tobacco products that are burned, such as cigarettes, cigars, pipes or hookah, which statement best describes the rules about smoking a tobacco product inside your home?


  1. It is not allowed anywhere or at any time inside my home

  2. It is allowed in some places or at sometimes inside my home

  3. It is allowed anywhere and at any time inside my home

999 Prefer not to answer


ASK: All respondents




H3. Other than you, has anyone who lives with you used any of the following during the past 30 days? Select all that apply.

[PROGRAM SO THAT RESPONDENTS CAN SELECT MORE THAN ONE RESPONSE ON 2–5]

  1. Cigarettes

  2. Traditional cigars, cigarillos, little cigars, or filtered cigars, such as Macanudo, Romeo y Julieta, Arturo Fuente, Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, or Winchester

  3. Tobacco out of a water pipe (also called “hookah”)

  4. Electronic vapor products, also called e-cigarettes, e-cigars, e-hookahs, e-pipes, vape pens, tanks, mods, and hookah pens

  5. Any other form of tobacco

  6. No, no one who lives with me has used any form of tobacco during the past 30 days

999 Prefer not to answer


IF ANY RESPONSE 1- 6 IS SELECTED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “YOU CANNOT SELECT THE OPTION ‘PREFER NOT TO ANSWER’ AND ANY OTHER OPTION ’. IN LOWERCASE LETTERS.


IF RESPONSE 6 IS SELECTED WITH ANY OF THE RESPONSES 1 – 5, ERROR MESSAGE SHOULD SAY “YOU CANNOT SELECT THE OPTION “NO, NO ONE WHO LIVES WITH ME HAS USED ANY FORM OF TOBACCO DURING THE PAST 30 DAYS” AND ANY OTHER OPTION”. IN LOWERCASE LETTERS


ASK: All respondents




POLITICAL PHILOSOPHY


H4. How would you describe your overall political philosophy? Would you describe yourself as . . .


  1. Very conservative

  2. Somewhat conservative

  3. Moderate—neither liberal nor conservative

  4. Somewhat liberal

  5. Very liberal

  6. None of the above

999 Prefer not to answer


ASK: All respondents




PHYSICAL HEALTH


H5. In general, how would you rate your physical health?


  1. Poor

  2. Fair

  3. Good

  4. Very good

  5. Excellent

999 Prefer not to answer


ASK: All respondents




MARITAL STATUS


H6. What is your marital status?


  1. Now married–> GO TO H8

  2. Widowed

  3. Divorced

  4. Separated

  5. Never married

999 Prefer not to answer


ASK: All respondents




H7. [IF H6>1 OR H6=999]


Do you share a household with a boyfriend, girlfriend, or partner?


  1. Yes

  2. No

999 Prefer not to answer


ASK: Respondents who are not married.




MILITARY SERVICE


H8. Have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? Note: Active duty for the Reserves or National Guard does not include the regular training for the Reserves or Guard. It does include being activated for deployment, such as for the Iraq War.


  1. Yes, on active duty in the past, but not now

  2. No, training for Reserves or National Guard only

  3. No, never served in the military

999 Prefer not to answer


ASK: All respondents




H9. [IF B5=1 OR 3 OR 999]


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


    1. Less than $5,000

    2. $5,000 to $7,499

    3. $7,500 to $9,999

    4. $10,000 to $12,499

    5. $12,500 to $14,999

    6. $15,000 to $19,999

    7. $20,000 to $24,999

    8. $25,000 to $29,999

    9. $30,000 to $34,999

999 Prefer not to answer


ASK: All respondents who indicated their total household income in the past 12 months was below $35,000; all respondents who don’t know their total household income in the past 12 months; all respondents who indicated they preferred not to answer what their total household income was in the past 12 months.




H10. [IF B5=2]


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

999 Prefer not to answer


ASK: All respondents who indicated their total household income in the past 12 months was $35,000 or more.




MENTAL HEALTH


H11. Now thinking about your mental health, which includes stress, depression, and emotional problems, for how many days during the past 30 days was your mental health not good?


_____ Number of days (Range: 0–30)



999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 30


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 30” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NUMBER OF DAYS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: All respondents





H12. [IF H11 >0] During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?


_____ Number of days (Range: 0–30)


999 Prefer not to answer


PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 30


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 30” IN LOWERCASE LETTERS


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NUMBER OF DAYS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: All respondents




SEX/GENDER


H13. What is your current gender identity?

  1. Male

  2. Female

  3. Trans male/Trans man

  4. Trans female/Trans woman

  5. Genderqueer/Gender non-conforming/Intersex

  6. Different identity

999 Prefer not to answer


ASK: All respondents




H13OT. [IF H13=6]


Please specify your current gender identity.


________ [ALLOW 20 ALPHA CHARACTERS]


999 Prefer not to answer


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


ASK: Respondents who indicate a different gender identity than those listed in H13





H14. What sex were you assigned at birth, on your birth certificate?


  1. Male

  2. Female

999 Prefer not to answer


ASK: All respondents





SEXUAL ATTRACTION


H15. People are different in their sexual attraction to other people. Which statement best describes your feelings?


  1. I am only attracted to males

  2. I am mostly attracted to males

  3. I am equally attracted to males and females

  4. I am mostly attracted to females

  5. I am only attracted to females

  6. I am not sure

999 Prefer not to answer


ASK: All respondents



SEXUAL ORIENTATION


H16. Which of the following best represents how you think of yourself?


  1. Lesbian or gay

  2. Straight, that is, not lesbian or gay

  3. Bisexual

  4. Something else

  5. I don’t know the answer

999 Prefer not to answer


ASK: All respondents




H16OT. [IF H16=4]


Please specify how you think of yourself.


________ [ALLOW 20 ALPHA CHARACTERS]


999 Prefer not to answer


PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX


ASK: Respondents who indicated something else best represents them than the responses listed in H16.



ENDCASI. Thank you for your answering these questions.


When you leave this screen, the responses you entered into the laptop can no longer be seen by you, the interviewer, or anyone else who uses this computer. When you are ready, please press NEXT to complete this part of the interview.


ASK: All respondents




ENDCASI2. Please tell your interviewer that you are finished.


INTERVIEWER: ENTER THE CODE TO MOVE TO THE NEXT SECTION.


ASK: All respondents



SECTION AL: LOCATOR MODULE




INSTRUCTIONS TO INTERVIEWER: READ ALL TEXT AND QUESTIONS IN REGULAR TYPE.


[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]


AL_INT1. Thank you for completing the interview. Finally, we would like to offer you the opportunity to participate in future interviews (approximately three over the next two years). To help us reach you in the future, it would be helpful if you provided us with some additional contact information. This information will be held securely and confidentially by RTI, and will only be used to help contact you in the future.


  1. CONTINUE


ASK: All respondents



AL_INT2. Would you be willing to give us some additional personal contact information? IF NECESSARY: Your household might be contacted by RTI to verify that I followed the correct steps in completing this interview, and we would also like to be sure that we have the best contact information for you for future interviews. This information will be stored in a secure location (e.g., locked file cabinet, encrypted computer file) and destroyed after 3 years. We will not share this information with anyone outside of the study.

  1. YES

  2. NO–> GO TO EXIT 1

999 PREFER NOT TO ANSWER–> GO TO EXIT 1


ASK: All respondents


[END CARI RECORDING IF SECA_CONSENTCARI = 1]




AL_FNAME. [IF AL_INT2 = 1] We need to record your full name for future mailings, and we want to make sure we have it spelled correctly. Could you spell your first and last name for me?


INTERVIEWER: CONFIRM SPELLING OF NAME BY READING IT BACK TO RESPONDENT.


FIRST NAME: ________[ALLOW 20 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE RESPONDENT’S FIRST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_LNAME


ASK: Respondents willing to provide additional personal contact information.





AL_LNAME. What is your last name?


LAST NAME: ________ [ALLOW 20 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE RESPONDENT’S LAST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_FNAME


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NAME WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents willing to provide additional personal contact information.



AL_EADV1. [IF AL_INT2 = 1]


Thank you. Do you have a home telephone number?

  1. YES

  2. NO

999 Prefer not to answer


ASK: Respondents willing to provide additional personal contact information




AL_EHPH2A. [IF AL_EADV1= 1]


What is your home telephone number, including area code?


(__ __ __) __ __ __ - __ __ __ __ PHONE NUMBER [ALLOW 10 NUMERIC CHARACTERS]


999 PREFER NOT TO ANSWER


OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999


PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY: “PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A TELEPHONE NUMBER WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents who have and are willing to provide a home telephone number



AL_ECPH1 [IF AL_INT2 = 1]


Do you have a cell phone?

  1. YES

  2. NO

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information




AL-ECPH1A [IF AL_ECPH1 = 1]


Is it a smartphone?


IF NECESSARY: A smartphone is a cell phone that has many of the functions a computer has. Usually they have a touch screen and you can do things like access your e-mail and install programs on it.

  1. YES

  2. NO

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information and have a cell phone




AL_ECPH1B [IF AL_ECPH1 = 1]


What is your current cell phone number, including area code?


(__ __ __) __ __ __ - __ __ __ __ CELL PHONE NUMBER [ALLOW 10 NUMERIC CHARACTERS]

999 PREFER NOT TO ANSWER


OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999


PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:


“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A TELEPHONE NUMBER WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents willing to provide additional personal contact information and have a cell phone



AL_ECPH2 [IF AL_ECPH1A NE 1]


May we use your personal cell phone to contact you about the study?

  1. YES

  2. NO

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information who do not have a smartphone or preferred not to indicate whether they have a smartphone



AL_ECPH3 [IF AL_ECPH1A = 1]


Do you send and receive text messages on your personal cell phone?

  1. YES

  2. NO

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information and who have a smartphone



AL_ECPH4 [IF AL_ECPH3 = 1]


May we send text messages to contact you about the study?

  1. YES

  2. NO

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information and who have a smartphone and indicated they can send and receive text messages on their person cell phone



AL_EPEM1 [[IF AL_INT2 = 1]


Do you have a personal (non-work) e-mail address that you use at home?

  1. YES

  2. NO

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information




AL_EPEM2 [IF AL_EPEM1 = 1] What is this e-mail address?


INTERVIEWER: ENTER THE ADDRESS AS: ___________@______ [ALLOW 40 CHARACTERS]

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information and have a personal (non-work) e-mail address that they use at home



AL_EPEM3 [IF AL_EPEM1 = 1 AND IF AL_EPEM2 NE 999]


May we use your personal email address to contact you about the study?

  1. Yes

  2. No

999 Prefer not to answer


ASK: Respondents willing to provide additional personal contact information, have a personal (non-work) e-mail address that they use at home, and provided the e-mail address



[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]


AL_INT3 [IF AL_INT2 = 1]


It is often difficult to get in touch with people if their contact information changes. Should this occur, we would still like you to participate in the follow-up interviews. In case we have difficulty getting in touch with you in the future, could you please give me the contact information for another person, who is not currently living with you, who will always know your whereabouts? This information will be kept confidential and not shared with anyone outside the study. We will only use this information if we need to contact you and are unable to do so using the information you have already provided to us.


IF NECESSARY: This might be a family member, a close friend, or someone else who knows where you are. We would only contact this person if we could not reach you.


  1. Yes

  2. No

999 Prefer not to answer


ASK: Respondents willing to provide additional personal contact information


[END CARI RECORDING IF SECA_CONSENTCARI = 1]



AL_A1NAF [IF AL_INT3 = 1]


What is this person's name?


FIRST NAME: ________ [ALLOW 20 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON'S FIRST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A1NAL


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NAME WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A1NAL [IF AL_INT3 = 1]


What is this person's name?


LAST NAME: ________ [ALLOW 20 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON’S LAST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A1NAF


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NAME WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A1REL [IF AL_INT3 = 1]


How is [IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person] related to you?


  1. MOTHER

  2. FATHER

  3. STEPMOTHER (INCLUDING FOSTER OR ADOPTED MOTHER)

  4. STEPFATHER (INCLUDING FOSTER OR ADOPTED FATHER)

  5. GRANDMOTHER

  6. GRANDFATHER

  7. DAUGHTER

  8. SON

  9. AUNT

  10. UNCLE

  11. SISTER (INCLUDING HALF, STEP, FOSTER OR ADOPTED SISTER)

  12. BROTHER (INCLUDING HALF, STEP, FOSTER OR ADOPTED BROTHER)

  13. OTHER RELATIVE

  14. FRIEND

  15. GIRLFRIEND (NOT LIVING WITH RESPONDENT)

  16. BOYFRIEND (NOT LIVING WITH RESPONDENT)

  17. COWORKER

  18. HUSBAND/WIFE (NOT LIVING WITH RESPONDENT)

  19. EX-HUSBAND OR WIFE

  20. OTHER, SPECIFY


999 PREFER NOT TO ANSWER


PROGRAMMER: IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person


DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A1RELs [IF AL_A1REL = 20]


Please specify how [IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person] is related to you?


SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person


DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A1HPH [IF AL_INT3 = 1]


What is [IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s] home telephone number, including area code?


HOME TELEPHONE NUMBER: __________________________[ALLOW 10 NUMERIC CHARACTERS]


999 PREFER NOT TO ANSWER


OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999


PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:


“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PHONE NUMBER WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s


DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A1CPH [IF AL_INT3 = 1]


What is [IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s] cell phone number, including area code?


CELL PHONE NUMBER:______________ [ALLOW 10 NUMERIC CHARACTERS]


999 PREFER NOT TO ANSWER


OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999


PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:


“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PHONE NUMBER WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s


DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts.



AL_A1PEM [IF AL_INT3 = 1]


What is [IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s] personal e-mail address?


Interviewer: Enter the address as _______@___[ALLOW 40 CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s


IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER AN EMAIL ADDRESS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.


DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]


AL_INT4 [AL_INT3 = 1]


To be certain that we are able to contact you for a future interview, we would also like the contact information for one additional person, who is not currently living with you, who would always know your whereabouts. This information will be kept confidential and will only be used by the study to help contact you for a future interview. Could you share this information with us?


If necessary, read: This might be a family member, a close friend, or someone else who knows where you are. We would only contact this person if we could not reach you.

  1. YES

  2. NO

999 PREFER NOT TO ANSWER


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts


[END CARI RECORDING IF SECA_CONSENTCARI = 1]



AL_A2NAF [IF AL_INT4 = 1]


What is this person's name?


FIRST NAME: ________[ALLOW 20 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON'S FIRST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A2NAL


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A2NAL [IF AL_INT4 = 1]


What is this person's name?


LAST NAME: ________[ALLOW 20 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON’S LAST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A2NAF


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A2REL [IF AL_INT4 = 1]


How is [IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person] related to you?


  1. MOTHER

  2. FATHER

  3. STEPMOTHER (INCLUDING FOSTER OR ADOPTED MOTHER)

  4. STEPFATHER (INCLUDING FOSTER OR ADOPTED FATHER)

  5. GRANDMOTHER

  6. GRANDFATHER

  7. DAUGHTER

  8. SON

  9. AUNT

  10. UNCLE

  11. SISTER (INCLUDING HALF, STEP, FOSTER OR ADOPTED SISTER)

  12. BROTHER (INCLUDING HALF, STEP, FOSTER OR ADOPTED BROTHER)

  13. OTHER RELATIVE

  14. FRIEND

  15. GIRLFRIEND (NOT LIVING WITH RESPONDENT)

  16. BOYFRIEND (NOT LIVING WITH RESPONDENT)

  17. COWORKER

  18. HUSBAND/WIFE (NOT LIVING WITH RESPONDENT)

  19. EX-HUSBAND OR WIFE

  20. OTHER, SPECIFY

999 PREFER NOT TO ANSWER


PROGRAMMER: IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person


DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A2RELs [IF AL_A2REL=20]


Please specify how [IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person] is related to you?


SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person


DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A2HPH [IF AL_INT4 = 1]


What is [IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s] home telephone number, including area code?


HOME TELEPHONE NUMBER: _______________[ALLOW 10 NUMERIC CHARACTERS]


999 PREFER NOT TO ANSWER


OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999


PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:


“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.


IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s


DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A2CPH [IF AL_INT4 = 1]


What is [IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s] cell phone number, including area code?


CELL PHONE NUMBER:______________ [ALLOW 10 NUMERIC CHARACTERS]


999 PREFER NOT TO ANSWER


OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999


PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:


“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.


IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s


DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts



AL_A2PEM [IF AL_INT4 = 1]


What is [IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s] personal e-mail address?


Interviewer: Enter the address as _________@____[ALLOW 40 CHARACTERS]


999 PREFER NOT TO ANSWER


PROGRAMMER: IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s


DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.


ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts.



INTERVIEWER READ: Thank you for providing this information.


SECTION J: APP-BASED PORTION OF STUDY



[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]



APP_CONSENT [If AL-ECPH1A= 1]


[INSERT APP CONSENT SCRIPT]


ASK: Respondents willing to provide additional personal contact information and have a smartphone



APP_REFUSAL [IF APP_CONSENT = 2]


INTERVIEWER: WHY DID THE PARTICIPANT REFUSE TO DOWNLOAD THE APP? SELECT ALL THAT APPLY


[PROGRAM SO THAT INTERVIEWERS CAN SELECT MORE THAN ONE RESPONSE]


APP_REFUSAL1 1 DOES NOT HAVE A SMARTPHONE AFTER ALL

APP_REFUSAL2 2 CONCERNED ABOUT PRIVACY

APP_REFUSAL3 3 CONCERNED ABOUT DATA USAGE

APP_REFUSAL4 4 PARTICIPANT REFUSED AFTER DIFFICULTY IN DOWNLOADING AND INSTALLING THE APP

APP_REFUSAL5 5 SAID THE INCENTIVE IS TOO SMALL

APP_REFUSAL6 6 SOME OTHER REASON (SPECIFY)


ASK: Asked of interviewers when participant refuses to participate in the app-based portion of the study



APP_REFOTR [IF APP_REFUSAL = 6]


INTERVIEWER: SPECIFY WHY PARTICIPANT REFUSED TO DOWNLOAD THE APP


SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]


ASK: Asked of interviewers that indicate there is another reason the participant refused to participate in the app-based portion of the study



APP_INSTRUCTIONS1 [APP_CONSENT = 1]


[INSERT APP INSTRUCTIONS]


[END CARI RECORDING IF SECA_CONSENTCARI = 1]



APP_EMAIL [IF APP_CONSENT = 1 AND ((AL_EPEM1 = 2 OR 999) OR (AL_EPEM2 = 999))]

We need your e-mail address to contact you about the study, such as providing information about your gift for completing a short questionnaire. What is your personal (non-work) e-mail address that you use at home?


INTERVIEWER:


E NTER THE ADDRESS AS: _______@___ [ALLOW 40 CHARACTERS] GO TO EXIT 3


I do not have an e-mail address GO TO EXIT4

9 99 PREFER NOT TO ANSWER GO TO EXIT4


ASK: Respondents who agreed to app-based data collection but did not provide an e-mail address



[IF (AL-ECPH1A = 2 OR 999) OR (AL_ECPH1 = 2 or 999)]

EXIT 1: Thank you for answering all of our questions. Here is $25 in cash as a token of our appreciation for your participation.


FI PROVIDE RESPONDENT WITH $25 CASH.


I also need to fill out a receipt to certify you received (or declined) the cash incentive. Since maintaining the privacy of your information is important to us, I will not include your name on the receipt.


FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.


Here is a copy of the receipt for your records. Thank you again for answering all of our questions


1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE


Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 minutes per response (time to read and agree to the assent/consent and respond to the questionnaire). Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].


PROGRAMMER: COMPLETED CASE THAT WILL NOT PARTICIPATE IN APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2690.


ASK: Respondents reaching the end of the survey who either don’t have a smartphone or won’t provide contact information



[IF APP_CONSENT = 2]


EXIT 2: Thank you for considering this part of our study. Here is $25 in cash as a token of our appreciation for your participation.


FI PROVIDE RESPONDENT WITH $25 CASH.


I also need to fill out a receipt to certify you received (or declined) the cash incentive. Since maintaining the privacy of your information is important to us, I will not include your name on the receipt.


FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.


Here is a copy of the receipt for your records. Thank you again for answering all of our questions.


1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE


Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 minutes per response (time to read and agree to the assent/consent and respond to the questionnaire). Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].


PROGRAMMER: COMPLETED CASE THAT WILL NOT PARTICIPATE IN APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2690.


ASK: Respondents reaching the end of the survey who have a smartphone but do not want to participate in the app-based portion of the study



[APP_CONSENT = 1 AND (AL_EPEM2 NE 999 OR (APP_EMAIL NE 999 OR “I do not have an email address”))]


EXIT 3: Thank you for answering our questions. As a reminder, the app will not work if you delete the app, change the app settings, or turn off location services. As a result, we hope that you will not delete the app, change any of the app’s settings, or turn off location services while participating in this study. If you want to stop participating in this portion of the study, please e-mail us at [email protected], and we will send you instructions on how to remove the app from your phone. If you change phones, accidentally delete the app, or lose your phone, or the app stops working, please contact RTI study staff at [email protected].

Here is $25 in cash as a token of our appreciation for your participation.


FI PROVIDE RESPONDENT WITH $25 CASH.


I also need to fill out a receipt to certify you received (or declined) the cash incentive. Since maintaining the privacy of your information is important to us, I will not include your name on the receipt.


FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.


Here is a copy of the receipt for your records. Thank you again for answering all of our questions.


1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE




Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 minutes per response (time to read and agree to the assent/consent and respond to the questionnaire). Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].


PROGRAMMER: COMPLETED CASE THAT AGREES TO APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2691.


ASK: Respondents reaching the end of the survey who want to participate in the app-based portion of the study



EXIT4 [IF APP_EMAIL = 999 OR “I do not have an e-mail address” ] We provide electronic gift cards for participation in the app surveys via email. If you aren’t comfortable providing your e-mail address we can help you uninstall the app. INTERVIEWER: ASK RESPONDENT IF S/HE WOULD LIKE HELP UNINSTALLING THE APP.


Thank you for answering all of our questions. Here is $25 in cash as a token of our appreciation for your participation.


FI PROVIDE RESPONDENT WITH $25 CASH.


I also need to fill out a receipt to certify you received (or declined) the cash incentive. Since maintaining the privacy of your information is important to us, I will not include your name on the receipt.


FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.


Here is a copy of the receipt for your records. Thank you again for answering all of our questions.


1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE


Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 minutes per response (time to read and agree to the assent/consent and respond to the questionnaire). Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].


PROGRAMMER: COMPLETED CASE THAT WILL NOT PARTICIPATE IN APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2690.


ASK: Respondents who agreed to app-based data collection but would not provide an e-mail address



EXIT5_REFUSAL [IF SECA_CONSENT = 2]


FI: ATTEMPT TO CONVERT THE REFUSAL. IF CONVERT GO BACK TO INFORMED CONSENT AND UPDATE RESPONSE TO ‘YES’. IF UNABLE TO CONVERT, WHY DID THE PARTICIPANT REFUSE? SELECT ALL THAT APPLY


[PROGRAM SO THAT INTERVIEWERS CAN SELECT MORE THAN ONE RESPONSE]


  1. CONCERNED ABOUT CONFIDENTIALITY OR PRIVACY

  2. SAID THE INCENTIVE IS TOO SMALL

  3. TOO BUSY/NO TIME/DID TOO MANY ALREADY

  4. SURVEYS/GOVT. INVASIVE

  5. NOTHING IN IT FOR ME”/UNCOOPERATIVE

  6. SOME OTHER REASON (SPECIFY)


Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 minutes per response (time to read and agree to the assent/consent and respond to the questionnaire). Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].


ASK: Respondents who do not consent to the interview



REFOTR [IF EXIT5_REFUSAL = 6]


INTERVIEWER: SPECIFY WHY PARTICIPANT REFUSED


SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]


ASK: Asked of interviewers that indicate there is another reason the participant refused to participate



REMAIL: COMBINE EMAIL COLLECTED IN AL_EPEM2 AND APP_EMAIL INTO 1 VARIABLE FOR EXPORT.


CAPI REFUSAL STATUS CODE TRIGGERS


CAPI Question

Final

Input

Medium

Title

EXIT5_REFUSAL = 5

2412

Manual

IFMS

Refusal - Nothing in it for me/Uncooperative

EXIT5_REFUSAL = 3

2413

Manual

IFMS

Refusal - Too Busy/No Time

EXIT5_REFUSAL = 2

2414

Auto

IFMS

Refusal - Incentive too small

EXIT5_REFUSAL = 4

2415

Auto

IFMS

Refusal – Surveys/Govt. invasive

EXIT5_REFUSAL = 1

2416

Auto

IFMS

Refusal – Confidentiality or privacy

EXIT5_REFUSAL = 6

2429

Manual

IFMS



OMB No: 0910-#### Expiration Date: ##/##/20##

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 minutes per response (time to read and agree to the assent/consent and respond to the questionnaire). Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].


RIHSC #17-082CTP


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGittleson, Daniel
File Modified0000-00-00
File Created2021-01-20

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