Example Instrument: Survey for Rough-cut Testing

Form Approved

OMB No. 0920-0910

Exp. Date 05/31/2021

National Tobacco Education Campaign

Online Questionnaire for

Rough Cut Testing of Television Advertisements

Public reporting burden of this collection of information is estimated to average 13 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

{E-Cigarette Behavior}

{PREAMBLE}

The next questions are about electronic vapor products. These are devices that usually contain a nicotine

based liquid that produces an aerosol that is inhaled by the user. You may also know them as e-cigarettes,

vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e

pipes), e-vaporizers, or tank systems. Some brand examples are Blu, NJOY, Vuse, MarkTen, Juul, and Starbuzz. For

the rest of this survey we will call all of the products in this category “e-cigarettes.”

{Base = All Current Smokers}

E1. Have you ever used an e-cigarette, even one time?

1. Yes

2. No

{Base = E1 = 01}

E2. Do you now use e-cigarettes…?

1. Every day

2. Some days

3. Not at all

{Base = E2 = 01 or 02}

E3. On how many of the past 30 days did you use an e-cigarette?

Enter number: _______

777 Don’t know/Not Sure

999 Prefer not to answer

{Base: All respondents}

DEMO1. What is your gender?

1. Male

2. Female

3. Prefer not to answer

DEMO3. Ethnicity

{PREAMBLE}

Please indicate your race or ethnic background. Are you….?

SELECT ONE

1. Hispanic or Latino

2. Not Hispanic or Latino

DEMO4. Race

SELECT ONE OR MORE

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Native Hawaiian or Other Pacific Islander

5. Asian

{Section: Attitudes and Behaviors}

{Smoking Behavior}

{PREAMBLE}

The next questions are about traditional cigarettes, which are a form of tobacco wrapped in paper. Traditional cigarettes typically come in packs of 20, and some brand examples include Marlboro, Newport, Camel, Lucky Strike and Pall Mall.

{Base: Respondents who SMOKE EVERY DAY (IF SCREENER.TS2 = 01)}

TS1a. On average, how many traditional cigarettes do you now smoke a day?

{{1 PACK = 20 CIGARETTES}

{{RANGE 1-100}

{Numeric response}

{Base: Respondents who SMOKE ON SOME DAYS (IF SCREENER.TS2 = 02)}

TS1b. On average, on days that you do smoke, how many traditional cigarettes do you now smoke a day?

{{1 PACK = 20 CIGARETTES}

{{RANGE 1-100}

{Numeric response}

{Base: Respondents who SMOKE EVERY DAY (IF SCREENER.TS2 = 01)}

TS2. When do you typically smoke your first traditional cigarette after waking up?

1. Within 5 minutes

2. Within 6-30 minutes

3. Within 31-60 minutes

4. After 60 minutes

{Base: All Smokers}

{Quit Attempts}

{Base: All Smokers}

QA1. During the past 3 months, how many times have you stopped smoking traditional cigarettes for one day or longer because you were trying to quit smoking traditional cigarettes for good?

_____ Number of times

{Base: If QA1 > 0}

QA2. When you last tried to quit smoking traditional cigarettes, did you do any of the following?

1. YES

2. NO

{ANSWER ALL, RANDOMIZE ORDER}

QA3_A. Give up traditional cigarettes all at once

QA3_B. Gradually cut back on traditional cigarettes

QA3_C. Substitute some of your traditional cigarettes with e-cigarettes such as vape-pens, hookah pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers

QA3_D. Switch completely to e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers

QA3_E. Switch to some other brand of traditional cigarettes

QA3_F. Use nicotine replacement products like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhaler

QA3_G. Use medications like Wellbutrin, Zyban, Buproprion, Chantix, or Varenicline

QA3_H. Get help from a telephone quit line

QA3_L. Enroll in a texting program

QA3_M. Download an app

QA3_N. Seek information on social media

QA3_I. Get help from a website such as cdc.gov/tips or Smokefree.gov

QA3_J. Get help from a doctor or other health professional

QA3_K. Get help from a pharmacist

{Base: If QA1 > 0}

QA30. What did you find most helpful when you last tried quitting smoking?

{OPEN END}

{Base: All Smokers}

QA4. How much do you want to quit smoking traditional cigarettes for good? Would you say you want to quit…

1. Not at all

2. A little

3. Somewhat

4. A lot

{Base: All Smokers}

QA5. Do you plan to quit smoking traditional cigarettes for good….

1. In the next 7 days

2. In the next 30 days

3. In the next 6 months

4. In the next 1 year

5. More than 1 year from now

6. I am not planning to quit

7. Not sure/uncertain

{Base: If QA1 > 0}

QA100. Which of the following was the main reason why you were unable to quit smoking traditional cigarettes for good?

{randomize list}

02 I’m addicted to smoking traditional cigarettes

04 I wanted to smoke traditional cigarettes in order to relax or calm down

05 I wanted to smoke traditional cigarettes when I’m drinking alcohol

07 I wanted to smoke traditional cigarettes to help with boredom

08 I wanted to smoke traditional cigarettes to help me lose weight or not gain weight

09 I wanted to smoke traditional cigarettes with others at the work place

12 I did not have access to nicotine replacement products like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhalers

13 I did not have the money to buy nicotine replacement products like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhalers

14 I did not have the money to buy medications like Wellbutrin, Zyban, Buproprion, Chantix, or Varenicline

10. Other ______________ {anchor}

11 None of the above {anchor}

{Base: If QA1 > 0}

QA102. Has your doctor talked to you about quitting smoking?

1. Yes

2. No

3. Not sure/uncertain

{Psychographic/Attitudinal}

{Base: All Smokers}

P5a. Are you afraid of dying from a tobacco-related disease?

1. Yes

2. No

{Base: All Smokers}

P5c. Do you think you will die from a tobacco-related disease?

1. Yes

2. No

{Base: All Smokers}

P5b. Are you afraid of living with a tobacco-related disease?

1. Yes

2. No

{Base: All Smokers}

P5d. Do you think you will get a tobacco-related disease?

3. Yes

4. No

{Base: All Smokers}

P6. Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with the following statements.

{5-Point Agree Scale}

{RANDOMIZE}

P6_10. I get upset when I think about my addiction to cigarettes.

P6_11. I am disappointed in myself because I smoke traditional cigarettes.

P6_12. I get upset when I hear or read about illnesses caused by smoking traditional cigarettes.

P6_13. Warnings about the health risks of smoking traditional cigarettes upset me.

P6_14. Smoking traditional cigarettes will severely lower my quality of life in the future.

P6_16. Smokers should take warnings about traditional cigarette smoking and lung cancer seriously.

P6_17. Smoking cigarettes is pleasurable.

P6_18. Smoking cigarettes relieves tension.

P6_19. Smoking helps me concentrate and do better work.

{Base: All respondents}

D210. Please tell us if you agree or disagree with the following statement:

Smoking can cause immediate damage to your body, which can lead to long-term health consequences.

1. Strongly Agree

2. Agree

3. Neither Agree nor Disagree

4. Disagree

5. Strongly Disagree

{Base: All respondents}

D211. Please tell us if you agree or disagree with the following statement:

Smoking traditional cigarettes can cause medical complications and diseases that require surgeries and medical procedures to treat.

1. Strongly Agree

2. Agree

3. Neither Agree nor Disagree

4. Disagree

5. Strongly Disagree

{Base: All respondents}

P8. Are you aware of any advertising or tobacco education campaigns against smoking, tobacco products, or tobacco companies that are now taking place?

1. Yes

2. No

{Base: If P8=01}

P9. Please comment on what you remember about these ads or tobacco education campaigns against smoking, tobacco products, or tobacco companies.

{OPEN END}

{Base: All respondents}

P10. Are you aware of the Tips From Former Smokers campaign against smoking, sponsored by the Centers for Disease Control and Prevention?

01 Yes

02 No

{Base: If P10=01}

P11. Please comment on what you remember about the Tips From Former Smokers campaign?

{OPEN END}

{Section: Rough Cut Testing}

{Randomly select an eligible ad}

{Assign hidden variable to Ad selected}

We would now like to show you a television ad and then gather your reactions to that ad. Note that you can review the ad multiple times prior to moving forward. Please make sure the volume on your computer is turned up, so that you can both see and hear the video. Please click the forward arrow to continue. [Each respondent will review one ad]

{Programmer instruction: Display selected ad through entirety before showing the “next” button}

{Unaided Response}

{Base: All respondents}

M1. What are the first three words that come to mind about this ad?

{OPEN END}

{Base: All respondents}

M2. What do you believe is the main message of this ad?

{OPEN END}

{Aided Response (Monadic)}

{At top of page, before question, insert thumbnail image of ad for the rest of the questions in this survey}

{Base: Leonard Nimoy ad}

LN1. The person in the ad was talking about the death of a family member, Leonard Nimoy. Before watching the ad, did you know who Leonard Nimoy was?

1. Yes

2. No

{Base: Leonard Nimoy ad and LNY1 = No}

LNN1. Now that you’ve watched the ad, do you know who Leonard Nimoy was?

1. Yes

2. No

{Base: Leonard Nimoy ad and LNY1 = No and LNN1 = Yes}

LNN2. Describe what you know about him in a few words.

{open end}

{Base: All respondents}

RC5a. How believable or unbelievable was the person in the ad?

1. Extremely believable

2. Moderately believable

3. Slightly believable

4. Neither believable nor unbelievable

5. Slightly unbelievable

6. Moderately unbelievable

7. Extremely unbelievable

{Base: All respondents}

M3. People sometimes have different emotional reactions when they see ads like the one above.

On a scale from 1 to 5, where 1 indicates not feeling any emotion, and 5 indicates feeling emotion with extreme intensity, please indicate how much this ad made you feel:

1. I did not feel this emotion

2. Slight emotion

3. Moderate emotion

4. Very intense emotion

5. Extreme and intense emotion

{RANDOMIZED}

M3_1. Angry

M3_2. Afraid

M3_3. Ashamed

M3_4. Sad

M3_5. Hopeful

M3_6. Understood

M3_7. Surprised

M3_8. Trusting

M3_9. Motivated

M3_10. Regretful

{Base: All respondents}

M4. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you strongly agree, please indicate how much you disagree or agree with the following statements.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

{RANDOMIZED}

M4_1. This ad is convincing

M4_2. This ad grabbed my attention

M4_3. This ad was easy to understand

M4_4. I learned something new from this ad

M4_5. I trust the information in this ad

M4_6. This ad is believable

M4_7. I would talk to someone else about this ad

M4_8. This ad is annoying

M4_9. This ad is worth remembering

M4_10. This ad is powerful

M4_11. This ad is informative

M4_12. This ad is meaningful

M4_13. I can identify with what this ad says

M4_14. This ad makes me more confident that I will not smoke cigarettes in the future. {non-smokers only}

M4_15. This ad influenced me about whether or not to smoke traditional cigarettes.

{Base: All respondents}

M5a. Is there anything about the ad that is confusing, unclear, or hard to understand?

01 Confusing

02 Unclear

03 Hard to understand

04 None of the above

{Base: If M5a = 01-03}

M5b. What was confusing, unclear, or hard to understand? Please be as specific as possible.

{Open End}

{Base: All Smokers}

M6a. Does this ad make you want to quit smoking traditional cigarettes?

1. Yes

2. No

M6b. Does this ad make you want to quit all tobacco products (including e-cigarettes)?

1. Yes

2. No

{Base: M6b = 02}

M7a. Why doesn’t the ad make you want to quit all tobacco products (including e-cigarettes)? Please be as specific as possible.

{Open End}

{Base: M6a = 02}

M7b. Why doesn’t the ad make you want to quit smoking traditional cigarettes? Please be as specific as possible.

{Open End}

{Base: M6a = 01}

M8a. What about the ad made you want to quit smoking traditional cigarettes? Please be as specific as possible.

{Open End}

{Base: M6b = 01}

M8b. What about the ad made you want to quit smoking all tobacco products (including e-cigarettes)? Please be as specific as possible.

{Open End}

{Base: All Smokers}

M600. Do you plan to quit smoking traditional cigarettes for good ...

1. In the next 7 days

2. In the next 30 days

3. In the next 6 months

4. In the next 1 year

5. More than 1 year from now

6. I am not planning to quit

7. Not sure/uncertain

{Base: All Smokers}

RC14. In the future, if you saw this ad on television, on a scale from 1 to 5, where 1 indicates not at all likely and 5 is extremely likely, how likely would you be to take the following actions in the next 6 months?

1. Call 1-800-QUIT-NOW for assistance in quitting smoking

2. Visit an informational government website, such as www.cdc.gov/tips or Smokefree.gov for information on quitting

3. Download an app to help you quit smoking

4. Talk to your doctor about quitting smoking

5. Not smoke around others

6. Follow the Tips campaign on social media (e.g., Twitter, Facebook, Pinterest)

7. Try to quit on your own

8. Use an electronic vapor product to help quit smoking traditional cigarettes

9. Support smoke-free laws in your community

10. Enroll in a texting program to help you quit smoking

11. Do nothing

Scale for items RC14.A-H:

1. Not at all likely

2. A little likely

3. Moderately likely

4. Very likely

5. Extremely likely

{Base: Nonsmokers}

RC15. Does the ad make you want to encourage someone to quit smoking cigarettes?

1. Yes

2. No

{Base = ask only if Rc15.02}

RC16. Why doesn’t the ad make you want to encourage someone to quit smoking? Please be as specific as possible.

{Open End}

{Base = ask only if Rc15.01}

RC17. What about the ad makes you want to encourage someone to quit smoking? Please be as specific as possible.

{Open End}

{Base: All Non-Smokers}

RC14b. In the future, if you saw this ad on television, on a scale from 1 to 5, where 1 indicates not at all likely and 5 is extremely likely, how likely would you be to take the following actions in the next 6 months?

1. Call 1-800-QUIT-NOW for information to help someone you care about quit smoking

2. Visit an informational government website, such as www.cdc.gov/tips or Smokefree.gov for information to help someone you care about quit smoking

3. Talk to your doctor about helping someone you care about quit smoking

4. Ask someone to not smoke around you or others

5. Encourage someone you care about to use an electronic vapor product to help quit smoking traditional cigarettes

6. Encourage someone you care about to quit smoking traditional cigarettes completely

7. Follow the Tips From Former Smokers campaign on social media (e.g., Twitter. Facebook, Pinterest)

8. Support smoke-free laws in your community

9. Do nothing

Scale for items RC14.A-H:

1. Not at all likely

2. A little likely

3. Moderately likely

4. Very likely

5. Extremely likely

{Base: All respondents}

RC31. On a scale of 1 (not at all) to 5 (extremely), to what degree did the ad focus on the consequences of smoking cigarettes?

1. Not at all

2. Slightly

3. Moderately

4. Very

5. Extremely

{General Thank You Message}

Thank you for your participation in this study. We appreciate your enthusiasm for our study and hope you will join us on future surveys!

23