Example Instrument: Screener for Creative Concept Testing

Form Approved

OMB No. 0920-0910

Exp. Date XX/XX/XXXX

National Tobacco Education Campaign

Online Questionnaire Recruitment Screener for

Creative Concept Testing

Public reporting burden of this collection of information is estimated to average 2 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).

{PREAMBLE}

On behalf of the Centers for Disease Control and Prevention (CDC), we're conducting a study about different health and smoking related advertising and messages that you might see in the media, such as on TV or the internet. Your opinions are very important to us! The purpose of this survey is to gather your opinions on health and smoking-related advertising only; it is not to see products. We will not report your answers individually. We will report results from this survey for the group as a whole. Thank you for taking the time to help us! It will take about 2 minutes to determine your eligibility and about 13 minutes to complete the survey. Immediately upon completion of the survey, you will be provided with points equivalent to $0.50.

Your participation in this survey is voluntary. You may stop participating at any time.

{Demographic Information}

DAGE2. What is your current age, in years?

_ _ _ age in years

{Open-end}

999 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

{Terminate if <18 years old or >54 - go to GENERAL SCREEN OUT MESSAGE}

DEMO2: What state do you live in?

1. Alabama

2. Alaska

3. Arizona

4. Arkansas

5. California

6. Colorado

7. Connecticut

8. Delaware

9. Florida

10. Georgia

11. Hawaii

12. Idaho

13. Illinois

14. Indiana

15. Iowa

16. Kansas

17. Kentucky

18. Louisiana

19. Maine

20. Maryland

21. Massachusetts

22. Michigan

23. Minnesota

24. Mississippi

25. Missouri

26. Montana

27. Nebraska

28. Nevada

29. New Hampshire

30. New Jersey

31. New Mexico

32. New York

33. North Carolina

34. North Dakota

35. Ohio

36. Oklahoma

37. Oregon

38. Pennsylvania

39. Rhode Island

40. South Carolina

41. South Dakota

42. Tennessee

43. Texas

44. Utah

45. Vermont

46. Virginia

47. Washington

48. West Virginia

49. Wisconsin

50. Wyoming

51. District of Columbia

52. Other please specify

{Smoking Behavior}

{PREAMBLE}

The next questions are about traditional cigarettes, which are any 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 = All respondents}

TS1. Have you smoked at least 100 traditional cigarettes in your entire life?

1. Yes

2. No {GENERAL SCREEN OUT MESSAGE}

3. Don’t know/not sure {GENERAL SCREEN OUT MESSAGE}

4. Prefer not to answer {GENERAL SCREEN OUT MESSAGE}
   
   

{Base = TS1 = 01}

TS2. Do you now smoke traditional cigarettes every day, some days, or not at all?

1. I smoke every day

2. I smoke on some days

3. I do not smoke at all {GENERAL SCREEN OUT MESSAGE}

{Base = TS2 = 01, 02}

TS3. On how many of the past 30 days did you smoke traditional cigarettes?

Enter number: _______

777 Don’t know/Not Sure {GENERAL SCREEN OUT MESSAGE}

999 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

{Terminate if Respondent answers TS3 = 0, show GENERAL SCREEN OUT MESSAGE}

{If Respondent answers TS1 = 1 AND (TS2 = 1 or TS2 = 2) AND answers TS3 > 0, show GENERAL ELIGIBILITY MESSAGE and go to E-Cigarette Behavior}

{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, 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

{If E1 = 01 AND E2 = 01 or 02, then segment as “Dual User,” show GENERAL ELIGIBILITY MESSAGE}

{Quota Groups}

Segments	Definition	Criteria
Exclusive Conventional Cigarette Smokers	Smokers who use only conventional cigarettes between ages 18-54	IF TS1_1 AND (TS2_1 or TS2_2) AND TS3 > 0 AND (E1 = 02 OR E2 = 03)
Young Adult Exclusive Conventional Cigarette Smokers	Smokers who use only conventional cigarettes between ages 18-26	IF “Exclusive Conventional Cigarette Smokers” AND DAGE2 = 18-26 (1998-1990)
Dual Users	Dual users of conventional cigarettes and e-cigarettes between ages 18-54	IF TS1_1 AND (TS2_1 or TS2_2) AND TS3 > 0 AND E1 = 01 AND E2 = 01 or 02
Young Adult Dual Users	Dual users of conventional cigarettes and e-cigarettes between ages 18-26	IF “Dual Users” AND DAGE2 = 18-26 (1998-1990)

{GENERAL SCREEN OUT MESSAGE}

Thank you for your participation in this study. Unfortunately, your responses indicate that you do not fit the specific criteria needed for this particular study, or that we have already reached our required quota of responses from participants similar to you. We appreciate your enthusiasm for our study and hope you will join us on future surveys!

{GENERAL ELIGIBILITY MESSAGE}

Thank you for your participation in this study. Your responses indicate that you qualify and fit the specific criteria needed for this particular study. Click “next” to go to the next question.

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